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Aims and method Calls for the integration of spirituality into psychiatric practice have raised concerns about boundary violations. We sought to develop a method to capture psychiatrists’ attitudes to professional boundaries and spirituality, explore consensus and understand what factors are considered. Case vignettes were developed, tested and refined. Three vignettes were presented to 80 mental health professionals (53% said they were psychiatrists; 39% did not identify their professional status). Participants recorded their reactions to the vignettes. Four researchers categorised these as identifying boundary violations or not and analysed the factors considered. Results In 90% of cases, at least three of the four researchers agreed on classification (boundary violation; possible boundary violation; no boundary violation). Participants’ opinion about boundary violations was heterogeneous. There was consensus that psychiatrists should not proselytise in clinical settings. Reasoning emphasised pragmatic concerns. Few participants mentioned their religious beliefs. Equivocation was common. Clinical implications Mental health professionals seem unsure about professional boundaries concerning religion and spirituality in psychiatric practice.

Summary This article uses three fictitious case vignettes to raise questions and educate on how clinicians can appropriately approach patients experiencing spiritually significant hallucinations. Religious hallucinations are common but are not pathognomonic of mental illness. They are often intimate experiences for the patient that raise complex questions about psychopathology for clinicians. When assessing a patient with religious hallucinations it is important that clinicians hold at the centre that person's personal experience and create a safe space in which they are listened to and epistemic injustices are avoided. Involvement of chaplaincy services is important not just to support the patient but also to ensure that as clinicians we seek support in understanding the religious nature of these experiences.