The debate between Professors Poole and Cook ^{Reference Poole and Cook1} focuses on what might be termed an epiphenomenon of faith. Poole in particular avoids any interpretation of the values he espouses for psychiatry as a belief system. In my view, this is fundamentally erroneous. The set of principles avowed by Poole find their origin in both Greek philosophy and in the Judaeo-Christian system of ethics. These are essentially systems of beliefs and in that sense, particularly for the secularist, are no different from 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 Poole would take the position that psychiatrists should practise using ‘evidence-based’ techniques and therapies. If one is to take cognitive therapies as an example of this, problems of belief immediately arise, as a primary 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 the Alcoholics Anonymous programme. Would 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 in the 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 be of benefit when progress is slow, and that this faith in the future is a key element in their success. If the argument that faith is a fundamental part of 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 be considered as being more problematic and potentially dangerous. In a broad sense, depressive disorders may be considered to reflect a deficit of faith, whereas 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 in their debate 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 damaging without recourse to argument, but others may be appropriate only in certain situations. 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 programme which can only be justified in very particular circumstances. It should be accepted that there are occasions when its use is appropriate and therapeutic. Nonetheless, because of its controversial nature, and the possibility of abuse by both therapist and patient, prayer should be considered an unusual therapeutic modality. The therapist should therefore be prepared to justify its use on a case-by-case basis and be able to demonstrate that no harm was likely to arise.