COMMENTARY

Ethical Issues in the Psychiatric Treatment of the Religious 'Fundamentalist' Patient

Ronald W. Pies, MD; Cynthia Geppert, MD, PhD, MPH, MSBE

Disclosures

March 19, 2013

In This Article

Trends in Religious Belief

These conflicting patterns of mental healthcare are taking place in a context of great change and dynamism in the US religious community. For example, a recent study by the Pew Foundation[5] found that "...constant movement characterizes the American religious marketplace, as every major religious group is simultaneously gaining and losing adherents." Strikingly, the study also found that "...more than one-quarter of American adults (28%) have left the faith in which they were raised in favor of another religion -- or no religion at all."[5]

Psychiatrists who are unfamiliar with these trends, and with religious beliefs in general, may find themselves at a serious disadvantage when caring for patients with religious beliefs -- especially the more conservative and devout patients -- or patients who have abandoned the faith of their childhood owing to traumatic experiences. Moreover, unless the psychiatrist is aware of his or her own feelings toward religion and religious patients, management of transference and countertransference issues may be mishandled, and the therapeutic alliance severely strained. Practitioners who opine that religion is irrelevant to, or even undermines, mental health may dismiss, criticize, or fail to encourage beliefs and practices that may be sources of strength and resilience for the patient, failing to adopt a recovery-oriented stance to the patient's individual treatment.[6]

Fundamentalism, Evangelicalism, and Devotion

In this article, we will focus on the following:

Differences in core values between psychiatry and some conservative religious traditions;

Transference and countertransference issues that may arise in working with religiously conservative patients;

Issues of consultation with, or referral to, clergy or psychiatrists with faith-based commitments;

Ways in which shared religious beliefs with divergent interpretations may be bridged through the use of specific texts and "reframing" techniques; and

Specific therapeutic issues that may arise with "fundamentalist" patients.

Although there are many definitions of "fundamentalism," we take it to mean the belief that the holy scriptures of one's faith are literally the unerring and unchangeable word of God, representing infallible moral and spiritual teachings.

Fundamentalism is a growing movement in all 3 Abrahamic faiths -- Judaism, Christianity, and Islam -- and has a counterpart in some Eastern religions. Fundamentalist and evangelical Christians, although often lumped together in popular commentary, must be differentiated in the treatment approach of the psychiatrist.

Fundamentalism is a relatively small tributary of the deep and wide river of evangelical Christianity, which is now the prevailing current in US Protestant Christianity. Like fundamentalist Christians, many (although not all) evangelical Christians tend to be politically and socially conservative and emphasize the divine origin of biblical scripture. However, evangelical Christians do not generally share the ideological strictness, literal interpretations of the Bible, and cultural intolerance of modernity characteristic of many fundamentalists.[7] In a Public Broadcasting Service interview, John Green, author of Religion and the Culture Wars (Rowman and Littlefield Publishers, 1996), said:

The differences between fundamentalism and evangelicalism are a bit subtle, and oftentimes difficult to understand from the outside. A lot of it is a style. Fundamentalists tend to be very strict. They tend towards intolerance. Notice, I said, "tend towards intolerance." Many of them are not intolerant. But they tend towards that direction. They tend to be very judgmental. They tend to want to require an awful lot of individuals who would join their communion. And they tend to be very, very critical of other Christians -- even other evangelical Christians -- who don't share their very strict approach to religion.[7]

Religious devotion should be distinguished from both the denominational designation -- evangelical -- and from fundamentalist ideology. "Devotion" describes a depth and intensity of religious faith and practice that can be found in the adherents of any religion. A devout Jew or Christian will hold religion as the preeminent value and organizing principle of his or her thought and life, and this may generate tension with a psychiatrist who embraces opposing philosophical ideas and personal values.

The scenario of a devoutly religious psychiatrist treating a nonreligious patient does arise and presents its own pitfalls; however, in our professional experience, the more common and potentially countertherapeutic situation is one in which a psychiatrist of primarily secular orientation is treating a religiously observant or fundamentalist Jewish or Christian patient.

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