Roots of the
Religious or Spiritual Problem is a new diagnostic category
(Code V62.89) in the Diagnostic and Statistical Manual-Fourth
Edition (APA, 1994). While the acceptance of this new
category was based on a proposal documenting the extensive
literature on the frequent occurrence of religious and spiritual
issues in clinical practice, the impetus for the proposal came
from transpersonal clinicians whose initial focus was on
spiritual emergencies--forms of distress associated with spiritual
practices and experiences. The proposal grew out of the work of
the Spiritual Emergence Network to increase the competence of
mental health professionals in sensitivity to such spiritual
issues. This article describes the rationale for this new category,
the history of the proposal, transpersonal perspectives on
spiritual emergency, types of religious and spiritual problems
(with case illustrations), differential diagnostic issues,
psychotherapeutic approaches, and the likely increase in
number of persons seeking therapy for spiritual problems. It
also presents the preliminary findings from a database of
religious and spiritual problems.
"Religious or Spiritual Problem" is a new diagnostic category
(Code V62.89) in the Diagnostic and Statistical Manual-Fourth
Edition (APA, 1994). The Thesaurus of Psychological Index
Terms (Walker, 1991) states that religiosity "is associated with
religious organizations and religious personnel" (p. 184)
whereas spirituality refers to the "degree of involvement or
state of awareness or devotion to a higher being or life
philosophy. Not always related to conventional religious
beliefs" (p. 208). Thus religious problems involve a person's
conflicts over the beliefs, practices, rituals and experiences
related to a religious institution. Some forms of spirituality
presume no external divine or transcendent forces (e.g.,
humanistic-phenomenological spirituality) (Elkins, Hedstrom,
Hughes, Leaf, and Saunders,1988), and spiritual problems
involve distress associated with a person's relationship to a
higher power or transcendent force that is not related to a
While the acceptance of this new category was based on a
proposal documenting the extensive literature on the frequent
occurrence of religious and spiritual issues in clinical practice,
the impetus for the proposal came from transpersonal clinicians
whose initial focus was on spiritual emergencies--forms of
distress associated with spiritual practices and experiences. The
proposal grew out of the work of the Spiritual Emergence
Network (Prevatt and Park, 1989) to increase the competence of
mental health professionals in sensitivity to such spiritual
issues. This article describes the rationale for this new category,
the history of the proposal that was presented to the Task Force
on DSM-IV, transpersonal perspectives on spiritual emergency,
types of spiritual problems (with case illustrations), differential
diagnostic issues, therapeutic approaches for spiritual problems,
and the likely increase in number of persons seeking therapy for
Rationale For A New Diagnostic
Prevalence of Religious and Spiritual Problems
In a survey of APA member psychologists, 60% reported that
clients often expressed their personal experiences in religious
language, and that at least 1 in 6 of their patients presented
issues which directly involve religion or spirituality (Shafranske
& Maloney, 1990). Another study of psychologists found 72%
indicating that they had at some time addressed religious or
spiritual issues in treatment (Lannert, 1991). In a sample that
included psychologists, psychiatrists, social workers, and
marriage and family therapists, 29% agreed that religious issues
are important in the treatment of all or many of their clients
(Bergin & Jensen, 1990). Anderson and Young (1988) claim
that: "All clinicians inevitably face the challenge of treating
patients with religious troubles and preoccupations" (p. 532).
While little is known about the prevalence of specific types of
religious and spiritual problems in treatment, these surveys
demonstrate that religious and spiritual issues are often
addressed in psychotherapy.
Lack of Training in Religious and Spiritual Issues
In a survey of Association of Psychology Internship Centers
training directors, 83% reported that discussions of religious
and spiritual issues in training occurred rarely or never. One
hundred per cent indicated they had received no education or
training in religious or spiritual issues during their formal
internship. Most of the training directors did not read
professional literature addressing religious and spiritual issues
in treatment, and they stated that little was being done at their
internship sites to address these issues in clinical training
(Lannert, 1991). A national study of APA member
psychologists found that 85% reported rarely or never having
discussed religion and spiritual issues during their own training
(Shafranske & Maloney, 1990). Similar findings from other
surveys suggest that this lack of training is the norm throughout
the mental health professions (Sansone, Khatain &
Ethical Mandate To Provide Training
According to the Ethical Principles of Psychologists and Code
of Conduct (American Psychological Association, 1992),
psychologists have an ethical responsibility to be aware of
social and cultural factors which may affect assessment and
treatment (Canter, Bennet, Jones & Nagy, 1994). Since the
religious and spiritual dimensions of culture are among the
most important factors that structure human experience, beliefs,
values, behavior as well as illness patterns (James, 1958;
Krippner & Welch, 1992), sensitivity to religious and spiritual
issues is an important part of the cultural diversity competence
of psychologists. Certain issues in differential diagnosis require
knowledge of the patient's religious subgroup (Lovinger, 1984)
and/or the nature of acceptable expressions of subculturally
validated forms of religious expression. For example,
discussing one of the cases in the DSM-III-R Casebook,
Spitzer, Gibbon & Skodol (1989) noted that, "The central
question in the differential diagnosis in this case is whether or
not the visions, voices, unusual beliefs, and bizarre behavior are
symptoms of a true psychotic disorder...[or] Can this woman's
unusual perceptual experiences and strange notions be entirely
accounted for by her religious beliefs?" (pp. 245-6). Similarly,
distinguishing between a spiritual problem and
psychopathology requires knowledge about spiritual beliefs,
practices and their effects (Lukoff, 1985).
In the training of psychiatrists, such preparation is now required
by the Accreditation Council for Graduate Medical Education.
Their "Special Requirements for Residency Training in
Psychiatry" published in 1995 mandates instruction about
gender, ethnicity, sexual orientation, and religious/spiritual
beliefs in accredited residency training programs. Psychologists
are also required to be aware of their need for training (Canter
et al., 1994). Unfortunately, the current APA accreditation
guidelines for graduate training programs and internships do not
directly address competency in addressing religious and
spiritual diversity, despite indications that the training of
psychologists is inadequate in this area (Lannert, 1991).
Psychologists are also required to provide services only within
their boundaries of competence (Canter et al., 1994). The
surveys reviewed above show that psychologists are very likely
to work with the religious and spiritual issues of their clients.
Yet their lack of training in the assessment and treatment of
religious and spiritual problems may lead to insensitivity and/or
counter-transference issues that interfere with their ability to
understand and explore their clients' issues. (Meyer, 1988;
Shafranske & Gorsuch, 1984; Strommen, 1984) ). In addition,
there are unique ethical issues involved in working with
spiritual problems, especially those that involve altered states of
consciousness (Taylor, 1995). Ignorance, countertransference,
and lack of skill can impede the untrained psychologist's ethical
provision of therapeutic services to clients who present with
History of the Proposal for Religious or Spiritual
The initial impetus for this proposal came from the Spiritual
Emergence Network (then called the Spiritual Emergency
Network) which was concerned with the mental health system's
pathologizing approach to intense spiritual crises. The auhtors
decided to propose a new diagnostic category for the
then-in-development DSM-IV as the most effective way to
increase the sensitivity fo mental health professionals to
spiritual issues in therapy. A previous article in the Journal of
Transpersonal Psychology (Lukoff, 1985) had proposed a new
diagnostic category entitled Mystical Experience with Psychotic
Features (MEPF) for intense spiritual experiences that present
as psychotic-like episodes. An analogy was drawn between
MEPF and the DSM-III-R category of Uncomplicated
Bereavement, which is a V Code--a condition not attributable
to a mental disorder. The definition for this category notes that
even when the period of bereavement following a significant
loss meets the diagnostic criteria for Major Depression, this
diagnosis is not given because the symptoms result from "a
normal reaction to the death of a loved one" (p. 361). Similarly,
individuals in the midst of a tumultuous spiritual experience (a
"spiritual emergency") may appear to have a mental disorder if
viewed out of context, but are actually undergoing a "normal
reaction" which warrants a non-pathological diagnosis (i.e., a V
Code for a condition not attributable to a mental disorder)
Following this precedent of bereavement in DSM-III-R of a
nonpathological category for a distressing and disruptive
experience, we notified the American Psychiatric Association's
Task Force on DSM-IV in early 1991 of our intention to submit
a propoosal for a new V Code category entitled
"Psychospiritual Conflict." We contacted other experts in the
field, including several members of APA's Division 36
(Psychology of Religion), to obtain their support and
suggestions for relevant research and case studies. We also
conducted several literature searches on PsychINFO, Medline
and Religion Index to obtain references to clinical and research
literature (Lukoff, Turner & Lu, 1992; Lukoff, Turner & Lu,
1993). At the 1991 and 1992 Association for Transpersonal
Psychology Conferences, we presented our ideas for the new
category and received useful suggestions from other
transpersonally-oriented psychologists and psychiatrists.
As the proposal evolved, we substituted "problem" for
"conflict" to be more in line with the terminology employed in
the V Code section of DSM-III-R (e.g., Parent-Child Problem,
Phase of Life Problem). To obtain greater support for the
proposal and to acknowledge the many areas of overlap
between spirituality and religion, we expanded our proposal to
include both psychospiritual and psychoreligious problems. The
literature review established the most prevalent and clinically
significant problems within each category, enabling us to arrive
at the following definition for a proposed V Code:
Psychoreligious problems are experiences that a
person finds troubling or distressing and that
involve the beliefs and practices of an organized
church or religious institution. Examples include
loss or questioning of a firmly held faith, change in
denominational membership, conversion to a new
faith, and intensification of adherence to religious
practices and orthodoxy. Psychospiritual problems
are experiences that a person finds troubling or
distressing and that involve that person's
relationship with a transcendent being or force.
These problems are not necessarily related to the
beliefs and practices of an organized church or
religious institution. Examples include near-death
experience and mystical experience. This category
can be used when the focus of treatment or
diagnosis is a psychoreligious or psychospiritual
problem that is not attributable to a mental
In December 1991, the proposal for Psychoreligious or
Psychospiritual Problem was formally submitted to the Task
Force on DSM-IV. The proposal stressed the need for this new
diagnosis to improve the cultural sensitivity of the DSM-IV
since this was one of the priorities established for the revision
(Frances, First, Widiger, Miele, Tilly, David, & Pincus, 1991),
and also argued that the adoption of this new category would
result in the following benefits: 1) increasing the accuracy of
diagnostic assessments when religious and spiritual issues are
involved; 2) reducing the occurrence of iatrogenic harm from
misdiagnosis of religious and spiritual problems; 3) improving
treatment of such problems by stimulating clinical research; and
4) improving treatment of such problems by encouraging
training centers to address religious and spiritual issues in their
programs. Support for the proposal was obtained from the
American Psychiatric Association Committee on Religion and
Psychiatry and the NIMH Workgroup on Culture and
Diagnosis. The proposal in its entirety was published in the
Journal of Nervous and Mental Disease (Lukoff, Lu & Turner,
1992). In January 1993, the Task Force accepted the proposal
but changed the title to "Religious or Spiritual Problem" and
shortened and modified the definition to read:
This category can be used when the focus of
clinical attention is a religious or spiritual problem.
Examples include distressing experiences that
involve loss or questioning of faith, problems
associated with conversion to a new faith, or
questioning of other spiritual values which may not
necessarily be related to an organized church or
religious institution. (American Psychiatric
Association, 1994, p. 685)
Articles on this new category appeared in The New York Times
(Steinfels, 1994), San Francisco Chronicle (Lattin, 1994),
Psychiatric News (McIntyre, 1994), and the APA Monitor
(Sleek, 1994) where it was described as indicating an important
shift in the mental health profession's stance toward religion
and spirituality. What did not receive attention in the media is
that this new diagnostic category has its roots in the
transpersonal movement's attention to spiritual emergencies.
Transpersonal Perspectives on Spiritual
Assagioli (1989), in his seminal paper, "Self-Realization and
Psychological Disturbances," noted the association between
spiritual practices and psychological problems. For example,
persons may become inflated and grandiose as a result of
intense spiritual experiences: "Instances of such confusion are
not uncommon among people who become dazzled by contact
with truths too great or energies too powerful for their mental
capacities to grasp and their personality to assimilate" (p. 36).
Stanislav and Christina Grof coined the term "spiritual
emergency" and founded the Spiritual Emergency Network
(Prevatt & Park, 1989) in 1980 to identify a variety of
psychological difficulties, particularly those associated with
Asian spiritual practices that entered the West starting in the
1960's. They define spiritual emergencies as:
crises when the process of growth and change
becomes chaotic and overwhelming. Individuals
experiencing such episodes may feel that their
sense of identity is breaking down, that their old
values no longer hold true, and that the very ground
beneath their personal realities is radically shifting.
In many cases, new realms of mystical and spiritual
experience enter their lives suddenly and
dramatically, resulting in fear and confusion. They
may feel tremendous anxiety, have difficulty
coping with their daily lives, jobs, and
relationships, and may even fear for their own
sanity (Grof & Grof, 1989, back cover)
Grof and Grof (1989) note that "Episodes of this kind have
been described in sacred literature of all ages as a result of
meditative practices and as signposts of the mystical path" (p.
x). They have described the more common presentations
including: mystical experiences, kundalini awakening (a
complex physio-psychospiritual transformative process
observed in the Yogic tradition) (Greenwell, 1990), shamanistic
initiatory crisis (a rite of passage for shamans-to-be in
indigenous cultures, commonly involving physical illness
and/or psychological crisis) (Lukoff, 1991; Silverman, 1967),
possession states (Lukoff, 1993) and psychic opening (the
sudden occurrence of paranormal experiences) (Armstrong,
1989). Their list of types has expanded from an initial typology
of 8 to currently some 12 types, although in actual clinical
practice there is often overlap between these types. A
distinguishing characteristic of spiritual emergencies is that
despite the distress, they can have very beneficial
transformative effects on individuals who experience them.
Several types of spiritual emergency are illustrated below. The
diagnostic formulation of Psychospiritual Conflict in the initial
development of the proposal for a new category was
specifically intended to be inclusive of persons undergoing
Case Study Database on Religious and
While there is limited psychological theory that is useful in
understanding spiritual problems, there is an extensive
knowledgebase that has developed at the case level. Kazdin
(1982) has observed that, "Although each case is studied
individually, the information is accumulated to identify more
general relationships" (p. 8). Bromley (1986) likens this to the
building up of case-law in jurisprudence, which
provides rules, generalizations and categories
which gradually systematize the knowledge (facts
and theories) gained from the intensive study of
individual cases. Case-law (theory, in effect)
emerges through a process of conceptual
refinement as successive cases are considered in
relation to each other. (p.2)
Despite the disrepute in which case studies are generally held
(i.e., case study methods are rarely taught in the research
methods courses in graduate psychology programs), they are
still a primary mode of transmitting knowledge (Hunter, 1986).
Grand rounds and intake presentations are two institutionalized
forms by which health professionals disseminate the latest
understandings and make links between the generalized
abstractions of diagnostic categories and a particular patient. In
addition, case studies play a significant role in advancing
knowledge by focusing on anomalies that highlight
inadequacies in understanding, diagnosis and treatment
(Churchill & Churchill, 1982). Case study findings have played
a pivotal role in the evolution of academic psychology and
particularly psychotherapy (Edwards, 1991; Kazdin, 1982). In
transpersonal psychology (Boorstein, 1980; Chinen, 1988;
Lukoff, 1988b) and humanistic psychology (Bugental, 1990;
Schneider & May, 1995; Yalom, 1989) as well, published case
studies have guided the development of assessment and
Cases where a focus of therapy involves a religious or spiritual
problem are not very easy to find. A systematic analysis of case
reports involving religious or spiritual issues the Medline
bibliographic database from 1980-1996 located only 364
abstracts which addressed religious or spiritual issues in health
care. This was from a database containing 4,306,906 records
from this period (Glazer, National Library of Medicine,
personal communication, May 1997), indicating that a
shockingly low.008% of published articles in the major medical
health care database address religious and spiritual issues.
Through multiple searches on PsycINFO and Medline, over 100
cases that describe religious and spiritual problems have been
located (Lukoff et al., 1992; Lukoff et al., 1993). No claim is
made that the numbers of cases in the database shown in table 1
are representative of the prevalence of cases seen in clinical
practice. They are probably more indicative of the types of
problems that mental health professionals like to write about. In
addition, the quality of the case reports varies widely. Few use
any checks for reliability or validity (Yin, 1993). But as
Bugental (1995) has noted:
Writing about the work of psychotherapy is
challenging, apt to slide into oversimplification,
difficult to keep to a consistent level of specificity
or abstraction, and vulnerable to manipulation.
Nevertheless, it is important to bring the
experiences of our consultation rooms into our
literature and to attempt to convey the
uncommunicable, the subtle interplay between two
human beings trying to work with and improve the
life experience of one (or both?) of them. (p. 102)
Table 1. Numbers of Cases in Database
4 Change in denomination/Conversion
5 Intensification of religious belief or practice
12 Loss of faith
5 Joining or leaving a New Religious Movement or
5 Other religious problem
2 Loss of faith
4 Near-death experience
2 Mystical experience
4 Shamanistic Initiatory Crisis
2 Psychic opening
2 Past lives
2 Separating frm a spiritual teacher
2 Other spiritual problem
Combined Religious/Spiritual Problem
17 Serious illness
6 Terminal illness
Overlap of Religious/Spiritual Problem and
2 Religious/spiritual problem concurrent with
7 Religious/spiritual problem concurrent with
2 Religious/spiritual problem concurrent with mood
1 Religious/spiritual problem concurrent with
1 Religious/spiritual problem concurrent with
Types of Religious Problems
The most common examples of religious problems described in
the clinical literature include loss or questioning of faith,
change in denominational membership or conversion to a new
religion, intensification of adherence to the beliefs and practices
of one's own faith, and joining, participating or leaving a new
religious movement or cult. Usually people undergo such
changes without any significant psychological difficulty, but the
clinical literature documents cases of individuals who
experience significant distress and seek mental health
assessment and treatment for these problems. Discussions and
clinical examples of religious problems can be found in Lukoff
et al. (1992), Lukoff, Lu & Turner (1995), and Turner, Lukoff,
Barnhouse & Lu (1985). This article focuses on types of
spiritual problems, including spiritual emergencies, that have
been identified, particularly in the literature in transpersonal
psychology. Below summaries of published case studies are
used to illustrate the key differential diagnostic and treatment
issues involved in several types of spiritual problems.
Types of Spiritual Problems
Questioning of Spiritual Values The DSM-IV definition notes
that spiritual problems may be related to questioning of spiritual
values. In the clinical literature, many cases which involve a
questioning of spiritual values are triggered by an experience of
loss of a sense of spiritual connection. Barra, Carlson and
Maize (1993) conducted a survey study and also reviewed the
anthropological, historical, and contemporary perspectives on
loss as a grief-engendering phenomenon. They found that loss
of religious or spiritual connectedness,
whether in relation to traditional religious
affiliation or to a more personal search for spiritual
identity, frequently resulted in individuals
experiencing many of the feelings associated with
more "normal" loss situations. Thus, feelings of
anger and resentment, emptiness and despair,
sadness and isolation, and even relief could be seen
in individuals struggling with the loss of previously
comforting religious [or spiritual] tenets and
community identification. (p. 292)
Loss of faith is mentioned in the DSM-IV definition as a
religious problem, but as Barra et al. (1993) note, the same
sequalae can result from the loss of spiritual connection. One
case which involved questioning of spiritual values was
described by Emma Bragdon (1994).
In 1971, Emma's mother, then 56 was living alone
in a small town Vermont, and working as a visiting
nurse. She was a Zen Buddhist practicing
meditation 6-8 hours daily. Her friends noticed that
she was spending more time alone and was
becoming increasingly emotionally labile. They
contacted Emma, but she did not sense a problem
since she was having cheerful talks on the
telephone with her mother about plans for her
mother to visit during the birth of Emma's first
child. However, before this happened, Emma's
mother went into the woods alone, reading a
passage from Zen Mind, Beginner's Mind where
Suzuki Roshi compares enlightenment to physical
death. When found dead, her finger was pointing to
this passage. She had cut her wrists and throat.
In addition to the bereavement over her mother's
suicide, this loss also triggered a spiritual problem
for Emma who was herself a practicing Zen
Buddhist. How could her spiritual path lead to her
mother's suicide? Emma contacted Suzuki Roshi,
who flew with her to Vermont where he conducted
a traditional Buddhist funeral ceremony. During
this time, Emma had a number of powerful
spiritual experiences, including feeling herself
engulfed in white light accompanied by ecstatic
release. She sensed that her mother was fine, and
that her passing had been a happy occasion for her.
But afterwards, when back in California, she began
to have doubts. How did she really know her
mother was OK? As she became preoccupied with
questioning the validity of her spiritual experiences
and tenets, she also wondered if she was crazy.
When it was 10 days past her due date, she went
into her garden to pray, and made a commitment to
stop questioning her spiritual beliefs until 2 months
after giving birth. One hour later, she reports she
went into labor. (adapted from pp. 171-177)
During this period, Emma was in turmoil as she questioned her
spiritual beliefs and path. The guidance of a spiritual teacher,
Suzuki Roshi, and spiritual practices, such as praying, played
an important role in helping her to resolve these conflicts.
Asian traditions recognize a number of pitfalls associated with
intensive meditation practice, such as altered perceptions that
can be frightening, and "false enlightenment," associated with
delightful or terrifying visions (Epstein, 1990). Epstein (1990)
describes a "specific mental disorder that the Tibetans call
'sokrlung' (a disorder of the 'life-bearing wind that supports the
mind' that can arise as a consequence...of strain[ing] too tightly
in an obsessive way to achieve moment-to-moment awareness"
(p. 27). When meditative practices are transplanted into
Western contexts, the same problems can occur. Anxiety,
dissociation, depersonalization, altered perceptions, agitation,
and muscular tension have been observed in western meditation
practitioners (Bogart, 1991; Walsh & Roche, 1979). Yet Walsh
and Roche (1979) point out that "such changes are not
necessarily pathologic and may reflect in part a heightened
sensitivity" (p. 1086). The DSM-IV emphasizes the need to
distinguish between psychopathology and meditation-related
experiences: "Voluntarily induced experiences of
depersonalization or derealization form part of meditative and
trance practices that are prevalent in many religions and
cultures and should not be confused with Depersonalization
Disorder" (p. 488).
Kornfield (1993), a psychologist and experienced meditation
teacher, described what he termed a spiritual emergency that
took place at an intensive meditation retreat he was leading.
An "overzealous young karate student" decided to
meditate and not move for a full day and night.
When he got up, he was filled with explosive
energy. He strode into the middle of the dining hall
filled with 100 silent retreatants and began to yell
and practice his karate maneuvers at triple speed.
Then he screamed, "When I look at each of you, I
see behind you a whole trail of bodies showing
your past lives." As an experienced meditation
teacher, Kornfield recognized that the symptoms
were related to the meditation practice rather than
signs of a manic episode (for which they also meet
all the diagnostic criteria except duration). The
meditation community handled the situation by
stopping his meditation practice and starting him
jogging, ten miles in the morning and afternoon.
His diet was changed to include red meat, which is
thought to have a grounding effect. They got him to
take frequent hot baths and showers, and to dig in
the garden. One person was with him all the time.
After three days, he was able to sleep again and
was allowed to started meditating again, slowly and
carefully. (adapted from pp. 131-132)
The definitions of mystical experience used by researchers and
clinicians vary considerably, ranging from Neumann's (1964)
"upheaval of the total personality" to Greeley's (1974) "spiritual
force that seems to lift you out of yourself" to Scharfstein's
(1973) "everyday mysticism." A definition of mystical
experience both congruent with the major theoretical literature
and clinically applicable is as follows: the mystical experience
is a transient, extraordinary experience marked by feelings of
unity, harmonious relationship to the divine and everything in
existence, as well as euphoria, sense of noesis (access to the
hidden spiritual dimension), loss of ego functioning, alterations
in time and space perception, and the sense of lacking control
over the event (Allman, De La Roche, Elkins & Weathers,
1992; Hood, 1974; Lukoff & Lu, 1988).
Numerous surveys assessing the incidence of mystical
experience (Allman et al., 1992; Back & Bourque, 1970;
Gallup, 1987; Hood, 1974; Spilka, Hood & Gorsuch, 1985;
Thomas & Cooper, 1980) indicate that 30-40% of the
population have had mystical experiences, suggesting that they
are normal rather than pathological phenomena. While mystical
experiences are associated with lower scores on
psychopathology scales and higher psychological well-being
than controls (Greeley, 1974), case studies document instances
where mystical experiences are disruptive and distressing. This
is one type of spiritual problem that psychologists see regularly.
In a survey, psychologists reported that 4.5% of their clients
over the past 12 months brought a mystical experience into
therapy (Allman et al., 1992). In the first case below, the
mystical experience led to a spiritual problem, but not a
A woman in her early thirties sought out therapy to
deal with unresolved parental struggles and guilt
over a younger brother's psychosis. Approximately
two years into her therapy, she underwent a typical
mystical experience, including a state of ecstasy, a
sense of union with the universe, a heightened
awareness transcending space and time, and a
greater sense of meaning and purpose to her life.
For ten days, she remained in an ecstatic state. She
felt that everything in her life had led up to this
momentous experience and that all her knowledge
had become reorganized during its course. Due to
the rapid alteration in her mood and her unusual
ideation, her therapist considered diagnoses of
mania, schizophrenia, and hysteria. But he rejected
these because many aspects of her functioning were
either unchanged or improved, and overall her
experience seemed to be "more integrating than
disintegrating...While a psychiatric diagnosis
cannot be dismissed, her experience was certainly
akin to those described by great religious mystics
who have found a new life through them" (p. 806).
This experience increasingly became the focus of
her continued treatment, as she worked to integrate
the insights and attitudinal changes that followed.
The therapist reported that the most important gain
from it was a conviction that she was a worthwhile
person with worthwhile ideas, not the intrinsically
evil person, 'rotten to the core', that her mother had
convinced her she was. Her subsequent treatment
focused on expanding the insights she had gained
and on helping her to integrate the mystical
experience. (adapted from Group for the
Advancement of Psychiatry, 1976)
The second case (Lukoff & Everest, 1985) fits the spiritual
emergency model in that the mystical experience led to a crisis,
which resulted in hospitalization and medication that probably
were not necessary.
At age 19, after returning home from hitchhiking in
Mexico, Howard became convinced that he was on
a "Mental Odyssey." To his family and friends, he
began speaking in a highly metaphorical language.
For example, after returning from a simple
afternoon hike up a mountain, he announced to his
parents that "I have been through the bowels of
Hell, climbed up and out, and wandered full circles
in the wilderness. I have ascended through the
Portals of Heaven where I established my rebirth in
the earth itself, and now have taken my rightful
place in the Kingdom of Heaven." To one friend,
he stated: "I am the albatross; you are the dove."
The unusual actions and content of his speech led
his family to commit him to a psychiatric ward
where he was diagnosed with acute schizophrenia.
Once admitted to the hospital, Howard asked to see
a Jungian therapist, but this request was ignored
and he was given thorazine. While in the hospital,
he continued his self-proclaimed odyssey by
drawing elaborate "keys" that were mandalas
stocked with many well-known symbols and
cultural motifs, including the Islamic crescent and
star, the yin yang symbol, the infinity sign, and
pierced hands, eyes, and circles. In the hospital, he
also conducted elaborate self-designed "power"
rituals and rituals to the four directions, despite
being on high doses of medication. After two
months in the psychiatric hospital, his psychiatrist
wanted to transfer him to a long-term facility for
further treatment, but he refused to go and was
discharged. He left feeling totally exhausted,
physically and emotionally, but he continued
exploring the mythological, philosophical and
artistic parallels to his "Mental Odyssey." He read
works by Joseph Campbell and C. G. Jung and
joined a "New Age" religious group where he
encountered many similar motifs.
In the subsequent 24 years, he has not been
hospitalized or on medication, has held positions as
an operator of high tech video editing equipment,
and completed a college degree. When interviewed
11 years after the episode for a case study, he
maintained that, "I have gained much from this
experience. I am sorry for the worry and hurt that it
may have caused my family and friends. These
wounds have been slow to heal. I am deeply
grateful for the great victory of my odyssey. From
a state of existential nausea, my soul now knows
itself as part of the cosmos. Each year brings an
ever increasing sense of contentment." (adapted
from Lukoff and Everest, 1985, pp. 127-143)
The mystical nature of his experience is evidenced by his
euphoria, intense sense of noesis, and feeling of direct
connection to transcendent forces. He also had the several of
the prognostic signs indicating that a positive outcome would be
likely: acute onset, good pre- episode functioning, and
exploratory attitude (Lukoff, 1985). Thus he serves as an
example of how a spiritual emergency client, who in all
likelihood could have been treated on outpatient basis without
medication, was unnecessarily and inappropriately hospitalized.
Near-Death Experience (NDE)
The NDE is a subjective event experienced by persons who
come close to death, who are believed dead and unexpectedly
recover, or who confront a potentially fatal situation and escape
uninjured. It usually includes dissociation from the physical
body, strong positive affect, and transcendental experiences.
Phenomenologically, there is a characteristic temporal sequence
of stages: peace and contentment; detachment from physical
body; entering a transitional region of darkness; seeing a
brilliant light; and passing through the light into another realm
of existence) (Greyson, 1983). While only 1/3 of persons who
survive an encounter with death have this type of NDE (Ring,
1990), modern medical technology has resulted in many
persons experiencing NDEs. In 1982, Gallup estimated that
approximately 8 million American adults have had a NDE with
at least some of the features described above.
Although positive personality transformations frequently follow
a NDE, significant intrapsychic and interpersonal difficulties
may also arise (Greyson & Harris, 1987). Many individuals
report that they doubted their mental stability, and therefore did
not discuss the NDE with friends or professionals for fear of
being rejected, ridiculed, or regarded as psychotic or hysterical.
One person reported, "I've lived with this thing [NDE] for three
years and I haven't told anyone because I don't want them to
put the straightjacket on me" (Sabom & Kreutziger, 1978, p. 2).
A hospitalized patient recounted that, "I tried to tell my nurses
what had happened when I woke up, but they told me not to
talk about it, that I was just imagining things" (Moody, 1975, p.
87). Even religious professionals have not always been sensitive
to the spiritual dimensions of such experiences: "I tried to tell
my minister, but he told me I had been hallucinating, so I shut
up" (Moody, 1975, p. 86).
Fortunately, the many published scientific articles and first
person accounts have resulted in greater sensitivity to these
experiences (Basford, 1990; Kason & Degler, 1994). NDEs are
recognized as fairly common occurrences in modern ICUs, as is
the need to differentiate between ICU psychoses and NDEs,
and the importance of not "treating" NDEs with antipsychotic
medication (Greyson & Harris, 1987). In a recent publication,
Greyson (1997) described the distress associated with NDEs as
a Religious or Spiritual Problem and noted that, "The inclusion
of this new diagnostic category in the DSM-IV permits
differentiation of NDEs and similar experiences from mental
disorders and may lead to research into more effective treatment
strategies" (p. 327).
Leaving a Spiritual Teacher or Path
Persons transitioning from the "culture of embeddedness" with
their teachers into more independent functioning often seek
psychotherapeutic help (Bogart, 1992). Vaughan (1987) reports
that many individuals who have left destructive spiritual
teachers reported that the experience ultimately contributed to
their wisdom and maturity through meeting the challenge of
restoring their integrity. One such case was described by Bogart
Robert had spent 8 years as the disciple of a
teacher from an Asian tradition that emphasized
surrender and obedience. Robert had become one
of the teacher's attendants, and reported that he
"Loved the teacher very much." Yet there were
difficulties. The guru frequently embarrassed
Robert publicly, humiliating him in front of large
classes and castigating him for incompetence. He
even physically beat Robert in private. But Robert
didn't rebel and hoped that by continuing to remain
under the teacher's guidance, he might yet win
great praise, confirmation, or sponsorship from his
mentor that would enable him to advance
Robert left the community after the guru's sexual
and financial misconduct were revealed. Upon
leaving, he had intense and at times even
paralyzing feelings of betrayal, anger, fear,
worthlessness and guilt. Robert went into
psychotherapy with a spiritually sensitive therapist.
Later in psychotherapy, he realized that his
relationship with the guru replicated his
relationship with his father--an angry alcoholic who
had humiliated and physically injured Robert, but
whose approval he had nevertheless sought. He
also worked on major issues around establishing a
life outside the structure of the spiritual community
and integrating his spiritual beliefs and practices
into this new life. (adapted from pp. 4-5, 16-17)
In spiritual emergence, (another term from the transpersonal
psychology literature), there is a gradual unfoldment of spiritual
potential with minimal disruption in
psychological/social/occupational functioning, whereas in
spiritual emergency there is significant abrupt disruption in
psychological/social/occupational functioning. The Benedictine
monk, Brother David Steindl-Rast, describes the process:
"Spiritual emergence is a kind of birth pang in which you
yourself go through to a fuller life, a deeper life, in which some
areas in your life that were not yet encompassed by this fullness
of life are now integrated or called to be integrated or
challenged to be integrated" (cited in Bragdon, 1994, p. 18).
While less disruptive than spiritual emergencies, emergence can
also lead persons to seek out a therapist to help integrate their
new spiritual experiences (Grof, 1993).
Differential Diagnosis Between Mental
Disorders and Spiritual Emergencies
Making the differential diagnosis between a spiritual
emergency and psychopathology can be difficult because the
unusual experiences, behaviors and visual, auditory, olfactory
or kinesthetic perceptions characteristic of spiritual emergencies
can appear as the symptoms of mental disorders: delusions,
loosening of associations, markedly illogical thinking, or
grossly disorganized behavior. For example, the jumbled speech
of someone trying to articulate the noetic quality of a mystical
experience can appear as loose associations. Or the visions of a
NDE can appear as hallucinations. Or the need for solitude and
quiet of a person in a spiritual emergency can appear as
catatonia or depression-related withdrawal (Bragdon, 1993).
Wilber (1993) argues that the distinction between spiritual
emergencies and psychopathology hinges on the critical
distinction between pre-rational states and authentic
transpersonal states. The "pre/trans fallacy" involves confusing
these conditions, which is easy to do. "Since both prepersonal
and transpersonal are, in their own ways, nonpersonal, then
prepersonal and transpersonal tend to appear similar, even
identical, to the untutored eye" (Wilber, 1993, p. 125).
Lending further credibility to the existence of spiritual
emergency as a valid clinical phenomenon, there is considerable
overlap among the criteria proposed by different authors for
making the differential diagnosis between psychopathology and
spiritual emergencies. These constants include: 1) cognitions
and speech thematically related to spiritual traditions or to
mythology; 2) openness to exploring the experience; 3) no
conceptual disorganization (Buckley, 1981; Grof & Grof, 1989;
Lukoff, 1985; Watson, 1994). Lukoff (1985a) suggested using
good prognostic signs to help distinguish between
psychopathology and spiritual emergencies, including: 1) good
pre-episode functioning; 2) acute onset of symptoms during a
period of three months or less; 3) stressful precipitants to the
psychotic episode; and 4) a positive exploratory attitude toward
the experience. These criteria have been validated in numerous
outcome studies from psychotic episodes (reviewed in Lukoff
[1985a]), and would probably also identify individuals who are
in the midst of a spiritual emergency with psychotic features
that has a high likelihood of a positive outcome.
Spiritual Problems Concomitant With
DSM-IV Mental Disorders
All of the cases of spiritual problems described above are not
mental disorders, nor associated with co-existing mental
disorders. But clients may also present with spiritual problems
that are associated with mental disorders. The DSM-IV,
specifically notes that an individual can be diagnosed with both
a mental disorder and a related problem, as long as "the
problem is sufficiently severe to warrant independent clinical
attention" (p. 675). Thus, for example, Religious or Spiritual
Problem could be coded along with Bipolar Disorder (both on
Axis I) if the religious/spiritual content (frequently observed in
manic states [Goodwin & Jamison, 1990; Podvoll, 1990] is also
addressed during treatment of a manic episode. This greatly
expands the potential usage of this category since the symptoms
and treatment of many mental disorders include religious and
spiritual content, especially substance abuse disorders (where
the treatment frequently includes 12-step programs) and
psychotic disorders, although dissociative, mood, and obsessive
compulsive disorders often present with significant religious
and spiritual issues as well (Robinson, 1986).
Psychotherapeutic Approaches for
First it should be noted that religious and spiritual experiences
usually are not distressing to the individual and do not require
treatment of any kind. However, some spiritual conflicts do
lead persons to seek therapy. There are published cases studies
illustrating sensitive ways to conduct psychotherapy utilizing a
wide range of therapeutic approaches (e.g., psychoanalytic
[Finn & Gartner, 1992], cognitive-behavioral [Propst, 1980] ,
transpersonal [Chinen, 1988]). Rational emotive therapy is one
exception where published material consistently shows a hostile
attitude toward spirituality and religion (e.g., Ellis, 1980).
However, for spiritual emergencies, most of the models of
intervention come from the transpersonal psychology literature.
Grof and Grof (1990) recommend that the person temporarily
discontinue active inner exploration and all forms of spiritual
practice, change their diet to include more "grounding foods"
(such as red meat), become involved in very simple grounding
activities (such as gardening), engage in regular light exercise
(such as walking), and use expressive arts (such as drawing,
clay and evocative music) to allow the expression of emotions
and experiences through color, forms, sound and movement. In
the case described above, Kornfield made use of most of these
elements to avoid hospitalizing the individual who entered a
spiritual emergency during a meditation retreat. Reliance on the
client's self-healing capacities is one of the main principles that
guides transpersonal treatment of spiritual emergencies (Perry,
1974; Watson, 1994). In addition, psychologists should be
willing to consult, work closely with or even refer to spiritual
teachers who may have considerably more expertise in the
specific types of crises associated with a given spiritual practice
or tradition. Unfortunately mental health professionals rarely
consult with religious professionals or spiritual teachers even
when dealing religious and spiritual issues (Larson, Hohmann,
Kessler, Meador, Boyd, & McSherry, 1988).
Another key component of treatment of spiritual emergencies is
normalization of and education about the experience. While this
is a common technique in therapy, it plays an especially
important role with spiritual emergencies because persons in the
midst of spiritual emergencies are often afraid that the unusual
nature of their experiences indicates that they are "going crazy"
(as described in some of the above cases). An extremely
abbreviated version of normalization of an unusual spiritual
experience is reported by Jung (1964) in the following case:
I vividly recall the case of a professor who had a
sudden vision and thought he was insane. He came
to see me in a state of complete panic. I simply
took a 400-year-old book from the shelf and
showed him an old woodcut depicting his very
vision. "There's no reason for you to believe that
you're insane," I said to him. "They knew about
your vision 400 years ago." Whereupon he sat
down entirely deflated, but once more normal. (p.
A complete mind/body/spirit integrated approach to spiritual
emergencies would also make use of alternative therapeutic
treatments such as diet, bodywork, exercise and movement,
homeopathy, herbs (just to name a few) (Bragdon, 1993:
Cortright, 1997). There may even be times when medication
can play a role in recovery and integration of these experiences.
Increasing Incidence of Spiritual
Experiences and Problems
On virtually all measures, there has been a major decline in the
strength of the mainstream religious institutions and confidence
in religion and religious leadership in American culture
(Princeton Religious Research Center, 1985; Stark &
Bainbridge, 1985). While 70% of Americans report in Gallup
polls that they attend church regularly (Gallup, 1987), a recent
study of the actual religious behavior of Americans found that
half of persons who tell pollsters that they attend church
regularly are not telling the truth. Kosmin and Lachman (1993)
conducted an in depth interview study (rather than a simple poll
as has been used in most studies) with 4001 randomly selected
individuals about the nature and frequency of church
attendance, and membership in a denomination. By also
tracking attendance at churches, they found that only 19% of
adult Americans regularly practice their religion. Some 22.5%
exhibit "only trace elements" of religion in their lives; another
29% were rated as barely or nominally religious, and 7.5%
describe themselves as agnostics. The researchers concluded
that most Americans claim a religion that does not significantly
inform their attitudes or behavior.
Yet at the same time people are turning away from
conventional religious institutional forms, the number of people
who report that they personally believe in God or some spiritual
force, who pray or engage in some spiritual practice, and who
report a mystical experience has been increasing. In one survey,
75% of persons who are not members of a church or synagogue
say that they pray sometime during their everyday lives, and
58% of Americans reported the need to experience spiritual
growth (Woodward, 1994). During the last 25 years, there has
been a significant increase in people adopting spiritual
practices, including a wide array of meditation, marital arts, tai
chi, chanting, and yoga techniques. There has also been an
explosion of interest in mystical, esoteric, shamanic and pagan
traditions that involve participation in sweat lodges, goddess
circles and the rituals of many small new spiritual schools and
"New Age Groups" (Lewis & Melton, 1992). Twelve step
programs, with their focus on a "higher power" and spiritual
awakening, have been developed for a wide-range of problems
and have millions of adherents. Psychospiritually-oriented
cancer support groups are another recent phenomenon.
Gallup polls (1987) have shown an increase in percentages of
people who report: mystical experiences (from 35% in 1973 to
43% in 1986), contact with the dead (from 27% in 1973 to 42%
in 1986), ESP (from 58% in 1973 to 67% in 1986), visions
(from 8% in 1973 to 29% in 1986) and other unusual
experiences. Based on his 15 years of survey research, Greeley
(1987) concluded, "More people than ever say they've had such
experiences... whether you look at the most common forms of
psychic and mystical experience or the rarest...These
experiences are common, benign and often helpful. What has
been 'paranormal' is not only becoming normal in our time--it
may also be health-giving" (p.49). Even such unusual
experiences as UFO abductions (Ring, 1992), paranormal
(Braud, 1995; Hastings, 1983), and out-of-the-body experiences
(Gabbard & Twemlow, 1984) are often experienced as
meaningful, positively transformative, and spiritual.
Accordingly, as the number of persons who engage in spiritual
practices and have spiritual experiences increases, it seems
likely that the incidence of spiritual problems seen in
psychotherapy will also grow.
To date, religious problems have received much more attention
than spiritual problems in the clinical and research literature.
There is a handbook (Wicks, Parsons & Capps, 1993) and
about a dozen journals devoted to pastoral counseling, several
more to "Christian psychiatry," as well as professional
organizations and conferences that address religious problems.
There are no journals focused on spiritual problems.
Transpersonal psychologists actively investigate both spiritual
experiences that are trans, beyond our ordinary personal and
biological self, and also spiritual practices such as Zen
Buddhism and Patanjali Yoga, which are designed to lead to
intense spiritual experiences (Rao, 1995). While transpersonal
psychology is avowedly nonsectarian (Lajoie & Shapiro, 1992),
many transpersonal psychologists are hopeful that the
systematic study of these spiritual practices and their associated
experiences can facilitate their occurrence in their clients (when
clinically appropriate) (Tart, 1995). But this requires sensitivity
to the types of problems that are also associated with specific
Religious and spiritual problems need to be subjected to more
research to better understand their prevalence, clinical
presentation, differential diagnosis, outcome, treatment,
relationship to the life cycle, ethnic factors and predisposing
intrapsychic factors. While defining discrete religious and
spiritual problems for study clearly presents difficulties, such as
the frequent overlap in the categories discussed above, the
extensive and rigorous research on the phenomenology,
prevalence, outcome, clinical sequalae, treatment of NDEs
serves as a model demonstrating that the obstacles are not
insurmountable (Greyson, 1983, 1997; Greyson & Harris, 1987;
Ring, 1990, 1992). The acceptance of religious and spiritual
problems as a new diagnostic category in DSM-IV is a
reflection of increasing sensitivty to cultural diversity in the
mental health professions and of transpersonal psychology's
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