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

The Outcome of Ms. A's Dilemma

Our vignette presents another area of contention between fundamentalism and psychiatry: the belief that mental (as opposed to physical) illness is actually a spiritual malady, for which prayer (not medication) and faith (not psychotherapy) are the appropriate remedies. Among some fundamentalist groups, particularly in rural areas,[17] attitudes toward mental illness have changed little from the medieval view of depression as the sin of acedia,[18] and the moral stigma attached to drug addiction in the 19th and early 20th centuries.[19] It may be prudent for Ms. A's psychiatrist to seek out a pastor, or even a therapist, from Ms. A's faith community, who can credibly reassure the patient that medical illness is not always a reflection of a spiritual problem and that medication and prayer can work together, not against each other.

At the same time, the psychiatrist might also make use of the natural tendency of young adults to question authority, to challenge the proposition that Ms. A's bipolar disorder is the result of a "lack of faith." Indeed, this might well be the approach of a therapist trained in REBT. For example, the therapist might ask Ms. A, "If your best friend told you she was depressed and suicidal, would you take her to the student health center, or to a prayer meeting?" Of course, the "best" answer may be that Ms. A. would do both, as would most Christians who believe that God works through physicians -- even psychiatrists! -- and that discontinuing a beneficial medication would be contrary to God's plan.

Meeting the Therapeutic Challenge

Psychiatric treatment of the fundamentalist patient poses many therapeutic challenges, ranging from a clash of mores and values to unconscious acting out in transference or countertransference. The key to successful treatment is an attitude of respect and acceptance on the part of the psychiatrist, as well as an empathic understanding of the fundamentalist patient's world view. This is not to say that the psychiatrist must accept uncritically every claim and proposition put forward by the patient, or by the faith community of origin; on the contrary, extreme and self-injurious beliefs and behaviors may need to be challenged or confronted, commensurate with the physician's ethical obligations.

At the same time, the psychiatrist may need to find creative ways of enlisting the patient's own belief system, or that of the relevant faith community, in service of the treatment and the therapeutic alliance. In some instances, this may mean working cooperatively with members of the patient's religious community, as long as the combined effort is consistent with medical and psychiatric ethics.

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