Spiritual Emergence, Transpersonal Crisis or Mental Illness?
By Cian Kerrisk (Revised 2011)
Spiritual Emergence, Transpersonal Crisis or Mental Illness?
By Cian Kerrisk (Revised 2011)
Transpersonal means beyond the personal or literally beyond the mask. Transpersonal Psychology or Psychotherapy looks at other aspects of existence than just the here and now, the you-and-I. From the Transpersonal worldview our essential nature is spiritual and consciousness is multidimensional. As human beings we may have valid urges towards spiritual seeking, expressed as a search for wholeness through deepening individual, social, and spiritual awareness. The central concept in Transpersonal Psychology is therefore self-transcendence, or a sense of self-identity which is deeper or higher, broader, and more unified with the whole. The focus of transpersonal psychology can therefore extend to altered states of consciousness, peak experiences (Maslow, 1964), and spiritual emergence and crisis.
I personally have a longstanding interest in the spiritual traditions and practices of the world and have been aware of individuals allegedly having contact from gods, angels or ancestors, or other experiences of a religious or mystical nature. Some people have found these esoteric experiences to be profound and illuminating, while others have had experiences of “psychic attack”, “dark forces” or “demons” which have haunted and tormented them. Whether or not such occurrences actually exist or not is neither here nor there. From a phenomenological perspective the important factor is the meaning that the person experiencing these events attributes to them. Such transpersonal experiences may bring about confusing mental and emotional states with changes in perception or thought that could resemble psychiatric symptoms (Lukoff, 1985; Randal & Argyle, 2005).
From a modern western point of view, many experiences in meditation or shamanic initiations (e.g., trance states, out of body experiences, visions or voices, merging with nature) would be seen as madness. However, from the perspective of meditative traditions or indigenous cultures, these may be seen as normal signs of development or even indications of extraordinary mental health. These experience share many characteristics with brief psychotic reactions and other forms of mental illness and could be easily misinterpreted.Ideas that may seem delusional from a bio-medical standpoint may however be an acceptable part of some cultural or religious belief systems (Crowley, 2006). In society today there are great variations in peoples’ spiritual perspectives. Hearing the voices of one's ancestors for example would likely trigger psychiatric treatment in contemporary western society, but could be cause for celebration as a shamanic call among some indigenous peoples. There is also a growing acknowledgement of the need to be respectful of diverse beliefs that are often intrinsically part of people’s phenomenological worldview. It is worth noting that while I was working as an intern in a Psychiatric hospital in the Peruvian Andes I was astounded to discover that the majority of people suffering from mental or emotional problems would initially go to a currandero (traditional healer) or shaman, or alternatively a Catholic priest for help, and if this didn’t work they would only then resort to western psychiatric treatment including medication and inpatient treatment.
According to the “Ethical Principles of Psychologists and Code of Conduct” (APA, 1992) “psychologists have an ethical responsibility to be aware of social and cultural factors”. Similarly, the “Code of Ethics” of the New Zealand Association of Psychotherapists states that psychotherapists must “be sensitive to diversity” and must have “respect for the uniqueness and dignity of clients”. Balancing with these factors in a seemingly uneasy juxtaposition are the responsibilities of a therapist to “protect client wellbeing” and to “practice safely” (NZAP, 2007).
My own reflections on ethical responsibility as well as the experiences of some of my own patients has led me to wonder about how a psychotherapist can best work with a patient who presents with spiritual experiences or beliefs that resemble mental illness. This of course begs the question as to when one should accept the patient as having a genuine “spiritual crisis” (Grof & Grof, 1989), and when these symptoms should be viewed as mental illness. In other words, how does one know whether seemingly “unusual” experiences, beliefs or perceptions are part of a mental health condition which may require additional psychiatric support, or when they may be considered religious, spiritual and culturally sanctioned appropriate experiences (Spitzer, Gibbons & Skodal, 1989).
With the inclusion of “religious or spiritual problem” in the DSM IV clinical reference guide for mental health concerns (APA, 1994), it is imperative to know how such understandings can be applied to psychotherapy. The reasons why this clinical dilemma is important is that without being able to differentiate between psychosis and a “spiritual crisis”, a client may be diagnosed, assessed or referred incorrectly. Knowing how to address this dilemma is critical, as it would determine how and if a therapist could work with a client around such issues, or if they should be referred for psychiatric treatment.
My clinical dilemma is therefore as follows:
“When clients of psychotherapy experience delusional or psychotic symptoms related to spiritual or religious themes, how does a psychotherapist or psychologist differentiate between a genuine “spiritual emergency” or “spiritual or religious problem” compared to actual psychiatric illness, so that correct diagnosis and treatment may be provided.”
After conducting a literature search of articles and books on this topic a number of relevant data sources became evident, however I decided to summarise and critique three of the most pertinent. The first article I selected was a literature review, the second was a cross-sectional study and the third was a combination of expert opinion and clinical guidelines that outline the rational for the inclusion of the DSM IV category “religious and spiritual problem”.
The first source of literature is entitled ‘Spiritual Emergency’ – a useful explanatory model: A Literature Review and Discussion paper (Randal & Argyle, 2005). It was selected due to its relevance to the topic and the fact that it mentions New Zealand and the importance of culturally aware assessment and treatment in relation to Maori. The review posed a question through asking in the title whether spiritual emergency is a “useful explanatory model”.
The article summarizes literature reviews and published case studies sourced via databases, journals and quantitative research. A number of qualitative studies are discussed and in-depth interviews of ten subjects undergoing “spiritual emergencies” (Hood, 1987, cited in Randal & Argyle, 2005) were referred to. Other research sources included a summary of themes drawn from discussion groups, case studies and the “dimensional analysis of 30 recovery narratives” (Jacobson, 2001, cited in Randal & Argyle, 2005, p. 5).
The result of the study could, according to the authors “point towards the likelihood that there is ‘clinical utility’ in the notion of spiritual emergency” (Randal & Argyle, 2005, p. 2). This article seems to hold the opinion that the benefits of working with clients around issues of “spiritual emergencies” far outweigh any potential harm. There could however be a risk if therapists attempted to work with psychotic or high-risk clients without seeking appropriate mental health treatment. The authors do discuss this dilemma while acknowledging, “the balance of risks is an aspect that needs urgent attention” (Randal & Argyle, 2005, p. 8). The findings could also inform psychotherapy practice in New Zealand and as the Maori concept of Taha Wairua (the spiritual) in mental health is mentioned, it seems appropriate to consider such issues in light of the cultural sensitivity.
Even in New Zealand I have had a patient who while undoubtedly having serious mental health problems also believed they were affected by a maketu (Maori curse). As this belief in indigenous withcraft practices was part of their cultural worldview, who is to say this it is another fantasy? The best course of action for this case in my opinion was to engage the patient with psychiatric treatment services in addition to culturally appropriate mental health, social and spiritual support services, or even to consult with a Maori tohunga (ritual expert) or kaumatua (elder). In such ways the person’s lived experience and beliefs are honoured and validated while at the same time not jeopardising their safety or compromising treatment outcomes.
The second source of evidence is a study by Milstein et al (2000) entitled “Assessing problems with religious content: a comparison of rabbis and psychologists”. The study does not follow and observe the groups over time (a criteria for a cohort study), but would be defined as a “cross-sectional” or synchronic study (survey). The research outlines comparative research conducted with random American national samples of rabbis and psychologists. The aim was to evaluate (amongst other factors) whether participants could distinguish between schizophrenia/mental illness, a mystical experience and a “pure religious problem” (mourning after a death). The method used to test the hypotheses was to present unlabelled vignettes in order to see if the participants could differentiate between the scenarios.
The recruitment strategies were appropriate to the aims of the study and rabbis were selected so that the results were not confounded by cultural variation. The researchers also described how random, nationwide samples (210 psychologists and 210 rabbis) were identified and sent questionnaires and follow up letters. Rabbis from each denomination were equally represented and variables for the groups were weighted. In both samples the proportion of men to women was much higher, which could make the findings gender specific. In summary the entire research process is clearly documented and informed consent is sought from all participants.
With regards to findings, the authors state that “the parallel patterns of evaluation by the rabbis and psychologists also provide evidence for the utility and construct validity of the three (religious or spiritual problem) diagnostic categories” (Milstein et al, 2000). The authors do acknowledge some limitations to the study including the limitation posed by only using psychologists and rabbis and suggest further research with multi-faith and multi-ethnic samples as well as diverse mental health professionals.
It is not clear whether these findings can be related to a New Zealand context that includes diverse cultures and
religious/spiritual orientations. Apart from the comments by participants the research does not discuss how they were
able to distinguish between the vignettes. The relevance of this study to my own question is not so much the comparative
ability of two groups to differentiate such conditions, but rather that they were able to so. The most important factor is that
the study would suggest clinical utility for the use of the DSM IV categories of (non-pathological) religious/spiritual
problems. Many people experiencing spiritual/religious or mental health problems initially contact a religious minister
or spiritual teacher as their first point of call (Larson et al, 1998, cited in Milstein et al, 2000). It would therefore also
suggest that cooperation between therapists and spiritual/religious teachers or ministers could be beneficial for the client.
The third source of evidence derives from an article by a renowned expert who was influential in the inclusion of the “spiritual or religious problem” category in the DSM IV (APA, 1994). It is entitled “From Spiritual Emergency to Spiritual problem: The Transpersonal Roots of the New DSM-IV Category” (Lukoff, 1998). The paper describes the process of inclusion for the new DSM-IV category and the guideline objectives are clearly discussed giving the background and history to the proposal. The article describes transpersonal perspectives on spiritual emergency and types of ‘religious or spiritual issues’ illustrated by a systematic analysis of case reports. It also summarizes differential diagnosis methods comparatively drawn from various sources and discusses psychotherapeutic approaches.
The methods for the formation of the guidelines have been clearly stated and the proposal was based on extensive research showing the prevalence of religious/spiritual problems. The author and his colleagues had contacted other experts in the field and attended conferences of professional associations where ideas were presented and suggestions received from psychotherapists, psychologists and psychiatrists. The fact that the proposed guidelines were accepted by the DSM IV taskforce suggests they were based on credible research and the need for such concepts in the mental health professions.
Systematic methods were used to search for evidence including several literature searches on Psychinfo, Medline and
Religion Index databases. The author outlines the search limits and number of findings by including a table showing the
results by type and sub-category. The author does acknowledge that the quality of the case studies vary widely and
“few use any checks for reliability or validity”. The benefits of the new DSM category were clearly outlined and the
various religious and spiritual problems illustrated by case studies (including follow-up interviews 11 years later) and
reinforced by both qualitative and quantitative research findings.
When discussing psychotherapeutic approaches to working with spiritual/religious problems, case studies from diverse
schools of therapy are mentioned including psychoanalytic, cognitive-behavioral and transpersonal (Lukoff, 1998).
The author suggests that religious and spiritual problems need to be “subjected to further research to better understand
their prevalence, clinical presentation, differential diagnosis, outcome, treatment, relationship to the life cycle, ethnic
factors and predisposing intra-psychic factors”(Lukoff, 1998). He also points to the rigorous and extensive research
on near death experiences as an exemplar for investigation into other clinical factors. The health benefits as opposed to
risk factors are assessed and the author clearly shows a balanced and informed opinion. Although empirically
demonstrating the prevalence of religious/spiritual problems, he also discusses that spiritual problems can occur alongside
a mental disorder which “greatly expands the potential usage of this category” (Lukoff, 1998).
Overall I found that this article displayed a high level of rigor. The fact that the article is discussing clinical guidelines based on a systematic review highlights it as being a high level of research with much credibility. Certainly the DSM IV category, the associated clinical guidelines and the recommendations are applicable to psychotherapeutic work in New Zealand.
With regards to practical transpersonal psychotherapy with clients who present with spiritual or religious problems such as this the ‘I-Thou relationship’ can serve as a doorway that can lead into the transpersonal relationship and it has been suggested that truly relating between people already moves us past the narrow concerns of just our ego (Hycner, 1993). Buber reiterates that “one enters the spiritual domain through an I-Thou meeting with an otherness, this may be a person, or nature itself” (Buber, 1923/1958, cited in Hycner, 1993, p. 91). This ‘transpersonal’ aspect is concerned with “how the spiritual is expressed in and through the personal as well as the transcendence of self” and how these factors relate to our existence and experience (Cortright, 1997, p. 10; Hycner, 1993, p. 82). By its very nature the transpersonal relationship is difficult to describe, as it is includes the unexplainable dimension, and experiences that cannot always be explained in words.
Some characteristics of the transpersonal include timelessness, consciousness and an expansion from a focus on a person’s inner world to an awareness of inter-relatedness and the emptying of ego. Groff also explained the transpersonal as “experience involving an expansion or extension of consciousness beyond the usual ego boundaries and beyond limitations” (1979, p. 155, cited in Clarkson, 2003, p. 199). This is not about trying to ‘bypass’ the personal but to relate with a resonance and communion that is beyond normal awareness or consciousness, as Jung stated…to “place our ego-consciousness within a larger context” (Jung, cited in Hycner, 1993, p. 82).
In the therapy setting it has been explained that such intuitive illuminations burgeon the more the therapist “dissolves the individual ego from the therapeutic encounter – allowing wisdom and insight and transformation to occur as a self manifesting process” (Clarkson, 1990, p. 159). This emptying or dissolving can be analogous to a ‘letting go of all aims and assumptions’ and an acceptance of the unknown through which forces, energies or factors beyond the bounds of individuality may be present. Clarkson refers to this force or tendency as ‘Physis’, which relates to nature, evolution and creativity (Clarkson, 2003, p. 200). When working with clients in my own practice I acknowledge the ‘wider context’, the spiritual dimension, and a third “together-awareness” that is ‘greater than the sum of the parts’ created by just myself and the patient alone. Some ways I have found that can be useful in accessing this dimension of the therapeutic relationship include creative and expressive methods for accessing feelings and emotions that may arise from a patient’s unconscious by means of symbol and archetypal imagery.
My clinical question is addressed when treatment approaches (Lukoff, 1998, Randal & Argyle, 2005) and differential diagnosis factors from various expert opinions and research studies are synthesized by comparing the overlap of proposed criteria. As Lukoff (1998) states, this lends “further credibility to the existence of spiritual emergency as a valid clinical phenomenon”. Such criteria include speech or thoughts focused on spiritual or mythological themes with “no conceptual disorganization” and a willingness to explore the experience. In addition, positive prognosis factors include “good pre-episode functioning” and “low risk” of harming self and others (Lukoff, 1985; Lukoff, 1998).
In conclusion, it seems that “spiritual emergency” and the DSM IV religious/spiritual problem category could indeed serve as useful explanatory models. The three articles showed the importance of acknowledging spiritual or religious problems by outlining the prevalence of such experiences in society. The cross-sectional study showed that informed therapists could distinguish between mental illness and spiritual problems, that the current DSM IV categories have clinical utility and that it could be helpful to consult cultural/spiritual leaders during the treatment process. It seems clear that “the concept of ‘spiritual emergency’ does not deny the seriousness of a psychotic condition” and that not all “psychological disturbances (containing) spiritual aspects” are ‘spiritual emergencies’ (Crowley, 2006, pp. 5-7). The consideration of these concepts does however open up a new dimension to working with clients in a sensitive, creative and culturally appropriate manner that acknowledges diversity and the transpersonal aspects of human experience.
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