Spirituality and boundaries in psychiatry

Poole et al ¹ appear to be reproving the Spirituality and Psychiatry Special Interest Group for neither endorsing nor refuting their stated opinion that spiritual and religious practices are breaching professional boundaries. They begin by taking issue with the views of Professor Koenig ² (a paper to which four members of the Group Executive Committee have also made a considered response ³ ), further citing General Medical Council (GMC) guidance ⁴ that, (1) doctors should not discuss their personal beliefs with patients unless these beliefs are directly relevant to patient care, and (2) doctors should not impose their beliefs on patients.

Concerning the GMC guidance, since the Group agrees with both points, it seems there is no argument to be had on this front. As for the Group's response to Professor Koenig's paper, we have highlighted why we think the relationship of spirituality (including secular spirituality) to mental health is important for every psychiatrist to be aware of. ³ Although we advocate extreme caution in the matter of prayer with patients because of the complex boundary issues raised, we do not see this as something to be ruled by fiat.

Enquiring about a patient's spirituality can be extremely helpful. Psychiatrists routinely ask about other central aspects of patients' lives such as sexuality which might influence, and be influenced by, psychopathology. There is evidence that religious and spiritual beliefs may similarly affect psychological functioning both positively and negatively and that those beliefs may, in turn, be influenced by mental illness. A tactful enquiry about patients' belief systems frequently reveals information that may be helpful in understanding coping strategies. Atheism, as a belief system, is no exception.

There is evidence that many patients want to be able to share with mental health professionals their spiritual and religious beliefs and values, to which they frequently turn when under stress. ⁵ Indeed, by enabling such issues to come up for discussion, the psychiatrist may well be facilitating the therapeutic relationship. ⁶

Mental illness causes fragmentation of the self and finding healing or wholeness (the root of the words is the same) is intrinsic to recovery. This has been endorsed by the World Health Organization: ‘Patients and physicians have begun to realise the value of elements such as faith, hope and compassion in the healing process’. ⁷

Given that religious and spiritual beliefs are important for many patients and that for these patients showing interest in, and concern for, their beliefs may have therapeutic value, we feel it is appropriate to routinely enquire about such beliefs. As with all aspects of the clinical consultation, this needs to be done with sensitivity and tact. If a patient does not want to discuss such issues, the subject is gently dropped - there is no question of putting anyone under pressure. The agenda is set by the patient.

We see it as important that enquiry should be carried out in a manner that conveys openness to every kind of belief - humanist, secular, spiritual and religious alike. Patients who have experienced trauma with religious or spiritual organisations (sometimes associated with sexual abuse) may be fearful of speaking out. The psychiatrist who conveys concern, empathy and understanding will give the best chance of finding out which spiritual concerns may need understanding in order to enhance a good therapeutic outcome. The same GMC guidance on personal beliefs and medical practice cited by Poole et al goes on to state:

For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs. You must respect patients' right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options.

Last, we should make clear that the Spirituality and Psychiatry Special Interest Group is precisely that - a special interest group. Its function is neither prescriptive nor prohibitive. We would no more advocate proselytising than see spiritual concerns ousted from the clinical consultation.

We wish to make clear that we welcome the debate to which Poole et al are contributing and look forward to further discussion when Professor Poole will be talking at the Group's programme in October 2010 on ‘Intolerant secularisation’. We do not look for uniformity of opinion, but we do hold that every viewpoint is worthy of consideration and respect.