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DSM-IV Religious and Spiritual Problems

LESSON 3.1 Spiritual Emergence

Emergence versus Emergency Extraordinary Experiences and Spiritual EmergenceMisdiagnosis of Spiritual CrisesClinical Impact of Misdiagnoses

Emergence versus Emergency
In the DSM-IV, spiritual problems are defined as distressing experiences that involve a person's relationship with a transcendent being or force but are not necessarily related to an organized church or religious institution. Sometimes such experiences emerge from intensive involvement with spiritual practices such as meditation or yoga, as in the Meditation and Spiritual Practice type of spiritual problem.

The connection between spiritual emergences and psychological problems was first noted by Roberto Assagioli,MD who described how persons may become inflated and grandiose as a result of intense experiences associated with spiritual practices:

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. [1] (p. 36)

Beginning in the 1960s, interest in Asian spiritual practices such as meditation, yoga, and tai chi, as well as experimentation with psychedelic drugs, triggered many mystical experiences and visionary experiencies, some of which were problematic for their practitioners.

Whereas spiritual masters have been warning their disciples for thousands of years about he dangers of playing with mystical states, the contemporary spiritual scene is like a candy store where any casual spiritual "tourist" can sample the "goodies" that promise a variety of mystical highs. When novices who don't have the proper education or guidance begin to naively and carelessly engage mystical experiences, they are playing with fire. Danger exists on the physical and psychological levels, as well as on the level of one's continued spiritual development. (Halfway Up the Mountain: The Error of Premature Claims to Enlightenment by Mariana Caplan)
Christina Grof and Stanislav Grof,MD, coined the term "spiritual emergency" and founded the Spiritual Emergency Network at the Esalen Institute in 1980 to assist individuals and make referrals to therapists for people experiencing psychological difficulties associated with spiritual practices and spontaneous spiritual experiences. Dr. Grof describes a spiritual emergency:
There exist spontaneous non-ordinary states that would in the west be seen and treated as psychosis, treated mostly by suppressive medication. But if we use the observations from the study of non-ordinary states, and also from other spiritual traditions, they should really be treated as crises of transformation, or crises of spiritual opening. Something that should really be supported rather than suppressed. If properly understood and properly supported, they are actually conducive to healing and transformation. (Interview with Stanislav Grof,MD)

The term spiritual emergence is used to describe the whole range of phenomena associated with spiritual experiences and development from those (probably the vast majority) which are not problematic, do not disrupt psychological/social/occupational functioning and do not involve psychotherapy or any contact with the mental health system, to spiritual emergences that are full-blown crises requiring 24-hour care.

David Steindl-Rast [2], a Benedictine monk who teaches spiritual practices, has also noted that spiritual emergence can be disruptive:
    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 . . . Breakthroughs are often very painful, often acute and dramatic.

As described in Lesson 1 Background of DSM-IV Religious or Spiritual Problem (V62.89), the impetus for proposing this new diagnostic category came from transpersonal clinicians whose initial focus was on such spiritual emergencies. Then the proposal was broadened to include religious problems.


Spiritual emergency is a term developed by C. G. Jung.


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Assagioli first proposed that spiritual practices can be associated with psychological disturbance.


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Extraordinary Experiences and Spiritual Emergence
Some forms of spiritual emergence can take the form of extraordinary experiences, such as alien encounters and NDEs. Kenneth Ring, PhD, Professor Emeritus of Psychology at the University of Connecticut and one of the world's chief authorities on near-death experiences, found that groups of people reporting alien encounters and NDE show similar changes over time, and many report that their lives have been radically altered on a deep spiritual level by their NDEs and encounters with aliens. They develop a heightened reverence for nature and human life, and report that their personalities are transformed as result of these experiences. He concluded that both alien abduction and NDE (and potentially other extraordinary experiences) are,

in effect alternate pathways (Ring's emphasis) to the same type of psychospiritual transformation...that expresses itself in greater awareness of the interconnectedness and sacredness of all life and necessarily fosters a heightened ecological concern for the welfare of the planet. (The Omega Project)

Because of the role such extraordinary experiences as alien encounters and NDEs play in some people's spiritual lives, they are included in this course as spiritual problems.

Center for Extraordinary Explorations This site covers the research and study of extraordinary experiences including: Reincarnation/Past Lives, Alien Contact, Angel Encounters, Out of Body and Near Death Experiences (OBE's and NDE's).

Misdiagnosis of Spiritual Crises

Spiritual emergencies warrant the DSM-IV diagnosis of Religious or Spiritual Problem (V62.89), even when there may be symptoms of a mental disorder present, including hallucinations and delusions. In this way, Religious or Spiritual Problem is comparable to the category Bereavement for which the DSM-IV notes that even when a person's reaction to a death meets the diagnostic criteria for Major Depressive Episode, the diagnosis of a mental disorder is not given because the symptoms result from a normal reaction to the death of a loved one.

Similarly, spiritual emergencies can be disorienting and frightening. They can preoccupy the individual and lead to the performance of private rituals. All of these can present as symptoms of mental disorder. Hallucinations, delusions, anger, and interpersonal difficulties occur so frequently that they should be considered normal and expectable reactions to the spiritual emergence. Yet such spiritual problems often lead to long-term improvements in overall well-being and functioning.

The clinical literature has long recognized that some episodes with psychotic symptoms can result in improvements in an individual's functioning. Karl Menninger, MD, considered by many the father of modern Amercian psychiatry, observed that,
    Some patients have a mental illness and then get well and then they get weller! I mean they get better than they ever were . . . . This is an extraordinary and little-realized truth (Menninger cited in Silverman [3], p. 63).

Many clinicians and researchers have proposed a category for episodes with psychotic-like symptoms but which have the potential for positive outcomes:

problem-solving schizophrenics (Boisen [4])
positive disintegration (Dabrowski [5])
creative illness (Ellenberger [6])
metanoiac voyages (Laing [7])
visionary states (Perry [8])

Allen Bergin, Ph.D. [9] has observed that,

    Some religious influences have a modest impact, whereas another portion seems like the mental equivalent of nuclear energy...The more powerful portion can provide transcendent conviction or commitment and is sometimes manifested in dramatic personal healing or transformation. (p. 401)

This nuclear analogy also applies to the spiritual emergence process. It has tremendous healing power for the individual, and even for society, but can also be destructive if not channeled properly. Note that while this type of intense emergence process is discussed under this lesson on spiritual problems, a similar process occurs in religious conversion experiences, many of which involve mystical experiences (see Lesson 3.3 Mystical experiences). Unfortunately such experiences are often misunderstood by both the mental health and religious professions.

Clinical Impact of Misdiagnoses
The clinician's initial assessment can significantly influence the eventual outcome. As Greyson and Harris [10] point out, the clinician's response to a person's near-death experience can determine whether the experience is integrated and used as a stimulus for personal growth, or whether it is repressed as a bizarre event that may be a sign of mental instability. Similarly, with mystical experience, negative reactions by professionals can intensify an individual's sense of isolation and block his or her efforts to seek assistance in understanding and assimilating the experience.

Individuals undergoing powerful religious and spiritual experiences are at risk for being hospitalized as mentally ill. Even many religious professionals seem unable to make the distinction between genuine and pathological religious experiences.

If a member of a typical congregation were to have a profound religious experience, its minister would very likely send him or her to a psychiatrist for medical treatment. (Stanislav Grof, Beyond the brain: Birth, death and transcendence in psychotherapy).

One person who had had a near-death experience reported:

"I tried to tell my minister, but he told me I had been hallucinating, so I shut up" (Raymond Moody Life After Life: The Investigation of a Phenomenon — Survival of Bodily Death p 86).

If tumultuous episodes with growth potential and those which indicate a mental disorder could be differentiated, the prognosis of individuals with spiritual emergence problems could be improved by providing appropriate treatment consistent with their need to express and integrate the physical, psychopathological, and spiritual symptoms.

(see Lesson V Differential Diagnosis)

1 Assagioli, R. (1989). Self-realization and psychological disturbances. In S. Grof & C. Grof (Eds.), Spiritual emergency: When personal transformation becomes a crisis, Los Angeles: Tarcher.

2 David Steindl-Rast cited in Bragdon, E. (1993). A sourcebook for helping people with spiritual problems. Aptos, CA: Lightening Up Press. p. 18.

3 Silverman, J.(1967). Shamans and acute schizophrenia. American Anthropologist, 69(1), 21-31.

4 Boisen, A. T.(1962). The exploration of the inner world. New York: Harper and Row.

5 Dabrowski, K. (1964). Positive disintegration. Boston: Little Brown.

6 Ellenberger, H. (1970). The discovery of the unconscious. New York: Basic Books.

7 Laing, R.D. (1972). Metanoia: Some experiences at Kingsley Hall, London. In H. M. Ruitenbeck (Eds.), Exploring Madness (pp. 113-121). Monterey, CA: Brooks/Cole.

8 Perry, J. (1974). The far side of madness. Englewood Cliffs, NJ: Prentice Hall.

9 Bergin, A. (1991). Values and religious issues in psychotherapy and mental health. American Psychologist, 46(4), 394-403.

10Greyson, B., & Harris, B. (1987). Clinical approaches to the near-death experience. Journal of Near-Death Studies, 6(1), 41-52.



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