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

Bridging Religious and Psychiatric Values

Are there times when the fundamentalist teachings of religion can be reframed in a way that seems compatible with secular psychiatric ethics? Alternatively, if a devoutly religious patient cites some scriptural prohibition or condemnation, is it ever useful or prudent to rebut this with a counteracting quotation from scripture? There are many pitfalls in "fighting fire with fire," particularly if the psychiatrist is not deeply versed in the relevant religious tradition. In addition to the potential for adversarial religious debates with the patient, there is always the risk that the patient may recall Shakespeare's line from The Merchant of Venice: "The devil can cite Scripture for his purpose."

Nonetheless, if the psychiatrist is comfortable with and reasonably knowledgeable about a particular religious tradition, it is sometimes possible to use religious teachings in service of the treatment. For example, consider the case of a scrupulously religious patient whose obsessive-compulsive and perfectionist traits were causing depression and interfering with her ability to enjoy her success. The patient resisted any attempts to relinquish these rigid defenses, insisting that Christ commanded perfection. The patient quoted the Bible, "You therefore, must be perfect, as your heavenly father is perfect." The biblically informed psychiatrist quoted the rest of the passage in response, to clarify the context of the quotation.

You have heard that it was said, "You should love your neighbor and hate your enemy." But I say to you, love your enemies and pray for those who persecute you, so that you may be sons of your Father who is in heaven; that he makes his sun rise on the evil and on the good, and sends rain on the just and the unjust. For if you love those who love you, what reward have you? Do not even the tax collectors do the same? And if you salute only your brethren, what more are you doing than others? Do not even the Gentiles do the same? You, therefore, must be perfect, as your heavenly Father is perfect. (Matthew 5:43-48, Revised Standard Version)

The psychiatrist pointed out that when read in its context, the admonition to perfection did not demand harsh self-discipline, but rather the imitation of God's love and justice toward human beings -- which included the patient.

Psychologist Dr. Hank Robb,who has been trained in Ellis's Rational Emotive Behavioral Therapy (REBT) and also has expertise in religious studies, describes how he uses passages from the Bible to dispute the devoutly religious patient's "irrational beliefs" (which are not necessarily religious in nature).[15] For example, Robb describes the religious patient who believes, "I must have love and approval from everybody." The therapist might bridge the gap between sacred and secular traditions by quoting, for example, from Luke 9:25; "What does it profit a man if he gain the whole world, but lose himself?"

Similarly, in the Jewish tradition, the Talmudadmonishes us to "...not consider yourself wicked." (Pirke Avot 2:18). Rabbis believe that although we can certainly judge our individual acts as wicked, we should not entirely condemn our very beings. (Hence, the modern-day expression, "Hate the sin, not the sinner.").

All of this is quite compatible with Ellis's REBT, which insists that "If human beings have any intrinsic worth or value, they have it by virtue of their mere existence, their being, rather than because of anything they do to earn it...You are good or deserving just because you are..."[16]

In principle, therefore, a Talmudic teaching of this nature might be used to bridge the worldviews of secular psychiatry and Orthodox Judaism.

Notwithstanding these intriguing bridging techniques, we would urge caution in using religious texts to counteract a patient's fundamentalist beliefs, given the potential for exacerbating tensions that are already present in the treatment; assuming dual or conflicting roles that confuse the patient; or engaging in activities beyond the scope of one's psychiatric training.

Therapeutic Issues With "Fundamentalist" Patients

Many specific issues can arise in the psychiatric care of fundamentalist patients. With respect to sexual mores and behaviors, the American Puritan heritage still reverberates in the attitudes of conservative Christianity. Psychiatrists raised in a postmodern urban society may find it difficult to empathize with the suffering and dilemmas of religiously devout or fundamentalist patients concerning issues of sexual orientation, abortion, birth control, and even premarital sex. A psychiatrist working with a young person from a fundamentalist family, for example, who is struggling with the biblical condemnation of homosexuality (Leviticus 18:22) must be careful not to impose his or her own moral judgments, or to insist that the patient adopt a "liberal" value system to attain mental health.

Such impositions are no less damaging to the patient's autonomy than is strict obedience to religious authority. Indeed, the religious patient may feel as coerced on the psychiatrist's couch as below the preacher's pulpit. The prudent and religiously literate psychiatrist will help the patient realize that the wider message of scripture is one of compassion and acceptance. If the patient's church or family responds with rejection or condemnation, the nonobservant therapist can enlist clergy from more tolerant denominations or advocacy groups. The therapeutic goal is to help religious patients remain true to themselves, within a supportive community.

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