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

Issues of Consultation or Referral

With respect to conducting psychotherapy with Orthodox Jewish patients, Margolese[13] provides general guidance for working with religious patients of any denomination. "The first key in working with cultural minorities is patience. Patience is required to allow a therapeutic alliance to develop in which the therapist -- the outsider -- can be trusted. When patients are reluctant to accept the treatment proposed, patience is necessary to give them the time required to verify the treatment with someone they trust..."

For some Orthodox Jewish patients, this verification is likely to involve checking with the patient's rabbi. A Catholic might wish to consult a priest before making major life choices that a secular therapist would consider far outside the realm of religion. Similarly, evangelical Christian patients may need to "check it out" with their pastors before fully engaging in psychiatric treatment or adhering to a specific medical treatment -- like Ms. A, in the opening vignette. Psychiatrists who underestimate, or even criticize, the devout patient's trust and respect for religious leaders may create unnecessary splitting of the patient's loyalties, with the potential for a psychological or spiritual crises. Wiser practitioners will be open to the possibility that the pastor or rabbi is a source of ego-strength for the struggling patient, and a parallel professional with whom the psychiatrist can collaborate in fostering the patient's recovery.[14]

Psychiatrists with some personal or academic knowledge of religion may be tempted to "handle the spiritual stuff" and thereby unwittingly commit a boundary violation in the treatment. Psychiatrists of strong religious faith, particularly a faith shared with the patient, may decide to engage the patient in prayer or other religious practices. Depending on the context, such decisions may constitute a boundary crossing that shifts the nature of the relationship from clinical to spiritual.

On the other hand, some psychiatrists who feel intimidated by the devoutly religious patient will "act out" by precipitously transferring care to another clinician with religious inclinations, or to the patient's designated clergy. In some instances, this may be tantamount to abandonment and would be a breach of psychiatric ethics.

In contrast to such inappropriate actions, it is sometimes useful and appropriate for the psychiatrist to consult directly with the patient's clergyperson, if clarifying a matter of religious import can resolve an impasse in the treatment or help preserve the therapeutic alliance. Such consultation must only be done with the patient's informed consent.

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