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

Disruptions to the Therapeutic Alliance

Given these divergent world views and values, it is not surprising that many patients raised in the more conservative or fundamentalist denominations within the major faiths -- such as Orthodox Jews or evangelical Christians -- are not likely to be comfortable with the secular and "humanistic" values of psychiatry. The term humanistic has taken on a new and sometimes pejorative meaning for some devoutly religious groups, who may object to what is called "secular humanism." Indeed, the secularly oriented psychiatrist may come into conflict with devoutly religious patients in several important spheres. Thus, many religious groups have strongly held views on sexuality, gender issues, sexual orientation, feminism, abortion, contraception, drug and alcohol use, and -- of greatest importance to this writing -- mental illness. More abstract issues, such as how one copes with guilt, grieving, repentance, and sin, may also be conceptualized very differently in psychiatry than in the religious sphere.

In some cases, the religious position, especially the more liberal versions, may be harmonized with the views of secular psychiatry -- but in other instances, these positions may be in direct conflict. Orthodox Judaism, for example, considers masturbation to be a violation of Jewish law, whereas most psychiatrists and psychologists would see it as a harmless or (within limits) even a healthy behavior. Similarly, Roman Catholicism views premarital sex as sinful, and evangelical Protestantism judges it to be contrary to biblical teaching. In contrast, most secularly oriented psychiatrists would not address premarital sex or even adultery in terms of "sin," but rather in terms of the maturity and health of the relationship.

By the same token, homosexuality is among the most controversial issues dividing the Christian faith today, whereas psychiatry settled its own internal rift on this matter with the removal of homosexuality as a psychiatric diagnosis from the Diagnostic and Statistical Manual of Mental Disorders in 1973. These examples illustrate that the sacred/secular schism may cause severe disruptions of the therapeutic alliance, if not properly addressed.

Transference and Countertransference Issues

Many transference/countertransference issues can arise when there is a mismatch between the religious convictions of therapist and patient. For example, the secularly oriented therapist may unconsciously fantasize that he or she will "liberate" the devoutly religious patient from the fetters of religious dogma. Some secular therapists may unconsciously (or consciously) feel that devoutly religious patients are weak-minded, deluded, dependent, or incapable of independent thought. Conversely, the religiously oriented therapist may unconsciously entertain the wish to convert or "save" the nonreligious patient, viewing the therapy in terms of redemption rather than the restoration of mental health.

As psychologist and Judaic scholar M.H. Spero observed[12]:

Generally speaking, the therapist of religious patients must monitor a continuum of transference-countertransference responses. These range from rescue fantasies to disdain brought on by projection of [the therapist's] personal insecurity, guilt or prejudice. On the patient's part, responses range from the need to replace loved objects and to obtain gratification through identification with the therapist's religious life, to the expectation of magical cure...e.g., the [patient may believe]...that the therapist is determined to destroy the patient's religious beliefs; or, alternatively, that the therapist will readily join the patient in warm and protecting friendship.

We may hypothesize, for example, that a nonobservant patient might develop transference-based fears while working with a devoutly religious therapist (eg, a fear that the therapist will seek to impose his or her religious beliefs, just as the patient's father or mother may have done -- at least from the patient's perspective.) On the other hand, a devoutly religious psychiatrist working with a disturbed patient of similar faith may develop a strongly positive countertransference (eg, unconsciously placing the patient in the role of troubled son or daughter, in need of love, care, and rescue.) The patient's resistance to treatment in the latter situation could evoke narcissistically based feelings of injury in the therapist, if he or she is unable to gain insight into the countertransference. Psychiatrist Howard C. Margolese explains that "flexibility is required to choose treatment modalities that best fit with the patient's beliefs; to respect the patient's beliefs no matter the extent to which they deviate from the therapist's own; and finally, to be critical of oneself when examining transference and countertransference reactions."[13]

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