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Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

  • Rob Poole (a1) and Christopher C. H. Cook (a2)
Summary

The extent to which religion and spirituality are integrated into routine psychiatric practice has been a source of increasing controversy over recent years. While taking a patient's spiritual needs into account when planning their care may be less contentious, disclosure to the patient by the psychiatrist of their own religious beliefs or consulting clergy in the context of treatment are seen by some as potentially harmful and in breach of General Medical Council guidance. Here, Professor Rob Poole and Professor Christopher Cook debate whether praying with a patient constitutes a breach of professional boundaries in psychiatric practice.

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References
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1 General Medical Council. Good Medical Practice: duties of a doctor. GMC, 2011 (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp).
2 General Medical Council. Personal beliefs and medical practice – guidance for doctors. GMC, 2008 (http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs.asp).
3 Jarrett, P, Milaviè, G, Roy, A. Vulnerable Patients, Safe Doctors: Good Practice in our Clinical Relationships (College Report CR146). Royal College of Psychiatrists, 2007.
4 Poole, R, Higgo, R. Psychiatric Interviewing and Assessment. Cambridge University Press, 2006.
5 Koenig, HG. Religion and mental health: what should psychiatrists do? Psychiatr Bull 2008; 32: 201–3.
6 Dein, S, Cook, CCH, Powell, A, Eagger, S. Religion, spirituality and mental health. Psychiatrist 2010; 34: 63–4.
7 Koenig, HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry 2009; 54: 283–91.
8 McCord, G, Gilchrist, VJ, Grossman, SD, King, BD, McCormick, KF, Oprandi, AM, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med 2004; 2: 356–61.
9 Nicholls, V. Taken Seriously: The Somerset Spirituality Project. Mental Health Foundation, 2002.
10 Poole, R, Higgo, R, Strong, G, Kennedy, G, Ruben, S, Barnes, R, et al. Religion, psychiatry and professional boundaries [letter]. Psychiatr Bull 2008; 32: 356–7.
11 Taylor, C. A Secular Age. Belknap, 2007.
12 Ulanov, A, Ulanov, B. Primary Speech: A Psychology of Prayer. Westminster John Knox Press, 1985.
13 Poole, R, Higgo, R. Clinical Skills in Psychiatric Treatment. Cambridge University Press, 2008.
14 Spirituality and Psychiatry Special Interest Group. Newsletter No. 30, December 2008. Royal College of Psychiatrists (http://www.rcpsych.ac.uk/members/specialinterestgroups/spirituality/publicationsarchive/newsletter30.aspx).
15 Baillie, D, McCabe, R, Priebe, S. Aetiology of depression and schizophrenia: current views of British psychiatrists. Psychiatr Bull 2009; 33: 374–7.
16 Cook, C. Demon possession and mental illness. Nucleus 1997; Autumn: 13–7 (http://www.cmf.org.uk/literature/content.asp?context=article&id=619).
17 Royal College of Psychiatrists. Good Psychiatric Practice (Third Edition) (College Report CR154). Royal College of Psychiatrists, 2009.
18 Royal College of Psychiatrists. Royal College of Psychiatrists' Position Statement on Sexual Orientation. PS01/2010. Royal College of Psychiatrists, 2010.
19 Perry, M, (ed). Deliverance: Psychic Disturbances and Occult Involvement (2nd edn). SPCK Publishing, 1996.
20 Koenig, HG, Cohen, HJ, Blazer, DG, Pieper, C, Meador, KG, Shelp, F, et al. Religious coping and depression among elderly, hospitalized, medically ill men. Am J Psychiatry 1992; 149: 1693–700.
21 Boelens, PA, Reeves, RR, Replogle, WH, Koenig, HG. A randomized trial of the effect of prayer on depression and anxiety. Int J Psychiatry Med 2009; 39: 377–92.
22 Gallanter, M, Larson, D, Rubenstone, E. Christian psychiatry: the impact of evangelical belief on clinical practice. Am J Psychiatry 1991; 148: 90–5.
23 Craddock, N, Antebi, D, Attenburrow, MJ, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 69.
24 Burns, T. The dog that failed to bark. Psychiatrist 2010; 34: 361–3.
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The British Journal of Psychiatry
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Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

  • Rob Poole (a1) and Christopher C. H. Cook (a2)
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eLetters

Re: Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

Andrew Sims, Emeritus Professor of Psychiatry
21 October 2011

The Journal is to be congratulated for including this topic in debate(August 2011). Until recently religion and spirituality have been a silent area for psychiatric discourse, to the detriment of patient care.

Poole and Cook have entered the debate with enthusiasm, and it is likely that discussion will continue. Much of Poole's argument seems to bebased on a misunderstanding of the nature of prayer: what religious believers are doing when they pray, that prayer can be a persistent state of mind, an on-going conversation rather than just a list of requests. He states, without further qualification, "prayer is not the business of psychiatrists". With this brief phrase he has sought to invalidate more than 40 years of my clinical practice! I would, like Cook, interpret what Poole writes in stating "that my silent or implicit prayers with and for virtually all of my patients are a breach of professional boundaries".

It is unusual for traditional believers to find themselves as 'liberals' in a debate, attacked by 'authoritarianism', but it is Poole who would be prescriptive - "no praying" - and Cook who wants to be permissive - "respect patient autonomy". It is unlikely that praying out loud with patients would ever be frequent, but to have such an act meriting professional disciplinary action would be calamitous for doctors,their patients and the practice of psychiatry.

Poole has a predilection for inappropriate analogies between religionand sex: prohibition of sexual behaviour during medical consultation is utterly different from preventing discussion of a patient's religious values. Only harm can come to the patient out of inappropriate, sexual approaches by the doctor; however, the evidence would suggest that religious belief and practice is, most often, beneficial to health rather than damaging . He would impose secularism on patients and psychiatrists, whether they want it or not.Poole acknowledges that his"debating style mayseem strident to some" but claims that his fear of negative consequences (of praying with patients) "is based on widely accepted principles of clinical practice unrelated to personal atheism". One of the advantages ofreligious belief is that it does tend to take the blinkers off the way youview yourself and your own behaviour; I freely acknowledge that this letter is influenced by my personal beliefs. I hope that Poole does not have his authoritarian way; I hope that generations-to-come of psychiatrists with religious beliefs will not face disciplinary action fordaring to pray with and for their patients, whether silently or out loud.

Koenig HG, McCullough ME & Larson DB (2001) Handbook of Religion and Health, page 381, Oxford University Press.

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Conflict of interest: None declared

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Re:Author's response

Gordon R W Davies, psychiatrist
21 October 2011

Professor Poole is correctly concerned with the ethics involved in the use of prayer in therapy but seems to have interpreted my view as advocacy.

I would like to emphasise that while I would not advocate the incorporation of prayer in therapy, neither would I absolutely proscribe it. As an analogy I would look at it in the same light as the old rules onabortion: normally proscribed but in special cases justifiable.

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Conflict of interest: None declared

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Re:Re:Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

Selim Ahmed, CT3
30 September 2011

I do not agree with the statement of the title of this article. Muslims for instance, who are well known to be obligated to pray five times a day have been a major cause for the emergence of several prayer rooms is hospital premises. In these rooms you will find patient and doctor sitting together praying in unison. It occurs with psychiatric patients and other patients. Is this practice being questioned? The doctorand patient together ask God for what they ask, not individually but in congregation.

When in a consultation room with a patient who believes in demonic possession along with the patient's family who believe in demonic possession and also the doctor who believes in demonic possession - to notthen talk about it is like ignoring the elephant in the room or akin to the analogy that antidepressants dampen symptoms but do not address the issues.

It has been productive when the doctor acknowledges this shared belief, clarifies his professional remit and proceeds then to explain his medical findings. The suggestion is not that the doctor, who is qualified in medicine would then behave as though he is qualified in Religious judgements. Recognition that the patient holds demonic possession as a differential diagnosis needs to be accepted in order to steer the tide away from how it is, that is poeple who avoid attending medical opinions for contempt of faithless doctors.

Muslim patients and their relatives often recognise Muslim doctors and they seek a bond due to it. Bonding serves to strengthen rapport and therepeutic outcome. In fact on the ward often I see patients who are not even under my care and who have never even met me, then greet me with "assalamu ^alaykum" to which I respond the same. This is itself like a prayer, a greeting that Muslims greet each other with that carries the meaning praying for peace. This also perhaps constitutes praying with the patient.

Acceptance of a patient's invitation to pray is the doctor's decisionand until it is proven that this is detrimental through example of case studies it should not be negatively viewed, much in the same way the doctor does not refuse the patient who requests to be seen at home rather than in clinic. The ability of discretion, if not present, houses an incompetent doctor and perhaps the question people might want to ask is "what is an appropriate type of prayer that can be performed with the patient" - as I have illustrated above prayer does occur with patients andit has never given cause for professional concern

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Conflict of interest: None declared

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Re:Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

Christopher C.H. Cook, Professorial Research Fellow
21 September 2011

I am grateful to Dr Davies for highlighting the importance of faith and belief in psychiatry. Atheism, materialism and biological determinism are as much belief systems as are religions. Because of a mismatch betweensystems of belief, it will often be inappropriate for clinicians to pray with patients. But what about prayer in contexts where faith and belief are shared? In Faith Based Organisations, in faith communities, and in other contexts where doctor and patient are brought together knowing that they share the same belief system, "praying with a patient" takes on a different connotation. The psychiatrist who prays with a patient in such contexts should still be able to justify their reasons for thinking that this would be helpful, and their reasons for expecting that it would do noharm, but I do not see why it should automatically be excluded.

Pace Dr Haley, I do not view prayer as a therapeutic tool that "can exclude the history of Christianity in the UK and the challenges this may pose". In some parts of the UK sectarianism is such that differences between some "Christian" groups are greater than those between people fromcompletely different faith traditions. Na?ve attempts to pray across thesedivides, in the clinical context, are ill advised. Dr Haley describes my view of prayer as a means of "the individual's connection to the Divine". I only limited prayer to being defined as "conversation with God" because this appeared to be the understanding of prayer that was causing concern. This approach to prayer is not associated preferentially with the protestant or dissenting tradition, and is encountered in the writings of catholic saints such as Ignatius Loyola and Teresa of Avila. The writings of Ignatius and Teresa, amongst others, now unite many Christians from different spiritual traditions (eg catholic and protestant).

The idea that spiritual and pharmacological treatments are analogous,and that they should be dealt with in completely separate departments, mayhave some attraction to Dr Haley. However, I am frequently approached by service users who find this kind of fragmentation of their care to be unhelpful and unacceptable. We do not accept separation of the psychological from other aspects of wellbeing. Similarly, I do not see whyprayer should be excluded.

A position statement on spirituality and religion in psychiatry has recently been published by the College (1). Whilst this statement does notexplicitly address Dr Sarkar's concerns about praying with patients, it provides guidance which should be very helpful in avoiding breaches of professional boundaries in clinical practice. I think that the situations where praying with a patient represent as serious a breach of professionalboundaries as preaching to a patient will usually be because they are justthat - preaching to the patient (albeit under the pretext of prayer). I find this just as unacceptable as those situations encountered by service users who feel that they have been "preached at" by their atheist psychiatrist.

1.Cook CCH. Recommendations for Psychiatrists on Spirituality & Religion. London: Royal College of Psychiatrists; 2011.

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Conflict of interest: CCHC is in receipt of a grant from the Guild of Health. CCHC is currently Chair of the Spirituality & Psychiatry Special Interest Group (SPSIG) at the Royal College of Psychiatrists. The views expressed in this article are his own. SPSIG does not adopt any particular position in relation to the matters debated in this article, but welcomes open debate about this and other matters related to spirituality and psychiatry, both in publication and at its meetings. CCHC is an Anglican priest, Lectures in Spirituality at St John's College, Durham, and is Director of the Project for Spirituality, Theology & Health at Durham University.

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Prayer is more than just a religious ritual

Aram Kim, Psychiatry Registrar
16 September 2011

As a Christian psychiatric trainee with a special interest in spirituality and cultural practices, I read with much interest the recently published article on the issue of prayer in psychiatric practice(1). Despite of what appears to be irreconcilable views from opposing sides, it was positive to see such discussion taking place as it highlights the increasing awareness of the importance of spiritual health in our patients' well-being.

Admittedly the focus of the debate was whether or not, the act of prayer with a patient crosses the professional boundary. Nevertheless it was disappointing to see the field of the discussion was restricted to theact itself and its merits (albeit some digression to demonic possession and arguments about homophobia which seemed irrelevant to the focus of thedebate) without recognising its wider implications on culturally appropriate delivery of care.

As a medical professional, the understanding of the role of social, cultural and spiritual influences on each patient's health beliefs and behaviours should be central to our daily practices. Such cultural competency is "essential for high quality healthcare"(2). I believe praying with a patient, without minimising its religious connotation, is first and foremost an act of recognition and validation of that patient's identity and values which can mediate better doctor-patient relationship and delivery of care. Of note, such cultural practice is actively endorsed by Medical Council of New Zealand (MCNZ) alongside recommendations to acknowledge traditional health beliefs, lifestyle and role of broader family (whanau) in our Maori patients(3).

In Te Whare Tapa Wha (4) - one of the most widely accepted Maori health model - Taha Wairua (Spiritual Health) is one of the four corner stones of health. In adopting this model of health, MCNZ endorses Tikanga M?ori (practice of M?ori custom) including practice of Karakia (blessings or prayer) which is "an essential way of protecting and maintaining spiritual, physical and mental health" (3) to promote health of our M?ori patients. Such culturally (and indeed spiritually) appropriate practice ofMaori prayer is widely seen in many psychiatric settings across New Zealand. In fact, Karakia was practiced on the ward every morning and at the opening and closure of each interview with Maori patients when I was working in a psychiatric unit in Rotorua, New Zealand. In my personal experience, it helped to enhance the professional relationship and was often a conduit for a rapport building.

Indeed Karakia was done by the expert M?ori cultural support workers on the ward due to my lack of depth in knowledge, experience and familiarity with Maori culture just as much as their expertise in this area. Hence I have no doubt that if I were to have used Karakia with Maoripatients, it would not have yielded same positive effect nor with any patients who does not identify with this values and customs. Similarly, I believe that Professor Poole's concern about the potential dangers of prayer within psychiatric setting is not inherent to the act of prayer - whether implicit or explicit - but how it is used or delivered.

Professor Poole's example of sexual history taking within psychiatricconsultation is an ideal example to illustrate this point. Although it would be widely acceptable to explore such area in most psychiatric consultations, it is not in the content of history that this can be justified but rather in the way it is conducted as well as the motivation behind it. Exploring any such sensitive personal history stays within professional boundary so long as it is done in a respectful and a sensitive manner with an intention to utilise the information to benefit the patient. So is the act of prayer.

When a psychiatrist who has adequate knowledge and experience in certain spiritual system or world view (whether Christian, Muslim, Buddhist, Secular or otherwise) including use of its unique practices and customs such as prayer engages a patient who identifies with that particular beliefs, I believe, the psychiatrist may pray with or for the patient at a 'right' time with a clear motivation to benefit the patient. If it is done in a 'sensitive' manner, acknowledging individual's possibleidiosyncratic differences even within that belief system as well as the patient's mental state and the setting in which this is done in an expert manner, it can help to build rapport, validate patient, and provide bettercare for the patient without breaching the professional boundary. So, in fact, if this act was to cross the professional boundary, it would likely be reflection on how and why this was done rather than what was done. This, in turn, would be a reflection of lack of skills and experience of the clinician (thus deficiencies in education and training) in this area of practice rather than being a reflection of any inherent 'evil' of the act itself that crosses the professional boundary to harm our patients.

References(1)Poole R, Cook CCH Praying with a patient constitutes a breach of professional boundaries in psychiatric practice. Br J Psych 2011; 199: 94-98(2)Bloomfield A, Logan R. Quality improvement perspective and healthcare funding decisions. BMJ 2003; 327: 439-43.6.(3)Medical Council of New Zealand. Best health outcomes for Maori: Practice implications. NZMC, 2006 (http://www.mcnz.org.nz/portals/0/publications/best%20health%20maori_complete.pdf)

(4)Maori Health [www.maorihealth.govt.nz] Ministry of Health; 2011 [updated 22 August 2011; cited 31 August 2011]. Available from http://www.maorihealth.govt.nz/moh.nsf/pagesma/196

AuthorDr. Aram Kim, Psychiatry Registrar, Rodney Adult Mental Health, Waitemata District Health Board, Auckland, New ZealandEmail : dr.aramkim@gmail.com

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Conflict of interest: None declared

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