King & Leavey ^{Reference King and Leavey1} offer some helpful reflections on Charles Taylor's A Secular Age, ^{Reference Taylor2} as a basis for better understanding the relationship between spirituality and psychiatry. In A Secular Age, Taylor, a leading philosopher and Templeton Prize winner, charts the currents by which we may understand secularity to have become what it is in Western society today. However, King & Leavey interpret his sophisticated, lengthy and nuanced account in such a way as to make it appear that transcendence has been lost forever and that spirituality is left with a limited sphere of legitimacy, confined largely to finding meaning in life. Their conclusions about its significance for psychiatric practice are accordingly limited and ambiguous.

Secularity

Taylor clarifies early in his book the different possible meanings of the word ‘secularity’. He focuses his attention on one of these, the way in which religious belief has become for us just one option among many, a state of affairs almost completely unknown to pre-modern societies. Many people assume that this is simply due to the rise of science in such a way as to leave superstitious and religious thought without plausible basis, thus allowing ‘secular’ ways of thinking to flourish in their place. Taylor argues that this hypothesis actually does not stand up to scrutiny. In its place he puts a much richer account which demonstrates that secularity has arisen from within Christian religious ways of thought, but that it is now associated with restrictive ‘closed world structures’ which make disbelief in God appear more incontrovertible than it really is.

Transcendence

Initially, Taylor identifies the concept of transcendence with that of religion. However, he later identifies a ‘nova effect’ which has given rise to an ‘ever widening variety of moral/spiritual options’ (p. 299) in the face of threatened loss of meaning. This nova effect makes available alternative understandings of transcendence alongside traditional religious options. It is therefore difficult to reconcile King & Leavey's view that transcendence ‘has largely been lost’ with Taylor's account. In fact, King & Leavey appear to be adopting just the kind of ‘closed world structure’ which Taylor identifies as placing hidden restrictions on the range of options for belief that are open to us.

Whereas the humanist view eschews religion, pace King & Leavey, the humanist does not necessarily eschew spirituality. It is true that the definition of spirituality is open to much debate, ^{Reference Cook3} and it might be argued that some understandings of it are very far from traditional religious views of transcendence. However, a balanced account of contemporary notions of spirituality cannot dismiss the views of those who affirm that they are both humanist and spiritual. Neither is a primarily immanent worldview necessarily incompatible with spirituality. In fact, spirituality is associated with conceptions of immanence, as well as conceptions of transcendence (and Christianity has historically affirmed both kinds of spirituality). ^{Reference Mackey4} Even if transcendence were as rare on the ground today as King & Leavey suggest, this would not necessarily imply a lack of spirituality in our age.

Prayer

Neither do King & Leavey appear to adequately understand the traditional religious options. When they suggest that a priest will only be likely to provide more psychotherapy and not ‘get down on bended knee to seek a solely divine solution’, this does not do justice either to the findings of their own research, ^{Reference Leavey, Loewenthal and King5} or the actuality of contemporary religious practice (whether or not it is in the minority within a ‘secular’ society) in the West today. ^{Reference Lewis, Breslin and Dein6} Belief in the importance and power of prayer is both more widespread and more complex than they appear to understand. It has never been the norm that Christians relied ‘solely’ on a ‘divine solution’ in response to their prayers. ^{Reference King and Leavey1} The origins of healthcare in Western society are deeply embedded in a Christian tradition of taking practical action to care for the sick, as well as to pray for them.

Meaning

King & Leavey appear to leave the door open for at least one possible understanding of spirituality, that of a search for meaning. However, Taylor argues strongly that any idea that meaning can be affirmed in a general way, devoid of specific content, is foolish:

This leaves, then, the question of what the meaning might be that is worth living and dying for, and this takes us back to notions of spirituality which are often (albeit not always) associated with transcendence. A Secular Age might be taken (and by this reader it is taken) as affirming the place of transcendence in our secular age and of challenging the closed world structures that appear to deny its continuing plausibility.

Psychiatric practice

Psychiatry and psychotherapy have emerged in a disenchanted world. However, King & Leavey are incorrect in asserting that disenchantment has shed ‘the “enchantment” of spirituality’. Disenchantment, according to Taylor, is about emergence of a world in which ‘the only locus of thoughts, feelings, spiritual élan is what we call minds…and minds are bounded, so that these thoughts, feelings, etc, are situated “within” them’ (p. 30). In other words, the spirituality of our world is not generally associated with a medieval understanding of demons and spirits as external forces, but rather resides within each of us. This being the case, it is difficult to see how spirituality can helpfully or justifiably be separated from the business of psychological therapies.

King & Leavey dismiss a huge body of research on spirituality and religion with a single reference that is now 10 years old. ^{Reference Sloan, Bagiella and Powell7} Both the quantity and quality of research in this field have expanded considerably since then. It is true that there are dangers in a utilitarian approach, which sees spirituality as merely another commodity to improve health, ^{Reference Shuman and Meador8} but this does not change the empirical evidence associating spirituality/religion with lower morbidity and better outcomes for a whole range of physical and mental disorders. ^{Reference Huguelet and Koenig9-Reference Cook, Powell and Sims11}

What, then, would the practice of psychiatry look like if spirituality took an integral part within it? Based upon the now extensive empirical literature, and the contemporary context as described in A Secular Age, I would suggest the following.

1. 1 Spirituality and religion would be routine aspects of assessment, as has been urged over a period of at least two decades by the Royal College of Psychiatrists' Presidents ^{Reference Casey12,Reference Cox13} and others, ^{Reference Sims14,Reference Culliford, Eagger, Cook, Powell and Sims15} including Harold Koenig. ¹⁶

2. 2 Spiritual practices would be affirmed and better understood by psychiatrists as valuable coping resources, which may well have secondary empirical benefits for mental health as well as primary benefits for spiritual well-being (a concept which is in any case inseparable from mental well-being).

3. 3 Clergy, chaplains and other trained members of faith communities would be more integrally involved, where relevant and with patients' permission, in the process of understanding mental disorder within the framework of different spiritual traditions. This may, or may not, also involve offering prayer and other spiritual practices alongside conventional medical treatment.

All of this is much along the lines that Koenig urged in his editorial, ¹⁶ which leaves the simple question that King & Leavey pose, ‘Why all the fuss?’

Andrew Sims, in his address to the College in 1993, ^{Reference Casey12} suggested that psychiatrists ignore the spiritual because they consider it unimportant or irrelevant, because they know little about it, or are embarrassed by it, or else because they consider it too personally challenging. The growing literature gives increasingly little excuse for ignorance and belies imputations of unimportance or irrelevance. Interestingly, this leaves us with a matter of importance and relevance that patients wish to discuss but which psychiatrists apparently find too embarrassing or too challenging. Perhaps this is the kind of thing that might be expected when the unacknowledged closed world structures of a secular age are challenged. What would seem clear is that it is not a good basis for clinical practice in such an age.