1. When Issues Become Emergencies: Assessment and Treatment of Spiritual Problems Nadine Duckworth University of Lethbridge Nadine Duckworth University of Lethbridge

2. IntroductionIntroduction FSpiritual practices have beneficial effects on health FFor healing of illnesses FPsychological growth FSelf-actualization FSpiritual problems FCan emerge spontaneously or during intense spiritual practice FCan resemble a variety of mental disorders FCan lead to disruption in social and psychological functioning FSpiritual practices have beneficial effects on health FFor healing of illnesses FPsychological growth FSelf-actualization FSpiritual problems FCan emerge spontaneously or during intense spiritual practice FCan resemble a variety of mental disorders FCan lead to disruption in social and psychological functioning

3. IntroductionIntroduction FMisdiagnosis can result in inappropriate treatment and intensification of distressful symptoms FIf properly diagnosed and treated, can result in personal growth and healing FSpiritual practices are gaining popularity worldwide FSpiritual problems are likely to increase as well FTherapists should be “spiritually-sensitive” FIncreased awareness and understanding FAppropriate treatment approach FMisdiagnosis can result in inappropriate treatment and intensification of distressful symptoms FIf properly diagnosed and treated, can result in personal growth and healing FSpiritual practices are gaining popularity worldwide FSpiritual problems are likely to increase as well FTherapists should be “spiritually-sensitive” FIncreased awareness and understanding FAppropriate treatment approach

4. DSM Diagnosis F1994 DSM IV - “Religious or Spiritual Problem” (Code V62.89), is used to diagnose a religious or spiritual crisis that is usually a brief reactive response to specific religious or spiritual experiences FDesignated as a “V code”, acknowledging a category of distressing religious and spiritual experiences that are nonpathological in nature FA religious or spiritual problem is not a mental disorder, but is a condition that requires clinical attention FTraditional psychiatry has not differentiated mysticism from psychosis Foften misdiagnosed as psychotic disorders Ftypically treated with psychotropic medication and hospitalization F1994 DSM IV - “Religious or Spiritual Problem” (Code V62.89), is used to diagnose a religious or spiritual crisis that is usually a brief reactive response to specific religious or spiritual experiences FDesignated as a “V code”, acknowledging a category of distressing religious and spiritual experiences that are nonpathological in nature FA religious or spiritual problem is not a mental disorder, but is a condition that requires clinical attention FTraditional psychiatry has not differentiated mysticism from psychosis Foften misdiagnosed as psychotic disorders Ftypically treated with psychotropic medication and hospitalization

5. Spiritual Issues FSpiritual issues or concerns are not as sudden or as intense as spiritual emergencies FInclude things like: FLoss or questioning of faith FConversion to new religion or denomination FMoral or ethical issues FPersonal identity issues FExistential issues FTrauma FRelationship and family problems FGrief and loss FPhysical or terminal illness FSubstance abuse FExtremes of thinking or living FPsychological disturbance FBurnout and working with other people in crisis FSpiritual issues or concerns are not as sudden or as intense as spiritual emergencies FInclude things like: FLoss or questioning of faith FConversion to new religion or denomination FMoral or ethical issues FPersonal identity issues FExistential issues FTrauma FRelationship and family problems FGrief and loss FPhysical or terminal illness FSubstance abuse FExtremes of thinking or living FPsychological disturbance FBurnout and working with other people in crisis

6. Spiritual Emergency Spiritual Emergency FSpiritual emergency/crisis - when one’s Self becomes overwhelmed by an infusion of spiritual energies or new realms of experience which it is not yet able to integrate FThe practice of personal or spiritual transformation can become a crisis, resulting from a process of growth or change that has become chaotic or overwhelming FIt has been described in the sacred literature of all ages, and is recognized as being the result of meditative practices and the mystical path FIndividuals may experience: Fself identity disintegrating Fold beliefs and values no longer hold true Freality is radically changing Fnew realms of spiritual experiences appear suddenly and dramatically Fimmense confusion, anxiety, and sometimes impaired functioning Fworry that they are going crazy, or experiencing psychosis FSpiritual emergency/crisis - when one’s Self becomes overwhelmed by an infusion of spiritual energies or new realms of experience which it is not yet able to integrate FThe practice of personal or spiritual transformation can become a crisis, resulting from a process of growth or change that has become chaotic or overwhelming FIt has been described in the sacred literature of all ages, and is recognized as being the result of meditative practices and the mystical path FIndividuals may experience: Fself identity disintegrating Fold beliefs and values no longer hold true Freality is radically changing Fnew realms of spiritual experiences appear suddenly and dramatically Fimmense confusion, anxiety, and sometimes impaired functioning Fworry that they are going crazy, or experiencing psychosis

7. Spiritual Emergencies FAnomalous experiences: Fdeviate from the usually accepted explanations of reality Fcan involve intense emotions, visions, perceptual disturbances, unusual thought processes, tremors, and sensations of heat and energy FExamples include: Fintense kundalini awakening  mystical or “ peak ” experiences Fnear-death experiences Fpsychic openings or psi-related phenomena Fpast-life experiences Fshamanic journeys FUFO/alien encounters or abductions Fcommunicating with spirits or channeling Fpossession states FAnomalous experiences: Fdeviate from the usually accepted explanations of reality Fcan involve intense emotions, visions, perceptual disturbances, unusual thought processes, tremors, and sensations of heat and energy FExamples include: Fintense kundalini awakening  mystical or “ peak ” experiences Fnear-death experiences Fpsychic openings or psi-related phenomena Fpast-life experiences Fshamanic journeys FUFO/alien encounters or abductions Fcommunicating with spirits or channeling Fpossession states

8. AssessmentAssessment 1.Brief Mental Status Exam: Fgeneral description and appearance of client Fmood and affect Fperception Fthought processes Flevel of consciousness Forientation to time, place, and people Fmemory Fimpulse control FDisturbances in perception, consciousness, or orientation may indicate: Fspiritual emergency Fpsychotic symptoms Forganic brain disorder 2. Subjective Units of Disturbance Scale (SUDS) 1.Brief Mental Status Exam: Fgeneral description and appearance of client Fmood and affect Fperception Fthought processes Flevel of consciousness Forientation to time, place, and people Fmemory Fimpulse control FDisturbances in perception, consciousness, or orientation may indicate: Fspiritual emergency Fpsychotic symptoms Forganic brain disorder 2. Subjective Units of Disturbance Scale (SUDS)

9. AssessmentAssessment 3. Clinical Interview FListening to client’s story FBuilding rapport FHistory-taking FChecklist of symptoms Fphysical, behavioural, cognitive, emotional Ffrequency, intensity, and duration 4. Global Assessment of Functioning Scale (GAF) 5. Psychological Tests FSCID-I and SCID-II - for Axis I and II FMMPI-III and MCMI-2 - for Axis I and II FSIRS - Structured Interview of Reported Symptoms 3. Clinical Interview FListening to client’s story FBuilding rapport FHistory-taking FChecklist of symptoms Fphysical, behavioural, cognitive, emotional Ffrequency, intensity, and duration 4. Global Assessment of Functioning Scale (GAF) 5. Psychological Tests FSCID-I and SCID-II - for Axis I and II FMMPI-III and MCMI-2 - for Axis I and II FSIRS - Structured Interview of Reported Symptoms

10. AssessmentAssessment 6. Religious and Spiritual Assessment  gain an understanding of the client ’ s worldview  determine whether the client ’ s religious-spiritual orientation is healthy or unhealthy, and what impact it has on the presenting problem  determine whether the client ’ s beliefs and community can be used as a resource Fdetermine whether the client has unresolved spiritual doubts, concerns, or needs that should be addressed in therapy  To aid in assessment and help identify client ’ s goals: FSpiritual Transcendence Scale FSpiritual Well-Being Scale FTheistic Spiritual Outcome Scale 6. Religious and Spiritual Assessment  gain an understanding of the client ’ s worldview  determine whether the client ’ s religious-spiritual orientation is healthy or unhealthy, and what impact it has on the presenting problem  determine whether the client ’ s beliefs and community can be used as a resource Fdetermine whether the client has unresolved spiritual doubts, concerns, or needs that should be addressed in therapy  To aid in assessment and help identify client ’ s goals: FSpiritual Transcendence Scale FSpiritual Well-Being Scale FTheistic Spiritual Outcome Scale

11. Differential Diagnosis FImportant to distinguish spiritual emergencies from psychotic-like symptoms/disorders Fhttp://www.spiritualcompetency.co m/dsm4/lesson5_1.asp FImportant to distinguish spiritual emergencies from psychotic-like symptoms/disorders Fhttp://www.spiritualcompetency.co m/dsm4/lesson5_1.asp

12. Spiritually-Sensitive Approach FPromote a positive context for client’s experience FProvide them with information about the spiritual emergence process FMove away from the concept of disease, and focus on the potential healing and transformative nature of the experience FInvolve client’s social support network if possible FPromote a positive context for client’s experience FProvide them with information about the spiritual emergence process FMove away from the concept of disease, and focus on the potential healing and transformative nature of the experience FInvolve client’s social support network if possible

13. Goals for Treatment 1) Respond to crisis situation FAim to reduce frequency, duration, and/or intensity of distressful symptoms 2) Normalize the experience FProvide information and resources to the client 3) Encourage emotional release/catharsis through creative expression Fart therapy 4) Psychotherapy to integrate the experience Fnarrative therapy Fexistential, contemplative/transpersonal, integrative approach 5) Enhance positive spiritual outcomes Fas identified by assessment and client goals 6) Facilitate the transformational process FPromote holistic well-being FEncourage psychological and spiritual healing, learning, and growth 1) Respond to crisis situation FAim to reduce frequency, duration, and/or intensity of distressful symptoms 2) Normalize the experience FProvide information and resources to the client 3) Encourage emotional release/catharsis through creative expression Fart therapy 4) Psychotherapy to integrate the experience Fnarrative therapy Fexistential, contemplative/transpersonal, integrative approach 5) Enhance positive spiritual outcomes Fas identified by assessment and client goals 6) Facilitate the transformational process FPromote holistic well-being FEncourage psychological and spiritual healing, learning, and growth

14. Interventions for Spiritual Emergencies For clients in a state of crisis: 1)Use the therapy session to help ground/center the patient “ here and now ”“ here and now ” 2)Create a therapeutic container therapist presence is key - warmth, compassion, non-judgment therapist presence is key - warmth, compassion, non-judgment 3)Normalize and educate 4)Help patient to reduce environmental and interpersonal stimulation 5)Have patient temporarily discontinue spiritual practices 6)Suggest the patient eat a diet of "heavy" foods and avoid vegan diet and fasting 7)Evaluate for medication - refer to psychiatrist For clients in a state of crisis: 1)Use the therapy session to help ground/center the patient “ here and now ”“ here and now ” 2)Create a therapeutic container therapist presence is key - warmth, compassion, non-judgment therapist presence is key - warmth, compassion, non-judgment 3)Normalize and educate 4)Help patient to reduce environmental and interpersonal stimulation 5)Have patient temporarily discontinue spiritual practices 6)Suggest the patient eat a diet of "heavy" foods and avoid vegan diet and fasting 7)Evaluate for medication - refer to psychiatrist

15. Interventions for Spiritual Emergencies After the immediate crisis has subsided: 8)Encourage the patient to become involved in calming activities gardening, walking, relaxation gardening, walking, relaxation 9)Encourage the patient to express their experience through creative and artistic mediums art, music, dance, writing, poetry, drama, etc. art, music, dance, writing, poetry, drama, etc. symbol and metaphor for nonverbal expressions and integration symbol and metaphor for nonverbal expressions and integration After the immediate crisis has subsided: 8)Encourage the patient to become involved in calming activities gardening, walking, relaxation gardening, walking, relaxation 9)Encourage the patient to express their experience through creative and artistic mediums art, music, dance, writing, poetry, drama, etc. art, music, dance, writing, poetry, drama, etc. symbol and metaphor for nonverbal expressions and integration symbol and metaphor for nonverbal expressions and integration

16. PsychotherapyPsychotherapy FAlong with these immediate responses, a more generalized psychotherapeutic intervention should be used to help the client integrate the experience FThis involves a narrative approach, including 3 phases: 1)telling the story of the experience 2)tracing its symbolic/spiritual heritage 3)creating a new personal mythology FAlong with these immediate responses, a more generalized psychotherapeutic intervention should be used to help the client integrate the experience FThis involves a narrative approach, including 3 phases: 1)telling the story of the experience 2)tracing its symbolic/spiritual heritage 3)creating a new personal mythology

17. Prevention Strategy FLearning stress management skills might also be useful for the client to help prevent a re-occurrence of the spiritual crisis: FSelf-monitoring of anxiety FDe-escalation of symptoms through relaxation therapies FKnowledge gained from the therapeutic interventions previously listed FLearning stress management skills might also be useful for the client to help prevent a re-occurrence of the spiritual crisis: FSelf-monitoring of anxiety FDe-escalation of symptoms through relaxation therapies FKnowledge gained from the therapeutic interventions previously listed

18. Spiritual Interventions Spiritual Interventions FFor other less severe spiritual issues and concerns, examples of major therapeutic techniques include: Fspiritual relaxation or guided imagery Fmeditation and/or prayer Fjournaling about spiritual feelings Fstudy of scripture or spiritual texts  using the client ’ s support system Fparticipating in religious services or spiritual gatherings Fencouraging the client to seek guidance from a compassionate religious or spiritual leader Fgiving/receiving blessings Fencouraging forgiveness and/or repentance Fcognitive restructuring of irrational religious or spiritual beliefs (discernment required) FFor other less severe spiritual issues and concerns, examples of major therapeutic techniques include: Fspiritual relaxation or guided imagery Fmeditation and/or prayer Fjournaling about spiritual feelings Fstudy of scripture or spiritual texts  using the client ’ s support system Fparticipating in religious services or spiritual gatherings Fencouraging the client to seek guidance from a compassionate religious or spiritual leader Fgiving/receiving blessings Fencouraging forgiveness and/or repentance Fcognitive restructuring of irrational religious or spiritual beliefs (discernment required)

19. http://www.youtube.com /watch?v=z9nOD6foI64& feature=related http://www.youtube.com /watch?v=z9nOD6foI64& feature=related

20. Mystical Experience http://www.youtube.com/watch?v=UQ44lJ-eItw