When Issues Become Emergencies: Assessment and Treatment of Spiritual Problems

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

2. Introduction • Spiritual practices have beneficial effects on health • For healing of illnesses • Psychological growth • Self-actualization • Spiritual problems • Can emerge spontaneously or during intense spiritual practice • Can resemble a variety of mental disorders • Can lead to disruption in social and psychological functioning

3. Introduction • Misdiagnosis can result in inappropriate treatment and intensification of distressful symptoms • If properly diagnosed and treated, can result in personal growth and healing • Spiritual practices are gaining popularity worldwide • Spiritual problems are likely to increase as well • Therapists should be “spiritually-sensitive” • Increased awareness and understanding • Appropriate treatment approach

4. DSM Diagnosis • 1994 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 • Designated as a “V code”, acknowledging a category of distressing religious and spiritual experiences that are nonpathological in nature • A religious or spiritual problem is not a mental disorder, but is a condition that requires clinical attention • Traditional psychiatry has not differentiated mysticism from psychosis • often misdiagnosed as psychotic disorders • typically treated with psychotropic medication and hospitalization

5. Spiritual Issues • Spiritual issues or concerns are not as sudden or as intense as spiritual emergencies • Include things like: • Loss or questioning of faith • Conversion to new religion or denomination • Moral or ethical issues • Personal identity issues • Existential issues • Trauma • Relationship and family problems • Grief and loss • Physical or terminal illness • Substance abuse • Extremes of thinking or living • Psychological disturbance • Burnout and working with other people in crisis

6. Spiritual Emergency • Spiritual 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 • The practice of personal or spiritual transformation can become a crisis, resulting from a process of growth or change that has become chaotic or overwhelming • It has been described in the sacred literature of all ages, and is recognized as being the result of meditative practices and the mystical path • Individuals may experience: • self identity disintegrating • old beliefs and values no longer hold true • reality is radically changing • new realms of spiritual experiences appear suddenly and dramatically • immense confusion, anxiety, and sometimes impaired functioning • worry that they are going crazy, or experiencing psychosis

7. Spiritual Emergencies • Anomalous experiences: • deviate from the usually accepted explanations of reality • can involve intense emotions, visions, perceptual disturbances, unusual thought processes, tremors, and sensations of heat and energy • Examples include: • intense kundalini awakening • mystical or “peak” experiences • near-death experiences • psychic openings or psi-related phenomena • past-life experiences • shamanic journeys • UFO/alien encounters or abductions • communicating with spirits or channeling • possession states

8. Assessment • Brief Mental Status Exam: • general description and appearance of client • mood and affect • perception • thought processes • level of consciousness • orientation to time, place, and people • memory • impulse control • Disturbances in perception, consciousness, or orientation may indicate: • spiritual emergency • psychotic symptoms • organic brain disorder 2. Subjective Units of Disturbance Scale (SUDS)

9. Assessment 3. Clinical Interview • Listening to client’s story • Building rapport • History-taking • Checklist of symptoms • physical, behavioural, cognitive, emotional • frequency, intensity, and duration 4. Global Assessment of Functioning Scale (GAF) 5. Psychological Tests • SCID-I and SCID-II - for Axis I and II • MMPI-III and MCMI-2 - for Axis I and II • SIRS - Structured Interview of Reported Symptoms

10. Assessment 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 • determine 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: • Spiritual Transcendence Scale • Spiritual Well-Being Scale • Theistic Spiritual Outcome Scale

11. Differential Diagnosis • Important to distinguish spiritual emergencies from psychotic-like symptoms/disorders • http://www.spiritualcompetency.com/dsm4/lesson5_1.asp

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

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

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

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

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

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

18. Spiritual Interventions • For other less severe spiritual issues and concerns, examples of major therapeutic techniques include: • spiritual relaxation or guided imagery • meditation and/or prayer • journaling about spiritual feelings • study of scripture or spiritual texts • using the client’s support system • participating in religious services or spiritual gatherings • encouraging the client to seek guidance from a compassionate religious or spiritual leader • giving/receiving blessings • encouraging forgiveness and/or repentance • cognitive restructuring of irrational religious or spiritual beliefs (discernment required)

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

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