Holistic psychiatry

David Crossley's paper on the self and holistic care¹ is timely in the context of the heated debate over the place of spirituality and religion in clinical practice. In a commentary on this paper, one of us (C.C.H.C.) raised the difficult matter of challenging unhealthy spiritual/religious beliefs.² In the course of making a point about the difficulties this entails, reference was made to a letter from a previously published correspondence between us,³ suggesting that one possible response might be to argue that ‘matters such as religion and spirituality should be excluded from all clinical practice’. This gave the unfortunate impression that the authors of that letter had taken this position. We would collectively like to correct this.

We are agreed that it would be impossible to completely exclude consideration of religion and spirituality from all aspects of clinical practice. Psychopathology often has religious content, and it can be important to understand the role of religion and spirituality in an individual patient's life. We are agreed that it is sometimes appropriate to involve chaplains and other religious advisors in helping people who have mental health problems. We are agreed that psychiatry cannot offer total solutions to mental illness and human unhappiness, and that in practice psychiatry is the application of a flawed science in the context of shared (but sometimes contended) professional values.

However, there are important differences between us as to best practice, and as to the proper approach to spirituality and religion when working with patients. Our fundamental disagreement concerns the extent to which it is appropriate or possible for psychiatrists to offer holistic care to patients, spirituality and religion being one important aspect of this.

C.C.H.C. believes that spirituality should routinely be considered as an important aspect of clinical practice, even where the patient does not directly raise it for discussion, and that a spiritual dimension to treatment renders it more meaningful and possibly more effective. He recognises that this creates real and complex challenges with regard to professional boundaries. However, he believes that the special expertise offered by psychiatry is at its best when actively engaged with a holistic perspective and that it is in such engagement that it becomes more apparent that psychiatry does not have all the answers. In this way, boundary issues are highlighted and the ensuing debate offers opportunities to reduce confusion and clarify good practice.⁴

R.P. and R.H. believe that the concept of holistic care takes psychiatrists out of a domain where they have special expertise and that ‘holism’ undermines the important role of other agencies and individuals in helping people with mental illness by implying that psychiatrists have all the answers.⁵ They believe that holistic care invites serious boundary breaches because it creates intrinsic confusion as to appropriate professional behaviour and the limitations of psychiatric expertise.

So far, this debate has been polarised and somewhat abstract. It would not be helpful to deny our differences, but we share an aspiration to understand the centre of gravity of professional and service user opinion on this matter by reference to tangible dilemmas in real-life practice.