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© 2010 by The Johns Hopkins University Press

Religious Beliefs and Psychiatric

Beliefs: Worlds Apart and

Perhaps Best Left That Way

Mona Gupta

Keywords: epistemology, ethics, involuntary treatment, patient-centered practice, religion

“R eligious Experience and Psy- chiatry: Analysis of the Conflict and Proposal for a Way Forward”

is a compelling paper that challenges our moral intuitions—and self-perceptions—about the inter- section of religious beliefs, culture, and psychiatric diagnosis. Rashed presents a case history of Femi, a 29-year-old British man of West African descent who had had an intense religious experience of being in direct contact with God. This spiritual revelation resulted in his social isolation, fasting, and purging of material possessions. Using Femi’s story, Rashed illustrates that, although we may want to think of ourselves as tolerant of a variety of cultural and religious belief systems, when these differences come up against mainstream social and medical belief systems, we may not be so gener- ous. Rashed also makes the subtler point that even well-motivated attempts to care for patients sensitively, using devices such as the DSM-IV’s

‘cultural criterion,’ may result in harm to patients by stripping away the meaningfulness of specific experiences. Rashed argues that diagnosing Femi’s religious experience as an acute psychotic episode transformed a positive existential moment into one of shame and sickness. Rather than adopting medi- cal language, and indeed a medical framework to approach patients, Rashed asks psychiatrists to find common ground with patients by negotiat- ing linguistic, moral, and explanatory terrain to describe subjective experiences. In this regard, his proposal is a more substantive and demanding version of patient-centered practice.

Although Rashed is appropriately attuned to patients’ values, language, and epistemologies, one is left wondering where practitioners’ values, languages, and epistemologies fit in to his pro- posal for an “open-ended process of communica- tion” with patients (2010, 185). The issue he is highlighting in the case history is that, “different languages and their associated values are adopted by the involved parties to attend to the problem” (Rashed 2010, 200). His proposal: “A way out of this crisis is for all parties to engage in a process of

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communication that involves an attempt to modify the language they use to talk about the problem” (Rashed 2010, 200). However, what he means is that practitioners ought to “adopt the patient’s own language, and frame the problem in terms that would meet her approval” (Rashed 2010, 200). Although patients’ values must dictate the choices about possible solutions to the presenting problem, it is unclear why prioritizing patients’ languages and epistemologies must occur. In de- scribing the clinical course of Femi’s case, Rashed points out that, “The psychiatrist and the social worker who did the mental health act assessment on Femi simply did not believe him” (2010, 198). Do they have to believe him? If so, why?

Health care professionals come by their episte- mologies and linguistic practices, at least in part, as a result of their training. A shared explanatory framework for the kinds of problems that each professional group tends to deal with is a funda- mental part of the group’s identity. There is room for debate about epistemology, but participants in these debates are generally committed to one or the other version and such commitments inform their clinical work. For example, psychiatrists adopting a women’s mental health perspective may differ from colleagues adhering to standard psychiatric theory by arguing that women’s depression is more a result of their marginalized social position rela- tive to men rather than defective neurophysiology. This explanatory difference may motivate feminist psychiatrists and psychotherapists to urge women to view their problems as resulting from systemic discrimination rather than individual conflicts and to work for social change. The commitment to the explanatory framework informs the clinical treat- ment and, as such, the commitment is essential to the clinical service being offered.

Epistemological commitments also inform clini- cal ethics. The interpretation and application of specific ethical principles and duties are tied to a profession’s epistemology. For example, in trying to execute the principle ‘do no harm,’ a practitio- ner is trying to offer patients medical care based on his/her best understanding of what is wrong (usu- ally a pathophysiological explanation) and how it can be treated. Indeed, we want practitioners to recommend treatments on the basis of what they

honestly believe is most likely to help patients. Do we really want physicians to be willing to recommend treatments they do not believe will help—such as attending a spiritual advisor—in the service of finding common linguistic ground with patients? When Rashed proposes that practitioners negotiate the language to describe patients’ experi- ences, one wonders if this opens up the potential for abandoning not only one’s epistemology, but the ethical duties that flow from it.

I doubt this is what Rashed intends. The harms that he identified as being done to Femi (restricting his physical freedom through involuntary hospital- ization, and stripping him of the meaningfulness of his experience by diagnosing an acute psychotic episode) resulted from the fact that Femi had no choice but to accept the psychiatrist’s interpreta- tion of events as he was involuntarily hospitalized and treated. Let us re-examine Femi’s case, imagin- ing that there were no legal powers to involuntarily hospitalize and treat patients. Presumably, the psychiatrist and the social worker would have recommended one course of action, Femi would have disagreed, he would have left the assessment, and that would have been the end of it. Under these circumstances, both the mental health staff and the patient would have retained their own language and explanations of what was happening. To be sure, they would have disagreed, but the patient’s values would have prevailed and he would have opted to disregard the staff’s interpretation and treatment recommendations. If this had been the case, none of the harms Rashed mentions would have been done. It seems that what the author is really objecting to are the legal powers retained by psychiatrists in many jurisdictions to involuntarily detain and treat patients that, when executed, necessarily impose psychiatric values, language, and epistemology on patients. Rashed is right to be concerned about the execution of these powers and the ways in which they can be misused.

Despite the potential for harm, Rashed allows that there are times when involuntary detention and/or treatment may be necessary: when there is grave risk of harm to self and when the attempt to find common linguistic grounds fails. He notes that in such cases an appeal to an independent, third party on moral grounds may be required

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to protect an individual at risk of killing him- or herself. The moral grounds to which I think he is alluding include society’s interest in valuing each individual’s life, and as a result, erring on the side of preserving life even in circumstances where the individual is refusing life-preserving interventions.

It seems then, that the solution least likely to result in the harms Rashed is worried about—the imposition of values, language, and epistemologies on patients—is to place a premium on patient au- tonomy and stringently limit psychiatrists’ powers to involuntarily hospitalize and treat. This is the model we have in most provincial jurisdictions in Canada. It has its own flaws, but seems to achieve Rashed’s aims without asking practitio- ners to do what we might not want them to do, and what might be impossible anyway: to be in a constant state of negotiation about the explana-

tory framework they use to understand patients’ problems, potentially compromising the ethical responsibilities that result from this framework. Do psychiatrists need to think more deeply and critically about their epistemological stance? Yes. Is Rashed correct to push psychiatrists harder to understand and accommodate the world views of their patients? Yes. But his proposal to achieve these accommodations, may lead us to forget that practitioners, like patients, have good reasons for having certain values, linguistic practices, and epistemologies and it might not be in patients’ interests to set these aside too easily.

Reference Rashed, M. 2010. Religious experience and psychia-

try: Analysis of the conflict and proposal for a way forward. Philosophy, Psychiatry, & Psychology 17, no. 3:185–204.