Psychiatrists' views on religion (editorial)

It is only in the past 15 years or so that psychiatrists and psychologists have taken religion seriously as an area of academic discourse. This is evidenced by the growing number of publication on religion and mental health in mainstream psychiatric and psychological journals (Baetz & Toews, 2009; Boehnlein, 2006; Koenig, 2009; Moreira-Almeida, Neto, & Koenig, 2006), and book publishers (e.g., Bhugra, 1996; Boehnlein, 2000; Cook, Powell, & Sims, 2009; Huguelet, & Koenig, 2009; Koenig, McCullough, & Larson, 2001; Loewenthal, 1995, 2007; Verhagen, van Praag, Lo´ pez-Ibor, Cox, & Moussaoui, 2010). Traditionally, psychiatry has held negative views towards religious practice, seeing it as outdated, guilt inducing, and dependency forming (e.g., Ellis, 1962), views that date from Freud’s writings on religion that cast religious practice as a form of psychopathology, or more specifically akin to an obsessional neurosis (Freud, 1907). There are signs however that the situation is slowly changing. In 1994, the American Psychiatric Association introduced a V code in the DSM-IV whose aim was to de-pathologise religious experience (American Psychiatric Association, 1994, p. 685). There is an emerging literature tentatively suggesting that being religious may positively influence both physical and mental health and examining the pathways through which religion/spirituality impact upon mental health. Recently, the literature on religion and health has moved beyond religiosity to examine religion/spirituality as coping strategies and their implications for mental health outcomes (Pargament, 1997; Pargament, Ano, & Wachholtz, 2005). One area which has recently attracted academic scholarship is the religiosity of psychiatrists and its impact upon clinical practice (e.g., Carter, 2008; Dein, Cook, Powell, & Eagger, 2010; Hollins, 2008; Koenig, 2008; Lepping, 2008; Mushtaq & Hafeez, 2008; Poole et al., 2008; Poole & Higgo, 2009). This edition of Mental Health, Religion & Culture focuses on this clinically relevant topic. The papers by Cook (2011), Poole and Higgo (2011), and Crossley (2011) focus on a number of interrelated concerns.

(1) How does the religiosity of psychiatrists compare to that of their patients and the religiosity of the general population? What is the evidence for a religiosity gap?

(2) Do service users want their psychiatrists to discuss religious/spiritual issues with them? (3) What attitudes do psychiatrists hold about including religious issues in psychiatric history taking? (4) How does the personal religiosity of the psychiatrist impact upon the care given to his or her patients? (5) Does inclusion of religion/spirituality breach professional boundaries? (6) How does psychiatry conceptualise the self and what are the implications for clinical practice? Cook (2011), in the Faith of the Psychiatrist begins his paper by discussing evidence for a religiosity gap between psychiatrists and their patients. He broadens the concept of faith to include not just religious faith, but also spiritual outlook, and the adherence to a specific theoretical framework. He provides a comprehensive and critical overview of published studies examining the religiosity of psychiatrists in the United Kingdom, Australia, New Zealand, and in the United States. Making the important point that this area of research is marked by lack of suitable comparison or control groups, he concludes, correctly in our opinion, that it is difficult to establish with any degree of certainty whether or not any religiosity gap actually exists. He moves on to examine the large number of often-heated responses to a paper by Koenig (2008) in the (then named) Psychiatric Bulletin which recommends: . Taking a spiritual history . Supporting healthy religious beliefs . Challenging unhealthy beliefs . Praying with patients (in ‘‘highly selected cases’’) . Consultation with, referral to, or joint therapy with trained clergy Cook (2011) analyses why this paper created such controversy, arguing for two factors: cultural and professional. He raises the significant issue of breach of professional boundaries which is the subject matter of Poole and Higgo’s (2011) paper in this edition. He then moves onto psychiatry as a faith community emphasising the need to understand health as something beyond the physical. He underscores the fact that human beings are of greater value than can be demonstrated by scientific method alone. We would fully agree with this assertion. Finally, he examines the implications of psychiatrist’s religiosity on patient care including a discussion of the attitudes of the Royal College of Psychiatrists Spirituality Special Interest Group. We would fully agree with Cook (2011) that the personal faith of the psychiatrist might influence the clinical encounter both in a positive (through compassion and shared understanding) and in a negative way (through prejudice). The issues discussed in Cook’s (2011) paper provide an agenda for future empirical research in this area: (1) Do psychiatrists possess a religious/spiritual perspective and how does this differ from those that they treat? (2) What factors (personal, professional, ethnic, religious) influence psychiatrist’s attitudes towards religion and spirituality? (3) How does the faith of the psychiatrist impact upon patient care in terms of clinical outcomes including patient satisfaction?

Poole and Higgo’s (2011) paper, Spirituality and the threat to therapeutic boundaries in psychiatric practice is a polemical paper taking issue with the assertion that religious and spiritual issues should be not just permissible components to routine clinical practice in the United Kingdom but necessary elements of all patients care in the United Kingdom. Their main bone of contention is that doing this is a clear breach of professional boundaries. Although they acknowledge that religion and spirituality can be healing for some people, they state:

SPSIG’s insistence that exploration of spirituality is a necessary part of assessment and treatment sits uneasily with their acknowledgement that some atheists do not accept any supernatural or transcendent dimension to life. The evidence suggests that 10% of practising Christians in Europe do not believe in God (Lepping, 2008). This illustrates the rich diversity of belief in the 21st century. In the face of this diversity, firm statements regarding universal spiritual principles will always generate significant exceptions and problems. (p.25) What are we to make of this statement? The answer hinges on what is meant by spiritual, an ongoing debate in the literature. While we cannot measure spiritual experience per se, we can measure the prevalence of beliefs as some have done (King, Speck, & Thomas, 2001). Whether spirituality is universal or not is an empirical question which can be answered by conventional scientific means. From the anthropological literature it appears that in all societies studied there are religious/spiritual beliefs (Dein & Littlewood, in press). There has been a lot of recent discussion about secularisation with many sociologists of religion arguing that it is not personal belief that has declined but rather institutional practice (Berger, Davie, & Fokas 2008). It does appear that religious beliefs are fairly resistant to the erosive forces of modernity. Scientific thinking has not lessened the importance of the sacred in everyday life. If we define spirituality in terms of ultimate meaning then we can legitimately argue that everyone possesses a spiritual element. Spirituality can be nontheistic – an attachment to the cosmos, nature or to humanity as a whole and appears to derive from the western cultural emphasis on individuality and subjectivity (Heelas, 2002). Furthermore, we see nothing wrong with asking about whether or not religious/ spiritual issues are important for patients just as we would ask about their sexual lives. Some people do not have (want) a sexual life, yet this is still an area that psychiatrists typically enquire about. However, there is no doubt that religious/spiritual issues are important for some people and that at the least it is necessary to ask whether there are religious/spiritual issues contributing to the presenting problem. These issues should be gently enquired about and the patient’s consent obtained to discuss them. As one of us has recently stated (Dein et al., 2011), inclusion of religious and spiritual issues in psychiatry does raise significant ethical concerns and clinicians must always be aware of overstepping boundaries. In no way do we agree with enforcing our personal views on patients, this would constitute a significant breach of boundaries. Also, we cannot deny that religious breach of boundaries can cause significant harm to patients, but this is not unique to religious issues alone. Poole and Higgo’s (2011) paper goes beyond vehement criticism of religion in psychiatry. They indirectly present an attack on faith generally arguing that faith, unlike science, is not open to public disconfirmation. For us faith is based upon emotion and is not a blind belief. It is constituted through experience in the world. We would reply that religious experience (like all internal experience) is not amenable to disconfirmation.

Psychiatrists deal with internal states all the time. Is depression/anxiety/hearing voices open to empirical disconfirmation? Crossley (2011), in Secular Psychiatry and the Self addresses the self in psychiatry. Arguing that it is a relatively neglected topic in psychiatric theory, he asks, what are the implications of a narrow view of selfhood for mental health practice? Based on the writings of Charles Taylor (2007), he agrees that the self (originally the soul) has been secularised. However, like religion, psychiatric practice is far from value free. Issues of morality, ethics, and power pervade psychiatric practice. We need to be aware of this both for patient care and for the development of the professional self. We totally agree with this assertion. In their response to Poole and Higgo (2011), Cook, Powell, Sims, and Eagger (2011) point out that psychiatry, as a profession, is conventionally understood as separate from matters of belief and can be conducted without reference to theology, doctrine or notions of transcendence. In contradiction to this view, they assert that psychiatry is intimately concerned with patients’ beliefs and its practice cannot ignore them. The fact that religious beliefs are now more respected within psychiatry and may be seen as helpful and adaptive rather than necessarily pathological, is encouraging and signifies that the profession has become more willing to engage with and understand the diversity of spiritual and religious beliefs and practices that are encountered among healthy and flourishing people in the world today. Although supposedly we are living in a secularised society (and it is not at all clear in most parts of the world that they are), religious beliefs are still very much a part of their patients worldviews that psychiatrists need to deal with. They propose that Taylor’s (2007) analysis of self and secularisation has important implications for psychiatry. More specifically, any attempt to argue that psychiatry has nothing to do with spirituality is likely to be the result of the operation of hidden closed world structures which distort the appearance of reality and are protective mechanisms which preserve healthy professional or ethical boundaries or defend personal religious belief. Furthermore, Taylor’s work also deals with the ‘‘nova effect,’’ which presents us (at least in the Western world) with an ‘‘ever widening variety of moral/spiritual options.’’ It is in this context, not the context of traditional religion that spirituality has become an important topic for psychiatric practice, but also for a proper philosophical account of the self-understanding of all human beings in the secular age. Arguing against Poole and Higgo (2011), they assert that secularity provides far from neutral ground when it comes to managing the good and bad influences of spirituality and religion on the clinical practice of psychiatry. By no means implying that psychiatry must be practiced in a religious context, it does suggest that the exploration of spiritual matters in the clinical context needs to be informed by better understandings of the hidden assumptions of the secular age in which we live and of the complex nature of the buffered self that this age has fostered. The SPSIG is not prescriptive and does not adopt any one religious/spiritual position. Its ‘‘mission’’ is to educate psychiatrists about the role and importance of spirituality in psychiatric assessment and treatment, and for more openness to talking about these topics both within and with those outside the profession. As the authors importantly point out, has not promoted discussion of such matters with patients who ‘‘resist’’ such discussion, it has not promoted praying with patients, and it is opposed to proselytising among patients in any form. Culliford (2011) addresses several of the concerns raised in Poole and Higgo’s (2011) paper. An ex-member of the Executive Committee of the Royal College of Psychiatrists’ Spirituality and Psychiatry Special Interest Group, he argues that these authors have

underestimated the extensive research now available that employs improved qualitative as well as quantitative methodologies to get more closely at people’s subjective experiences (King & Leavey, 2010; Koenig, McCullough, & Larson, 2001; Levin, 2001; Paloutzian & Park, 2005; Plante & Thoresen, 2007). He points out that territorial boundaries are redundant, and are not useful in a profession that involves many disciplines and faith communities. More pertinently, however, he questions their assumption that science and faith are diametrically opposed. Even scientists require faith in scientific methodology. Furthermore, although scientists can answer the how questions, they are unable to provide a response to the why questions relating to meaning that only religion/spirituality can adequately answer. He concurs with the view of both Fontana (2003) and Schermer (2003) that there is evidence for a paradigm shift in academic psychology and psychiatry, akin to the paradigm shift from classical physics to quantum physics. He continues by differentiating between the alleviation of symptoms in psychiatry and ‘‘healing’’ which necessitates the involvement of spirituality. Far from breaching professional boundaries, not asking about spirituality might be considered unprofessional. The new paradigm does, ‘‘Regard spirituality as a universal dimension to human experience, transcending individual religions.’’ In doing so, it points towards a liberal theology based more on experience and practice, rather than on beliefs. Thus he vehemently denies the assertions of Poole and Higgo (2011) that the SPSIG promotes ideas that constitute a specific theology. Dura Villa et al. (2011) examine the relationships between ethnicity and attitudes of UK psychiatrists towards religion/spirituality in their clinical work. Through semistructured interviews of psychiatrists working in London, of varied ethnic backgrounds, the authors found a strong degree of dissonance among the migrant psychiatrists between their practice in their home countries (incorporating patients’ religious beliefs) and in the United Kingdom (excluding them). They point out the need for more training in this area particularly in relation to the discussion of religious/spiritual issues and the implementation of religious strategies in clinical practice. This study is unique since it is the first to examine ethnicity in relation to beliefs and attitudes of psychiatrists in the United Kingdom. Finally, Leavey, Dura` -Vila` , and King (2011) examined the partnerships between faithbased organizations (FBO) and psychiatry. Beginning with a social history and rationale for promoting partnerships, they move on to examine welfare provision related to ethnicity, cultural competence and the contemporary emphasis in healthcare provision on the patient’s subjective world view. They make the important point that patients from religious backgrounds frequently find mainstream services stigmatizing and furthermore that religious experience is prone to misdiagnosis. Therefore religious individuals may be reluctant to use these services. Clergy, often with extensive experience of working with those in emotional distress, may play a pivotal role in facilitating access to mainstream services while at the same time advocating for the incorporation of religious/spiritual elements into treatment. They conclude by arguing that, while many secular sections of society, and indeed some clergy, resist a health and welfare role for FBOs, the management of mental illness occupies, de facto, much of what clergy do. There is a need for psychiatry and faith groups to explore the nature and boundaries of proposed relationships. At present we have little empirical data relating to current relationships between the two sectors including referral rates and attitudes of clergy towards referral to mental health services. Their paper is timely and underscores the urgent need for more research examining the strategies for promoting partnerships between FBO’s and the statutory sector. This might well be a

challenging enterprise since, as the authors point out, many psychiatrists are atheists and many clergy are poorly trained in mental health issues. The special issue closes with book reviews of three volumes recently published books in the area of religion and psychiatry: Greenberg (2011) provides a book review of Religion and Psychiatry: Beyond boundaries: Implications for clinical practice (Verhagen et al., 2010), Witzum (2011) provides a review of Religion and Spirituality in Psychiatry (Huguelet & Koenig, 2009), and Read (2011) provides a review of Spirituality & Psychiatry (Cook et al., 2009). These four provocative papers and the invited response, along with the three book reviews, provide much food for thought and we hope that you enjoy reading them. In closing, we wish to acknowledge the authors who provided stimulating articles and efficient revisions, and our reviewers for their judicious and insightful evaluations of the manuscripts submitted.