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DSM-IV Religious and Spiritual Problems

Lesson 1 Background of Religious or Spiritual Problem (V62.89)

Mental Health and Spirituality History of the DSM-IV Proposal
Nursing and Psychology

Mental Health and Spirituality
The mental health field has a heritage of 100 years of ignoring and pathologizing spiritual experiences and religion. Freud promoted this view in several of his works, such as in Future of an Illusion wherein he pathologized religion as:

A system of wishful illusions together with a disavowal of reality, such as we find nowhere else...but in a state of blissful hallucinatory confusion.

Freud also promoted this view in Civilization and Its Discontents, where he reduced the "oceanic experience" of mystics to "infantile helplessness" and a "regression to primary narcissism." The 1976 report Mysticism: Spiritual Quest or Psychic Disturbance [1] by the Group for the Advancement of Psychiatry (GAP) followed Freud's lead in defining religion as a regression, an escape, a projection upon the world of a primitive infantile state.

Albert Ellis,PhD is the creator of Rational Emotive Therapy, the forerunner of cognitive modification approaches now widely used in cognitive-behavioral therapies. In a recent (2001) interview, Ellis stated:

Spirit and soul is horseshit of the worst sort. Obviously there are no fairies, no Santa Clauses, no spirits. What there is, is human goals and purposes...But a lot of transcendentalists are utter screwballs.

In addition to his bias against spirituality as a constructive element in health, in many other of his writings he has also derided religion:

The elegant therapeutic solution to emotional problems is quite unreligious ...The less religious they [patients] are, the more emotionally healthy they will tend to be" [2]

BF Skinner,PhD, the psychologist who pioneered understanding of behavior modification principles that are the other half of cognitive-behavioral therapies, did not publish a single word on the topic of spirituality. He approached humans as stimulus response boxes with varying behaviors that depend on environmental contingencies. Skinner's psychology gave no attention to inner experience, which does leave out a lot of what makes people human beings. However, Skinner's implicit views on religion can be gleaned from the novel he wrote about a Utopian community, Walden Two. In this novel, one member describes religion as:

an explanatory fiction, of a miracle-working mind...superstitious behavior perpetuated by an intermittent reinforcement schedule

These founders' views on religion and spirituality have had a profound influence on the clinical approach to these issue. M. Scott Peck, MD, author of The Road Less Traveled, highlighted the disastrous clinical consequences for all the mental health professions:

Traditional neglect of the issue of spiritually has led to five broad areas of failure:

    occasional devastating misdiagnosis;
    not in frequent mistreatment;
    an increasingly poor reputation;
    inadequate research and theory; and
    a limitation of psychiatrists' own personal development.

As a result, research on both psychopathology and mental health has largely ignored religion.

Larson et al. Systematic analysis of research on religious variables in four major psychiatric journals, 1978-1982

Surveys conducted in the United States consistently show a "religiosity gap" between the general public and patients who in many surveys report themselves to be more highly religious and to attend church more frequently than mental health professionals.

And studies of training for psychologists and other mental health professionals show that despite the importance of religion and spirituality in most patients' lives, adequate training is not provided by most graduate programs and internship sites to prepare them to deal with these issues. (For a review see Lukoff D, Lu F, Turner R. Toward a more culturally sensitive DSM-IV: Psychoreligious and psychospiritual problems)

The pathologizing and ignoring of religion and spirituality has also resulted in clinical insensitivity towards individuals who present with religious and spiritual problems and issues.

These negative views of religion and spirituality are not warranted in light of recent studies showing no association between religiosity and psychopathology in the nonpatient population. Controlled studies have also found that "The notion that religion exerts a negative influence on mental health in patients was not generally supported by our findings" (Pfeifer and Waelty, 1995). In fact, a meta-analysis of religiosity and mental health found them to be positively related. Church-affiliated individuals showed greater happiness and satisfaction with marriage, work and life in general. Studies of the self-reported relationship between quality of relationships with divine others (e.g., Christ, God, Mary, etc.) and several measures of well-being also found a significant positive association. While there does seem to be a relationship between religiosity and psychopathology in the seriously mentally ill, for the vast majority of the population, spirituality and religion are associated with positive characteristics of mental health. Similarly, mystical experiences and spiritual practices are positively associated with mental health variables.

In " Psychopathology and religious commitment--a controlled study" Pfeifer and Waelty found that life satisfaction was significantly positively correlated with religious commitment.


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See International Center for the Integration of Health and Spirituality (ICIHS) for summaries of over 1600 studies on these issues or Dr. David B. Larson's slide presentation on the link between health and spirituality (must have Powerpoint to view the slideshow).

______ viewed religious beliefs as fantasies that prevent people from coming to terms with how things really are.
a) C G Jung
b) Sigmund Freud
c) Albert Ellis
d) b and c

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History of the DSM-IV Proposal
To redress the lack of sensitivity to religious and spiritual problems, the course author along with two psychiatrists (Francis Lu, MD and Robert Turner, MD) on the faculty at UCSF Department of psychiatry proposed a new diagnostic category to the Task Force preparing the 4th edition of the DSM which was due to be published in 1994. We viewed such an addition to the nomenclature as the most effective way to increase the sensitivity of mental health professionals to spiritual issues in therapy. The initial impetus for this proposal came from the Spiritual Emergence Network (then called the Spiritual Emergency Network, now the Center for Psychological & Spiritual Health (CPSH)) which was concerned with the mental health system's pathologizing approach to intense spiritual crises.

Detailed History of Proposal

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 and also argued that the adoption of this new category would result in the following benefits:

increasing the accuracy of diagnostic assessments when religious and spiritual issues are involved
reducing the occurrence of iatrogenic harm from misdiagnosis of religious and spiritual problems
improving treatment of such problems by stimulating clinical research
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 documenting the need for such a category 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:

V62.89: 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, San Francisco Chronicle, American Psychiaric Association Psychiatric News, and the American Psychological Association Monitor, where it was described as indicating an important shift in the mental health profession's stance toward religion and spirituality.

Religious or Spiritual Problem is

a) a type of neurosis b) a type of psychosis c) a proposed new diagnostic category for the DSM-V d) a new diagnostic category in the DSM-IV

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Nursing and Psychology

Historically the nursing profession has been more receptive to religion and spirituality. Spiritual Distress has been a category in the nomenclature of the National Group for the Classification of Nursing Diagnosis since 1983 [3]. It is defined as "The state in which the individual experiences or is at risk of experiencing a disturbance in his or her belief or value system that is his/her source of strength and hope." Examples include:

Inability to practice religious rituals
Conflicts between religious/spiritual beliefs and the prescribed health regimen
Lack of meaning in life
A disruption in the relationship with one's God
Lack of forgiveness toward a significant other

The mental health nursing journals also include religious and spiritual factors more frequently than psychiatry or psychology journals.

Weaver AJ, Flannelly LT, Flannelly KJ, Koenig HG, Larson DB. An analysis of research on religious and spiritual variables in three major mental health nursing journals, 1991-1995. Issues Ment Health Nurs 1998 May-Jun;19(3):263-76

The authors attribute this greater sensitivity to historical factors:

Whereas the founder of modern nursing, Florence Nightingale, taught that spirituality was intrinsic to human experience and compatible with scientific inquiry, the founder of modern psychiatry, Sigmund Freud, had a strongly held view of religion as pathological.

According to the American Psychological Association Ethical Principles of Psychologists and Code of Conduct, psychologists have an ethical responsibility to be aware of social and cultural differences that impact treatment. Section 1.08 Human Difference states,

Where differences of age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic status significantly affect psychologists' work concerning particular individuals or groups, psychologists obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals.

Ignorance, countertransference, and lack of skill can impede the untrained psychologist's ethical provision of therapeutic services to clients who present with religious or spiritual problems. Differential diagnosis require knowledge of the patient's religious subgroup and/or the nature of acceptable expressions of subculturally validated forms of religious expression. Allen Bergin (1980)[4] wrote in the American Psychologist,

Psychologists' understanding and support of cultural diversity has been exemplary with respect to race, gender, and ethnicity but the profession's tolerance and empathy has not adequately reached the religious client. (p. 95)

In contrast to psychiatric residency training where the Accreditation Council for Graduate Medical Education in 1995 issued "Special Requirements for Residency Training in Psychiatry" that mandates instruction about gender, ethnicity, sexual orientation, and religious/spiritual beliefs, such training is not specifically required in psychology.

Yet the mental health field is growing more sensitive to religion and spirituality as important factors in health and well-being. I concur with the assessment of Michael Washburn,PhD

There still is a pathologization of anything that has to do with difficult religious experience. We are overcoming that, I am pleased to say. There is a growing appreciation that a passage into spiritual life can be psychologically very challenging, and that we should expect it as a common occurrence, and learn better to understand it so we can deal with it when it happens. I think we are in a better situation as far as those possibilities are concerned than we have been in the past. But there's still some way to go.


1 Group for the Advancement of Psychiatry. (1976). Mysticism: Spiritual quest or mental disorder. New York: Group for the Advancement of Psychiatry.

2 Ellis, A. (1980). "Psychotherapy and atheistic values: A response to A, E. Bergin's "Psychotherapy and Religious Issues"." Journal of Consulting and Clinical Psychology 48: 635-639. (p. 637)

3 Carpenito, L. (1983). Nursing diagnosis: Application to clinical practice. Philadelphia, J. B. Lippincott.

4 Bergin, A. (1980) Psychotherapy and Religious Values. American Psychologist, 48, 1980, 95-105. (p. 95)



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