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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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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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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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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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Author's response

Rob Poole, Professor of Mental Health
14 September 2011

Drs Haley, Davies and Sarkar raise issues concerning religion, spirituality and clinical practice beyond the narrow question of prayer.

I am grateful to Dr Haley for setting a broader socio-political context. I concur with the points he makes, which underline the fact that this debate is concerned with tangible realities, not abstract differencesof belief.

Dr Davies uses three rhetorical devices that have been recurrently utilised by 'the other side' in the broad debate. Firstly, he argues on the basis of the fundamental philosophical fallacy of a category error. Religious faith, ethical codes, cognitive therapy and, for that matter, science may all in some way involve belief, but they are not comparable, competing belief systems. They are fundamentally dissimilar. Religious faith is concerned with transcendent, immutable truths that are outside ofthe realm of reason or evidence. This does not invalidate faith, but it isdissimilar to other types of belief.

Secondly, Dr Davies assumes that my position is primarily determined by my atheism. However, many professional with a strong religious faith agree with me 1, because the debate is concerned with professional boundaries not personal convictions. In the paper with Professor Cook I mention my participation in a meeting on 'Intolerant Secularism' at the Royal College of Psychiatrists in October 2010 2. Professor Andrew Sims, Lord Carey and Andrea Minichiello Williams had hoped to persuade the College's Spirituality and Psychiatry Special Interest Group (SPSIG) to campaign for the right of professionals to express disapproval of homosexual lifestyles in their work, and for a distinctively Christian orientation to public and professional life in general. SPSIG showed no inclination to support this, which does not suggest that it is only atheists who are troubled by the implications of some of the realities of integrating religion into clinical practice.

Finally, Dr Davies leaps to the suggestion that my stance is associated with an attachment to biological determinism and over attachment to a particular theoretical stance within psychiatry. There is no logical link. Personally, I reject biological determinism and theoretical fanaticism because, in my opinion, they are based on bad science. I cannot see how religious belief (or non-belief) is relevant.

Dr Sarkar has published extensively on boundary violations, and I am pleased that he agrees with me that the issues concerning prayer and religious practice are not intrinsically different to other boundary issues.

In calling for the Royal College to commission a working group, he echoes a similar suggestion published in The Psychiatrist in October 2010 3. This was addressed to the immediate past President of the College, who did not respond. Instead, a position paper, written by Professor Cook on behalf of SPSIG, has quietly passed through the College committee machinery, and is now Royal College of Psychiatrists policy 4.

On the one hand, the College's position paper emphasises that proselytisation is unacceptable, which is welcome. On the other hand, noneof the key boundary issues are addressed, a scientifically controversial position has been adopted with regard to evidence, and the official position of British organised psychiatry is that "Religion and spirituality and their relationship to the diagnosis, aetiology and treatment of psychiatric disorders should be considered as essential components of both psychiatric training and continuing professional development". This is already having an impact on services. For example, Mersey Care NHS Trust is holding a conference to promote integration of spirituality into psychiatric care 5 on the basis that this is a Royal College recommendation.

This debate has teeth, and we are already set on a course that I findextremely worrying. Those who agree with me on the importance of boundaries should make their voices heard now, as we may soon find ourselves in a very difficult place.

References

1.Poole R. Higgo R, Strong G, Kennedy G, Ruben S, Barnes R, Lepping P, Mitchell P (2008) "Religion, Psychiatry and Professional Boundaries", Psychiatric Bulletin, 32, 356-7.

2.http://www.rcpsych.ac.uk/members/specialinterestgroups/spirituality/publicationsarchive/newsletter30.aspx(retrieved 12/9/2011).

3.Poole R, Higgo R (2010) Psychiatry, religion and spirituality: a way forward. The Psychiatrist 34: 452-453.

4.http://www.rcpsych.ac.uk/pdf/PS03_2011.pdf (retrieved 13/9/11)

5.http://www.merseycare.nhs.uk/Library/Living_in_Hope/Living%20in%20Hope%20Flyer.pdf(retrieved 13/9/11)

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Conflict of interest: I am an atheist

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Medical affirmation yes, praying no

Gabor Kelemen, Consultant Psychiatrist in Addictions
14 September 2011

Recent debate over the issue of praying with patients (1) examines the problem mainly from the vantage point of the doctor. The focus is on what a doctor should or should not do, instead of examining what makes a patient ask to pray with his doctor. Having been overly concentrated on the problem of boundary violation, the debate has only sparingly been concerned with the subject of spirituality. A patient knows the differencebetween treatment and prayer. They are aware of the fact that prayer has to do with religion in the same way as treatment has to do with medicine. They also know that clerics, as a rule, do not supplement their praying with medication. Clerics apply metaphysical tools, doctors do not. Clericsoffer holy water or consecrated bread and wine, extreme unction etc., at least in the case of Christian religions. Doctors normally provide medication, surgery, psycho and physiotherapy, and do not supplement theirmedication with prayer. Nevertheless, doctors render personal, specific, present-centred, hope increasing, mindful affirmations. Unlike worship, medical affirmation does not refer to the divine or to grace, and in contrast to supplication or incantation it does not invoke supernatural forces and powers external to society. Medical affirmations are neutral interms of religion. Affirmations help patients to recover their healthy experience of personal, emotional, intellectual and social truth. They represent a kind of secular spirituality in so far as spirituality impliesthe care of self which transforms one in gaining access to the truth (2). Doctors affirm their patients' truth, faith, trust and believe that they have resources and abilities to recover and transform their lives. They affirm that patients are not victims and are competent to cope with shame and harsh self-criticism, as well as being capable of courageously, humblyand serenely acknowledging their limits.Regarding the motives of doctors to pray with a patient, Professor Poole mentions doctors' good intentions. Professor Cook takes into account the doctor's desire to respond as a human being to the patient's demand. None of them mentions the potentiality of their Good Samaritan impulse or counter-transference reaction. They are not concerned with the patient's motives or the historical context of the problem.I think when a doctor following the direct request of a patient to pray together ponders whether he or she should acquiesce or not, they have failed to understand the essential part of the appeal. Praying with the patient is simply unprofessional. During a one-to-one session, dancing, singing, telling jokes and playing with a patient is unprofessional as well. These actions may have relevant healing effects, but they are not within the scope of professional behaviour. (These kinds of interventions might be appropriate in the framework of psychodrama or creative therapy, which is nowadays under-sponsored and therefore rare.) When a patient asksto pray with his doctor, the doctor's job is neither to comply with their request, nor just to say an unempathic no, but to explore the underlying message of the demand and respond accordingly. They need to investigate the patient's unexpressed psychological "truth", i.e. the symbolic or metaphoric meaning of their request.Hippocrates, the father of our profession rejected any explanation of disease and treatment by divine intervention. Since he did not consider that diseases were caused by evil, he did not need to use prayer or purification to dispel demons. Hippocrates delineated prognosis on the basis of signs and symptoms of disease presented by the condition of the patient, not on the basis of messages sent by the gods. He simply did not need the hypothesis of God to explain the causes and treatment of diseases. On the other hand Hippocratic doctors were generalists, rather than the sort of specialists who were typical to Egyptian medicine (3). For doctors who were members of the Hippocratic school, personal compassion and consoling affirmation were imperative. In my view, the Hippocratic aphorism "cure sometimes, relieve often, comfort always" was based on honest empathy, not on sophistic manipulation and tranquillizing life-lies. Ancient Greek medical attitude was not so much about balance asabout acknowledging the limits of our actions (4). I think that without reflection on our limitations, medical affirmation leads to empty optimisminstead of empowering hope.Patients, especially those suffering from suicidal ideations, depression, addiction, chronic and terminal diseases, often have anguishing spiritual needs for trust, reconciliation, forgiveness and hope (5). When restoration of their health is not a realistic option, patients can still transform by learning new ways of self-care (6). Medical affirmation mightaddress these spiritual needs for self-transformation. Although direct encouragement of spiritual development towards Maslowian self-actualization and other growth needs is not an aim of medical treatment, it can be a by-product of proper medical affirmation.According to Foucault, historically there was no constitutive or structural opposition between science and spirituality. The opposition wasbetween theological thought and the requirement of spirituality. It was theology, not modern science that rigorously disengaged from spiritual tradition. The separation and demarcation of science from by that time de-spiritualized theology was a latter sequel (7). There is pressure on medicine, I assume, to rethink the issue of spiritual reflection within our practice. If medicine has been groping to find its way back to the progressive tradition and practice of self-transformation, then the way toconduct this quest, according to Foucault, is not via religion but withoutit.

References 1 Poole R, Cook CCH. Praying with a patient constitutes a breach of professional boundaries in psychiatric practice. The British Journal of Psychiatry 2011; 199: 94-98. 2 McGushin EF. Foucault's Askesis. Norhwestern University Press, 2007. 3. Jouanna J. Hippocrates. The Johns Hopkins University, 1999. 4. Castoriadis C. A Society Adrift. Fordham University Press, 2010. 5. Wallen, J. Addiction in Human Development: Developmental Perspectives on Addiction and Recovery. The Haworth Press, 1993. 6. Kelemen G, Erdos M. Health Learning as Identity Learning in the Therapeutic Community. Addictologia Hungarica, 2010; 9: 216-225. 7. Foucault M. The Hermeneutics of the Subject: Lectures at the College deFrance 1981-82. Palgrave Macmillan, 2005.

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

Gordon R. W. Davies, Psychiatrist
31 August 2011

The discussion between Dr. Cook and Dr. Poole focuses on what might be termed an epiphenomenon of faith. Dr. Poole in particular avoids any interpretation of the values he espouses for psychiatry as a belief system.This is in my view fundamentally erroneous. The set of principles avowed by Dr. Poole find their origin in both Greek philosophy and in the Judeo-Christian system of ethics. These are fundamentally systems of beliefs andin that sense, particularly for the secularist, are no different to a religious doctrine.In considering this issue it is impossible to start from a position that does not invoke shared belief, and that personal position of belief that is termed faith. I would assume that Professor Poole would take the position that psychiatrists should practice using "evidence based" techniques and therapies. If one is to take cognitive therapies as an example of this, problems of belief immediately arise as an immediate aim is to change patients' erroneous and maladaptive belief systems. I would ask to what belief system should one change them? Should it reflect the psychiatrist's beliefs, the patient's community and cultural beliefs or something else.A common example of the integral involvement of belief with therapy is theAlcoholics Anonymous program. Would Professor Poole refer a patient to this as part of his treatment or would he regard it as the unethical imposition of a belief in a "higher power"? More broadly, in psychotherapy there exist a number of theoretical belief systems which have some level of evidence in their favour, particularly inthe belief of their proponents. Having observed successful psychotherapists with a variety of backgrounds I am tempted to say that their theories support their therapies by providing a belief structure that supports their faith that treatment can provide benefit when progressis slow, and that this faith in the future is a key element in their success.If the argument that faith is a fundamental element in the treatment process is accepted, and I would argue that while this is particularly so for psychiatry it also applies in other areas of medicine, then the major question is the degree to which it is synonymous with belief.If faith provides strength and purpose to both psychiatrist and patient and can be asserted a positive asset without much criticism, belief can beconsidered as being more problematic and potentially dangerous. In a broadsense depressive disorders may be considered to reflect a deficit of faithwhile mania and psychoses reflect an excess of belief. This may apply to therapists as much as patients. Doctors with a high level of belief in particular therapeutic modalities have a history of causing harm as well as good. An uncritical belief in materialism and biological determinism can cause as many, if not more, problems than a Cartesian view.It seems that the divergence of opinion between Professors Poole and Cook arises not from the potential for good but the potential for harm. Both are men of belief and even if their beliefs are considered existentially "good" assertion that an atheistic belief system is the only basis for treatment is potentially treacherous if imposed on a patient. Even our present evidence based structure is predicated on a belief about an organised and regular universe.Speaking as a slightly irreverent theist I would argue that the question posed does not have a single correct answer. In judging the most appropriate manner of dealing with a particular situation the important thing is to consider the principles to be applied. There are some behaviours that would be generally agreed to be inappropriate and damagingwithout recourse to argument but others may be appropriate only in certainsituations.My recommendation would be that there should not be an overall statement or conclusion that the use of prayer in therapy is either right or wrong. It would have to be considered as an uncommon and unusual part of a therapeutic program which can only be justified in very particular circumstances. It should be accepted that there are occasions when its useis appropriate and therapeutic. Nonetheless because of its controversial nature, and the possibility of abuse by both therapist and patient, prayershould be considered an unusual therapeutic modality. The therapist should be therefore be prepared to justify its use on a case by case basisand be able to demonstrate that no harm was likely to arise.

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Conflict of interest: None declared

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Historical context and social boundaries in praying with patients

Clifford J Haley, Clinical Director, Consultant psychiatrist
03 August 2011

Dear Editor,

The debate between doctors Poole and Cookson (1) appears to ignore that spirituality, transcendency and individual religious beliefs expressed in prayer are historically and culturally bound to the social institution of organized religion: the first estate. Neither author acknowledges how the sociology of religion and its place in our society impacts on whether prayer should be shared between Doctor and patient. Christian religion has been firmly bound to the functioning of organized western society for well over a thousand years. Consideration of the spiritual needs of patients have been part of holistic care models for decades and is present in the delivery of mental health, individualised care plans in most mental health services. However, prayer in day to day life does not have an individual identity that is divorced from structuredreligion. There is a potent social boundary here and it should not be crossed for socio-cultural reasons as well as individual professional ethics.

Dr Poole focuses on the individual boundaries that are appropriate inthe Doctor/Patient relationship but we have social boundaries based on ourreligious history that have resulted in our modern social institutions having a broad secular base. When in the UK in 2011 religious assassination of police officers occurs within "the single faith Christiantradition", when football managers receive bullets in the post because of their particular Christian tradition, when the UK still has regions where religion is more about the fire in the belly and less about the angst between the ears, less "happy clappy" and more happy slappy, it seems a little naive of Dr Cookson to view prayer as a therapeutic tool that can exclude the history of Christianity in the UK and the challenges this may pose.

Dr Cookson's arguments emphasise the individual's connection to the Divine through prayer and the potential benefits this may bring. Historically, this is the argument of the "Dissenter"; the evangelical protestant tradition which is a rich faith that can deliver spiritual fulfilment as can all the branches of the Christian church that exist in the UK today. But again historically prayer is not just about an individual's spiritual needs and fulfilment. For St Augustine and St Patrick and onwards it is also a tool of the missionary for conversion. The form of words we use, the rituals and the rites of prayer have an uncomfortable history of conflict and even the unstructured prayer within a nonconformist "free church" comes with a history of struggle.

Within my own psychiatric service I am happy to say that we can alloweveryone who comes into our service the freedom to pray and express their religion as they wish, a right that has emerged from the religious historyof the British Isles. I am fortunate in having a specialised team of professionals with decades of training and expertise in meeting and fulfilling the spirituality of our service users. I turn to their wisdom and guidance often when prayer and religious needs present with mental health problems. We call them the hospital chaplains. I don't pray with the patients. They don't give depots. It works.

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Conflict of interest: None declared

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Over Boundary

Sameer P. Sarkar, Consultant Psychiatrist
03 August 2011

I read with interest the exchanges between Professors Poole and Cook in this month's journal. I have also been following closely the exchanges between these two highly polarized positions in the College for quite a while. Not wishing to take a position on the acceptability of praying withpatients, I find myself astounded by the inability in some quarters to accept, or even recognize the fact that praying with the patient may be asserious as preaching to the patient. Boundaries are set in professional practices to protect both the patient and the doctor. Would someone feel easy to take stockmarket tips from his Wall Street banker patient? Or get racing tips from his very informed horse-racing-mad patient? How about setting up a business venture with my venture capitalist patient with significant 'daddy issues'.

Would it be appropriate for a doctor to tell his patient that his Church offers the best chance of redemption, or to tell the patient that he should divorce his cheating wife because this is what is perpetuating his depression? These are all hypothetical examples of boundary violationsand are rightly proscribed in all codes of ethics worldwide. In deciding harm in a doctor-patient interaction, surely it is for the doctor to decide where the boundary lies, and then maintain it. Sexual boundary is not the only boundary we should be taught not to cross, although arguably this ought to be the first.

The fact the College has given so much column inches to the issue means that even if there are no cogent arguments, this matter is somethingthat has immense political clout. Matters are not being helped by let thisissue simmer. We need decisive action. Why can't the College commission a working group, representing all sides of this debate and issue a consensusstatement which will help the believers and non-believers equally to navigate through what appears not so much a moral conundrum but political posturing. When I am hauled before the GMC by a patient for inviting (and encouraging with his 'consent')him to give up his faith and join me as a fellow God-less person, where will the guidance come from?

It appears that the inequality of power in a doctor-patient relationship has been forgotten in the heat of this debate. God help me and my fellow confused brethren. Looks like we have been hit for a 'Six'.

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Conflict of interest: SPS is a member of the College's SCPPE and past member of College's Ethics Committee

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