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I am interested, although not surprised, to hear that Professor Poole thinks that my suggestion that a significant prospective study of religion and completed suicide 1 might have implications for British clinical practice is ‘profoundly misguided’. It is true that the study in question emanates from the USA, not the UK, but Poole concedes that a study undertaken here ‘would be likely to yield similar findings’. Nor did I have space to expand in any detail upon exactly how the matters in question might be discussed with patients, but I did cite Koenig et al 2 as urging caution with regard to any religious/spiritual interventions that might be contemplated. I am therefore surprised that Poole found necessary to emphasise the dangers of proselytism, as though I might have been opening the door to this, especially given that he notes that I wrote the College Position Statement that clearly states ‘Psychiatrists should not use their professional position for proselytising or undermining faith’. 3

Poole, in turn, does not expand upon his side of the ‘serious difference of opinion’ between us over ‘bringing religion into the clinical setting’. Presumably, he does not mean that religion may never under any circumstances be discussed with patients. But if we have reason to believe that religion might be one factor which influences the likelihood of completed suicide, is it not, as I suggested, ‘wise to take religion into account when assessing suicidal risk’? Some patients will raise the subject themselves and this study suggests that we should at least not discourage them from doing so. In other cases, should we not enquire about spiritual/religious beliefs that might contribute to a fuller understanding of a patient’s self-understanding?

My chaplaincy colleagues working in NHS mental health services tell me that ‘Will I go to hell if I kill myself?’ is one of the questions most frequently asked. Might referral to a suitably qualified mental health chaplain sometimes be a helpful intervention for some religious patients who have not previously felt able to discuss the matter with anyone else? And why do we not have more research on how patients deal with this question, and how we might help them to deal with it in a constructive way?

I certainly do think that the study by Kleiman and Lui has implications for British clinical practice. I think that we should be debating - in this journal and elsewhere - exactly what these implications are, and conducting research in order to provide an evidence base that will better define them. Happily, as Poole has indicated, he and I do at least find common ground for research which might clarify some of the boundary issues. But boundaries must not be created that will prevent us from sensitively and respectfully discussing spirituality and religion with our patients when it is clinically relevant to do so.

References

1 Kleiman, EM, Liu, RT. Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor. Br J Psychiatry 2014; 204: 262–6.
2 Koenig, HG, King, DE, Carson, VB. Handbook of Religion and Health (2nd edn). Oxford University Press, 2012.
3 Cook, CCH. Recommendations for Psychiatrists on Spirituality and Religion (Position Statement PS03/2013). Royal College of Psychiatrists, 2013.