DSM-IV religious or spiritual problem approach

1. Introduction

Version followed: David Lukoff's online continuing-education course SCRC 251: DSM-IV Religious and Spiritual Problems (Spiritual Competency Resource Center; undated, references run to about 2001). Lukoff wrote it as co-author of the category, and it sets out the clinical use of the DSM-IV V-code "Religious or Spiritual Problem" (V62.89) that Lukoff, Francis Lu and Robert Turner proposed. Where the course is silent, this guide says so. [source: SCRC 251 intro, lessons 1–6, course PDF]

What it is. This is not a therapy with its own manual. It is a diagnostic category plus a clinical framework built around it. In December 1991 Lukoff, Lu and Turner (UCSF Department of Psychiatry) formally submitted a proposed category called "Psychoreligious or Psychospiritual Problem"; the initial impetus came from the Spiritual Emergence (then Emergency) Network. The APA Committee on Religion and Psychiatry and the NIMH Workgroup on Culture and Diagnosis supported it. The full rationale appeared in Journal of Nervous and Mental Disease (Lukoff, Lu & Turner, 1992). In January 1993 the DSM-IV Task Force accepted it, renamed it "Religious or Spiritual Problem" and shortened the definition, and it was published in DSM-IV in 1994. [source: SCRC Lesson 1.1] According to the course, the published DSM-IV text gives loss or questioning of faith, problems with conversion to a new faith, and questioning of spiritual values as examples. It names only two of the original proposal's four religious-problem types. [source: SCRC Lesson 1.1; course PDF] Per the Lukoff profile at the Institute for Meditation and Psychotherapy, the code is "now a Z code in DSM-5-TR". [source: IMHU Lukoff page] Lu went on to help develop the DSM-5 Outline for Cultural Formulation and the Cultural Formulation Interview, which ask explicitly about religion and spirituality. [source: IMHU Lu page] [uncertain: the exact DSM-5-TR code number and wording; check your current DSM/ICD edition before coding.]

Core idea of change. Distressing religious and spiritual experiences, from loss of faith to mystical, near-death or kundalini-type crises, are often non-pathological problems. Treating them as disorders produces misdiagnosis and iatrogenic harm. Change comes from three things. First, accurate recognition and differential diagnosis. Second, a supportive, normalising container during any acute crisis. Third, psychotherapy that helps the person tell the experience, link it to shared religious and mythic meaning, and build a new life-guiding "personal mythology". The aim is to integrate the experience, not suppress it. [source: SCRC Lessons 1.1, 6.1, 6.2] The course's four stated aims for the category are greater diagnostic accuracy, less iatrogenic harm, more clinical research and better training. [source: SCRC Lesson 1.1]

2. Framework

The sources give no fixed session count or manualised stages. The structure below is the course's own sequence: types, then co-occurrence, then differential diagnosis, then interventions. Lesson 6.2 lays out the three-phase integration model. [source: SCRC intro TOC, Lessons 4–6] [synthesis: arranging the material into stages A–D is mine.]

Stage A – Recognition and religious/spiritual history. Goal: notice that religion or spirituality is a focus of clinical attention and identify the problem type. The course divides these into religious problems (loss or questioning of faith; changes in membership, practice or belief, including conversion and intensification; new religious movements and cults; terminal or life-threatening illness) and spiritual problems (mystical, near-death, meditation and spiritual-practice related including kundalini, psychic, visionary, shamanic, alien-encounter and possession experiences). [source: SCRC intro TOC; course PDF] Format: part of intake. Move on once the type and the person's religious context are known.

Stage B – Differential diagnosis and coding. Goal: decide whether this is a religious or spiritual problem alone, a mental disorder, or both. The V-code can be coded alongside any co-existing Axis I disorder. Use it when religious factors "warrant independent clinical attention and are explicitly addressed in treatment". [source: SCRC Lesson 4] Tools: Lukoff's three criteria, Greenberg and Witztum's criteria, and the OCD/scrupulosity criteria (§4). Move on once you have a working diagnosis and a risk judgement.

Stage C – Acute crisis management (only if functioning is impaired). Goal: stabilise without halting the process. Use the nine acute-crisis interventions (normalise, container, reduce stimulation, pause practices, ground in session, "heavy" diet, simple activities, creative arts, medication evaluation) and educate the family. [source: SCRC Lesson 6.1] Intensity of care ranges widely. At one end is time-limited support from relatives, friends, support groups and medical staff. At the other is intensive long-term psychotherapy, and in severe cases residential round-the-clock support. Choose by the problem's intensity, duration and type, the individual, and their support network. [source: SCRC Lesson 6.1] The main criterion the author gives for deciding on medication is whether the person's situation can support intensive inner work. [source: SCRC Lesson 6.1] Example durations in the sources: Perry's Diabysis residents usually resolved within 6–8 weeks, with Perry seeing one patient three times a week. At The Ojai Foundation, two weeks of round-the-clock support stabilised one person. [source: SCRC Lessons 3.7, 6.1] Move on when the person is oriented and safe, can function at the level their setting requires, and the acute intensity is settling. [synthesis: these transition criteria are mine; the course gives none.]

Stage D – Psychotherapy and integration (three phases). [source: SCRC Lesson 6.2]

D1, telling the story. Usually first, and it continues the acute normalising work. Goal: a full, co-authored account with a shared non-pathological name and a timeline.
D2, tracing the symbolic and spiritual heritage. After the story is told and the crisis has settled. Goal: separate valid spiritual elements from grandiose or inflated content, and link private symbols to shared religious imagery.
D3, creating a new personal mythology. After D1–D2, or on its own. Goal: a sustaining myth of identity, direction and purpose. Alongside these, use spiritual interventions where they fit: education, community, credible leaders, practices consistent with belief, and appropriate modelling. Session count is not specified. [uncertain] For an outpatient course without acute crisis, weekly sessions seem reasonable, with D1 taking a few sessions and D3 open-ended. [synthesis]

Type-specific tracks run alongside A–D, e.g. Hastings' seven-step counselling for psychic experiences, exit-counselling stance for cult involvement, chaplaincy collaboration in terminal illness (§4).

3. Guiding principles

[source: SCRC Lessons 1.1, 4, 5, 6.1, 6.2, 3.10; Stagno 2011 review of Peteet, Lu & Narrow; synthesis where marked]

Do not presume pathology. The course argues psychiatry has long pathologised religion, citing Freud, Ellis and the 1976 GAP report. It also cites findings that religiosity is not linked to psychopathology in non-patients. In practice: start from "this may be a normal, if painful, religious or spiritual process" and let the evidence move you.
Do not presume normality either. Religious and spiritual problems co-occur with the full range of disorders, especially mania and psychosis. The V-code can sit beside a disorder. In practice: assess for both, and code both when both are present.
Discernment. Chris Cook (quoted in the course): spiritual discernment is "of at least equal, if not greater, importance" than differential diagnosis. In practice: ask what the experience means and does within the person's tradition, not only whether it is a symptom.
Know the client's religious subgroup. Differential diagnosis needs knowledge of which religious expression is acceptable and culturally validated in the person's community. In practice: learn the norms, or consult someone who knows them, before calling a belief delusional or a ritual compulsive.
Cultural competence is an ethical duty. The course cites the APA Ethics Code standard on human differences (then 1.08): get training, consultation or supervision, or refer. In practice: if you lack the knowledge, consult or refer rather than improvise. [uncertain: the course cites the pre-2002 numbering; the current APA code places this under Competence (2.01b).]
Avoid iatrogenic harm. Labelling a devout person's beliefs neurotic preceded a suicide attempt in a course case, and hospital records in Lukoff's case studies omitted spiritual content and labelled it delusional. In practice: never interpret faith away, and record the spiritual content accurately.
Least restrictive care, safety first. Avoid hospitalisation or medication when less restrictive options suffice, but imminent danger to self or others overrides. In practice: decide level of care by risk and support system, not by how strange the content is.
Facilitate, do not interfere. Perry's container: empathy, active encouragement, loving appreciation of emerging qualities, facilitation rather than interference. In practice: your job is to support the process to its natural end, not to stop it.
Calm, warm presence. Cortright: warmth, softness, calm and quiet confidence reassure, while hardness or coldness can be "highly jarring". In practice: slow down, lower your voice, and stay steady.
Two-way understanding. Following Laing and Jaspers, the therapist must "reach across this abyss" rather than leaving all the work of being understood to the patient. In practice: you work to understand their language; they are not required to translate into yours.
Work within the client's belief system. Religious convictions can be used effectively in therapy even if the therapist doubts their objective value (APA Task Force, cited in the course). In practice: use their terms and symbols, and bring in their clergy where useful.
Judge consequences, not doctrine. With new religious movements, assess psychological consequences without judging the group's beliefs, and avoid coercive deprogramming. In practice: ask "how is this affecting you?", not "is this group legitimate?"
Informed, shared medication decisions. Any medication needs the person's full understanding and consent, and they should take an active part in the decision. In practice: present medication as a tool that can titrate intensity, not as proof of illness.
Involve the network. Family and friends' attitudes shape course and outcome, so educate them. In practice: offer a family session early in any acute crisis.
Countertransference awareness. Gellerman and Lu (via Stagno's review) warn of bias from limited knowledge or the clinician's own religious or cultural background. In practice: check your own faith, scepticism or enthusiasm before interpreting. [source: Stagno 2011]
Modelling one's own spirituality only "when appropriate". The course allows it but does not define when. In practice: disclose sparingly, only for the client's benefit, and never to recruit them. [synthesis on limits]

4. Intervention inventory

The inventory has four groups: A, assessment and diagnosis; B, acute spiritual-crisis interventions; C, psychotherapy and integration; D, problem-type-specific procedures. All example language is my own and marked (illustrative). Terms such as kundalini, chakras, spirits and possession are reported as the traditions' and authors' own concepts, not as fact.

A1. Recognising and coding Religious or Spiritual Problem

Purpose / when: At intake or whenever religious or spiritual material becomes a focus. Coding it makes the issue legitimate and documented. [source: SCRC Lessons 1.1, 4]
Steps: (1) Ask whether the presenting distress centres on faith, a religious or spiritual change, or an unusual spiritual experience. (2) Classify it by type (Stage A list in §2). (3) Decide whether it warrants independent clinical attention and will be explicitly addressed in treatment. If so, code the V-code (now a Z code; check your edition). (4) Code any co-existing disorder as well. The course is explicit that the category can be assigned alongside another Axis I disorder, e.g. with a psychotic disorder that has mystical features. (5) Record the spiritual content accurately rather than labelling it simply "delusional". [source: SCRC Lessons 4, 6.2]
Example language (illustrative): "What you're describing sounds like a real spiritual crisis, and I want our work to take that seriously, not just treat it as a symptom."
Watch for: Using the code to avoid diagnosing a treatable disorder, or the reverse. It is working when the client feels their experience was heard on its own terms and your notes reflect what they actually reported.

A2. Religious and spiritual history; cultural formulation

Purpose / when: Every client for whom religion or spirituality matters. It is essential in terminal illness, where the course recommends asking about "why me?" questions and taking a religious/spiritual history. [source: course PDF, Lesson 2.5] The course's dedicated spiritual-history lesson is not drawn on here. [uncertain] Gellerman and Lu's chapter offers practical interview questions for bringing religion into the DSM cultural formulation. [source: Stagno 2011] The DSM-5 Cultural Formulation Interview, co-developed by Lu, includes religion and spirituality as explicit areas. [source: IMHU Lu page]
Steps: [synthesis, organised around the domains the course and CFI name] (1) Upbringing and current affiliation, and the community's norms. (2) Current practices, including intensity and any recent intensification or retreats. (3) Recent changes: conversion, leaving, a group joined, a teacher left. (4) Unusual experiences: mystical, near-death, psychic, visionary, possession, energy phenomena. (5) Meaning the person makes of their illness or crisis, including sin-causes-illness beliefs, which the course notes are associated with worse outcomes. (6) Spiritual resources: community, clergy, practices. (7) The client's wishes about including religion in therapy and involving religious leaders.
Example language (illustrative): "Some people find their faith or spiritual life is part of what's going on, either as a support or as a source of struggle. Is that true for you?"
Watch for: Shame or fear of being called "crazy", which suppresses disclosure; ask in a matter-of-fact tone. It is working when spiritual content is volunteered rather than extracted.

A3. Lukoff's diagnostic criteria for spiritual emergency (1985)

Purpose / when: Unusual experiences with psychotic-like features: hallucinations, delusion-like beliefs, ecstatic states. Lukoff presented the criteria as hypotheses still needing validation for reliability and outcome prediction. [source: SCRC Lesson 5]
Steps: Check three criteria.
1. Phenomenological overlap with a spiritual-emergency type, illustrated for mystical experience by five features: (a) ecstatic mood; (b) a sense of newly gained knowledge or revelation; (c) perceptual alterations such as light experiences and religious voices or visions; (d) delusion-like content centred on mythic themes. The course lists eight themes, after Perry: death; rebirth; journey or mission; encounters with spirits; cosmic conflict; magical powers; a new society; divine union. (e) Absence of conceptual disorganisation: thought blocking, incoherence and language disturbance count against spiritual emergency.
2. Good prognostic signs: good functioning before the episode; acute onset (three months or less); a stressful precipitant; a positive, exploratory attitude toward the experience.
3. No significant suicidal or homicidal risk. This is exclusionary and applies only where danger appears imminent. Bizarre behaviour without danger does not trigger it.
Example language (illustrative): "When this started, what was happening in your life? … And how do you feel about the experience now: curious, frightened, or both?"
Watch for: The course itself says the distinction often stays difficult even with these criteria. Non-mythic, persecutory or bodily-intrusion delusions (e.g. thoughts broadcast by a transmitter) do not fit the mythic themes. Reassess repeatedly. [source: SCRC Lesson 5]

A4. Greenberg and Witztum's guidelines: religious experience vs psychotic symptoms

Purpose / when: Religious clients, especially from devout communities, with voices, visions or messages. Developed with ultra-Orthodox Jewish patients in Israel. [source: SCRC Lesson 5; course PDF]
Steps: Features that point toward psychosis: (1) very personal experiences such as special messages from religious figures; (2) details beyond accepted beliefs, or intensity beyond what is normal in the community; (3) terror rather than excitement; (4) preoccupation, with little else on the person's mind; (5) onset along with decline in social skills and personal hygiene. Weigh these against community norms.
Example language (illustrative): "In your community, would others recognise this kind of experience? How would your rabbi or pastor see it?"
Watch for: The course warns that genuine intense religious experiences can also be frightening, preoccupying and tied to private ritual. Apply the guidelines with cultural and contextual sensitivity, not mechanically.

A5. Distinguishing religious OCD (scrupulosity) from devout practice

Purpose / when: Excessive prayer, purity rituals, fears of doing rituals wrongly. [source: SCRC Lesson 4]
Steps: Check Greenberg and Witztum's four criteria: (1) the behaviour goes beyond what religious law requires; (2) it focuses on one specific area rather than overall practice; (3) the focus is typical of OCD (cleanliness, checking, blasphemous obsessions); (4) many important parts of religious life are neglected. For assessment they recommend meeting with the patient's religious leader present and using the patient's religious terms and symbols. Code the V-code alongside OCD where religious factors are explicitly addressed.
Example language (illustrative): "Would your community's teachers say this much prayer is required, or is this something you feel driven to do?"
Watch for: In the course's example a man prayed nine hours a day against a usual 40–90 minutes. If OCD is confirmed, standard OCD treatment applies, with any exposure work agreed with the client and ideally sanctioned by their religious authority. Exposure needs informed consent, a graded plan and a check for contraindications. [synthesis: the treatment step is mine; the course stops at differential diagnosis.]

A6. Content as a diagnostic clue

Purpose / when: Mystical vs psychotic vs drug-induced accounts. [source: course PDF, Lesson 3.3]
Steps: Listen to what the narrative centres on. In the content analysis the course cites (Oxman et al.), schizophrenic narratives emphasised illness and deviance, hallucinogen accounts emphasised sensory change, and mystical accounts emphasised religious or spiritual themes.
Watch for: This is one clue among several, never decisive alone. [synthesis]

A7. Risk and level-of-care assessment

Purpose / when: Every acute presentation. [source: SCRC Lessons 5, 6.1, 3.7]
Steps: (1) Assess suicide and homicide risk with standard practice. The course calls this a legal responsibility of licensed clinicians. (2) Assess judgement and reckless behaviour, e.g. reckless driving endangering others. (3) Map the support system. The author ties risk to the support available. (4) Decide the setting. A supportive community or retreat setting can allow deeper work. In a less supportive environment the person may need to keep functioning at a higher level to avoid hospitalisation or loss of job or housing, and may need medication for that. Refer for higher care if the person is a risk to self or, rarely, to others.
Example language (illustrative): "I want to support this process, and to do that well I need to know you're safe. Have you had thoughts of ending your life or hurting anyone?"
Watch for: Loss of faith can bring hopelessness and suicidal ideation; the course gives a graduate-student example. [source: course PDF] Follow standard risk assessment and safety planning, and use lethal-means counselling about storage and removal where indicated. [synthesis]

B1. Normalise the experience

Purpose / when: First response in any acute spiritual crisis. It gives a non-pathological framework. [source: SCRC Lesson 6.1]
Steps: (1) Educate the client and significant others about spiritual emergency as a concept. (2) Offer a "map" of the territory and show that others have travelled it (Cortright). (3) Reframe the experience as potentially positive and healing rather than "bad and sick". (4) Help the client welcome rather than suppress the inner experience. Course examples: Jung calmed a distressed professor by showing him a 400-year-old woodcut matching his vision, and Ram Dass framed a caller's tearfulness and energy as a kundalini reaction.
Example language (illustrative): "Many people across traditions have described experiences very like this. There are names for it, and people come through it, often changed for the better."
Watch for: Normalising must not override signs of disorder or risk (A3, A7). Podvoll is cited as warning the reframe is "not an easy process." Signs it is working: visible relief, less fear of "going crazy", and more willingness to describe the experience.

B2. Create a therapeutic container

Purpose / when: Throughout acute work. [source: SCRC Lesson 6.1]
Steps: Offer Perry's four elements: empathy, active encouragement, loving appreciation of the qualities that are emerging, and facilitation rather than interference. Embody Cortright's qualities of warmth, compassion, softness, calm and quiet confidence. Arrange one or more wise, compassionate guides around the person.
Example language (illustrative): "I'm here, I'm not alarmed, and we'll go through this at a pace you can manage."
Watch for: Your own anxiety leaking out as hurry or clinical coldness. It is working when the client settles in your presence.

B3. Reduce environmental and interpersonal stimulation

Purpose / when: When ordinary stimulation is painful or disrupts inner work. [source: SCRC Lesson 6.1]
Steps: With the client, list the people, places and situations that worsen the crisis, then agree how to limit them for now (e.g. time off, fewer visitors, a quiet room).
Example language (illustrative): "Who or what makes this harder right now? Let's see what we can step back from for a few weeks."
Watch for: Withdrawal sliding into isolation. Keep supportive contact. [synthesis]

B4. Temporarily discontinue spiritual practices

Purpose / when: When meditation (especially intensive retreats), yoga or qi gong triggered or is feeding the crisis. [source: SCRC Lesson 6.1; course PDF Lesson 3.5]
Steps: (1) Ask what practices the person does and how intensively. (2) Recommend pausing them. The course notes teachers usually advise this too, and symptoms often resolve when practice stops. (3) Plan a gradual reintroduction as the person stabilises, ideally with their teacher.
Example language (illustrative): "Your practice opened something big. Pausing it for now isn't abandoning your path; it's letting things settle so you can return to it."
Watch for: Documented meditation-related problems: anxiety, dissociation, depersonalisation, perceptual changes, agitation, muscle tension, and acute psychosis in people with a history of schizophrenia (Walsh and Roche, cited in the course). The course notes DSM-IV does not count voluntarily induced depersonalisation in meditation as Depersonalization Disorder. Screen for psychosis history before encouraging intensive practice. [source: course PDF] [synthesis: the screening advice]

B5. Use the session to ground the client

Purpose / when: When the client is cycling in despair or flooded. From Stuart Sovatsky (Kundalini Clinic) as reported in the course. [source: SCRC Lesson 6.1]
Steps: (1) Redirect the client's attention with your voice and words. (2) Re-establish contact through eye contact, inviting them to "look back at me," and through rapport. (3) Affirm their courage and trust. (4) Channel the energy into a creative outlet that fits them (Sovatsky's client was a singer, so the goal was singing). Sovatsky describes this mutual looking as the start of an open-eyed meditation that grounds the client. Adjust to the phase of the emergency.
Example language (illustrative): "Stay with my voice. Look back at me. That's it. You're here, in this room, with me."
Watch for: Steadier breathing and eye contact, and a return to the present tense. Eye contact can be culturally inappropriate or trauma-activating, so offer alternatives such as feet on the floor or naming objects. [synthesis]

B6. "Heavy" diet; avoid fasting

Purpose / when: The course recommends this as grounding during acute crises. [source: SCRC Lesson 6.1]
Steps: Encourage regular meals with "grounding" foods (whole grains, beans, dairy, meat) over fruit, juice and salads. Avoid sugar, caffeine and other stimulants, and do not fast.
Example language (illustrative): "For now, regular, substantial meals and no fasting. Let's keep your body anchored."
Watch for: This is traditional guidance reported by the course, not tested treatment. Respect religious dietary rules and eating-disorder history, and do not set food quantity targets. [synthesis]

B7. Simple, grounding, calming activities

Purpose / when: Day-to-day, during acute phases. [source: SCRC Lesson 6.1]
Steps: Encourage gardening, knitting, housecleaning, shovelling or sorting. Regular walks, ideally in nature, are "probably the best way" to bring awareness back to the body. Swimming or cycling are fine if already routine. Avoid competitive sports, which the course calls too stimulating.
Example language (illustrative): "What simple, hands-on things do you enjoy? Could you take a walk every day this week?"
Watch for: Better sleep and orientation.

B8. Creative arts

Purpose / when: To express and work through material that cannot be fully put into words. Use in session and at home. [source: SCRC Lessons 6.1, 3.7]
Steps: Offer drawing, painting, clay, music, journaling, poetry or dance. Explore the symbols and metaphors that come up. In Perry's case, drawing brought out death imagery that was then worked with.
Example language (illustrative): "Would you draw what you saw? We can look at it together."
Watch for: Material that escalates arousal. Slow down and return to grounding (B5). [synthesis]

B9. Evaluate for medication

Purpose / when: In every acute crisis, as a decision rather than a default. [source: SCRC Lesson 6.1]
Steps: (1) Weigh the views the course presents. Perry held that medication used only to suppress can freeze the process "in an unfinished state". Victor uses low-dose tranquillising or antipsychotic medication to reduce the most distressing feelings so the experience can be assimilated. Turner prescribes enough to dampen the process so patients can keep working as outpatients rather than be hospitalised. (2) Apply the author's main criterion: can the person's situation support intensive inner work? (3) Refer to a prescriber where the setting is unsupportive or risk is present. (4) Make the decision with the client's full understanding and consent. Prescribing is the prescriber's responsibility; this guide gives no drug or dose detail.
Example language (illustrative): "Medication wouldn't mean your experience isn't real. It can turn the volume down enough for you to work with it. Let's decide together, with a psychiatrist."
Watch for: The course's quiz is explicit that medication is not always contraindicated. Never discourage antipsychotics in established psychotic or bipolar illness. [synthesis]

B10. Educate and involve family and friends

Purpose / when: Acute crises. Their attitudes affect course and outcome. [source: SCRC Lesson 6.1]
Steps: Meet them; explain spiritual emergency and the possibility of positive transformation; teach practical support (calm presence, less stimulation, help with meals and routine); agree warning signs and who to call. [synthesis on the specifics]
Example language (illustrative): "What helps most right now is a calm, ordinary presence. Arguing with the experience or panicking about it tends to make it harder."
Watch for: Family fear driving pressure for hospitalisation, or a family that dismisses real risk.

C1. Telling the story of the experience

Purpose / when: The first integration phase. It reconstructs the person's own account and reconnects them with others. The course explicitly does not treat catharsis as the main mechanism. [source: SCRC Lesson 6.2]
Steps: (1) Have the client talk through, and also write out, a full account of the experience. (2) Agree a mutually acceptable name for the problem. The course proposes "spiritual emergency" as non-pathological. (3) Build a timeline marked with ages and key events; the course credits it with a "therapeutic ordering function". (4) Retell the story back through your interpretations, so that over repeated retellings a jointly authored story emerges. Hillman is quoted that "the story needed to be doctored, not her".
Example language (illustrative): "Would you write the whole thing down, from the first sign to now, and bring it next time? Then let's mark it on a timeline with your age at each point."
Watch for: Re-flooding while telling; pace it and ground as needed (B5) [synthesis]. In Lukoff's three case studies all three clients found writing the story with him "very helpful".

C2. Tracing the symbolic and spiritual heritage

Purpose / when: After the story is told and the crisis has settled. It recovers the valid religious or spiritual dimension and links private symbols to shared meaning. [source: SCRC Lesson 6.2]
Steps: (1) Address the religious content directly rather than dismissing it. (2) Identify the valid spiritual elements and set aside grandiose or inflated content. (3) Explore parallels between the client's images and traditional myths, scriptures and religious imagery (Eliade, Jung). (4) Use those parallels to move from private symbol to shared meaning. Perry is quoted that what remains is "an ideal model and a sense of direction". Lukoff reframed his own experience of being the Buddha and Christ in that way.
Example language (illustrative): "You felt you were Christ. Rather than ask whether that's literally true, what qualities of Christ did you feel? How might those guide how you live?"
Watch for: Embarrassment about past grandiose claims or demanding behaviour, which needs gentle handling. Jung notes psychotic imagery is often chaotic and lacks a coherent cultural context, so parallels may be partial. Ego inflation is called an "occupational risk" of mystical states (course PDF). [source: SCRC Lesson 6.2; course PDF Lesson 3.3]

C3. Creating a new personal mythology

Purpose / when: The third phase, or used on its own. It builds a sustaining personal myth that answers who am I, where am I going, and what it all means. Draws on Feinstein and Krippner, and Keen. [source: SCRC Lesson 6.2]
Steps: (1) Identify the client's existing personal myths and their sources: biological, cultural, personal history and spiritual. (2) Identify dysfunctional myths, especially ones that cast the person as essentially sick or that no longer fit their needs, capacities or circumstances. These are common after spiritual emergencies. (3) Build a new myth using material from the crisis: visions, past-life-type or parapsychological experiences. (4) Weave the images into a coherent mythology. (5) Explore the client's concerns, interests, temperament and imagery for vocational, social and ideological directions. Perry's "wounded healer" theme, and Sally Clay's "spiritual model of recovery", are given as examples. Self-guided writing and storytelling methods (Feinstein & Krippner, Keen) can be assigned as homework.
Example language (illustrative): "If your life were a story, what chapter just ended, and what is this experience asking the next chapter to be about?"
Watch for: A new myth that feeds grandiosity or isolation, or that recasts untreated illness as a mission. It is working when the client can describe a coherent, life-affirming direction and take concrete steps toward it. [synthesis on markers]

C4. Spiritual interventions used "at times"

The course lists five interventions that are "at times" essential to recovery. [source: SCRC Lesson 6.2]

Purpose / when: To counter the isolation of the crisis and use the client's own resources.
Steps: (1) Educate about the spiritual emergence process as a journey with possible positive outcome. (2) Encourage involvement with a spiritual path or community consistent with the client's experiences and values. (3) Encourage guidance from credible, appropriate religious or spiritual leaders; Lukoff integrated his own crisis partly through work with traditional healers. (4) Encourage practices consistent with the client's beliefs, such as prayer, meditation, spiritual reading, worship, ritual, forgiveness and service. Re-time meditation-type practices after an acute crisis (B4). (5) Model your own spirituality when appropriate, conveying meaning, hope and faith.
Example language (illustrative): "Is there a teacher or minister you trust who understands experiences like this? Would you like me to talk with them, with your permission?"
Watch for: The course gives no guidance on harmful practices or unsuitable leaders. Check credibility, get consent for contact, and avoid pushing any path or disclosing your own beliefs in a way that pressures the client. [synthesis]

D1. Loss or questioning of faith

Purpose / when: Doubt after faith-stage transitions (Fowler), ostracism or a shaken worldview, with anger, emptiness, despair, isolation or relief. The course calls this "disenfranchised grief". [source: course PDF, Lesson 2.2]
Steps: (1) Validate it as a real loss and grieve it. (2) Assess suicide risk (A7). (3) Consider Washburn's "dark night" frame, in which the loss may be a turning point. (4) Offer options: work with a religious professional, or build a new personal mythology (C3). (5) Where illness has shaken faith, take a spiritual history; the course cites a Duke study linking feelings of alienation from God or abandonment by one's church to higher mortality in older medical inpatients.
Example language (illustrative): "Losing faith can be like a bereavement that nobody around you recognises. What have you lost, and what, if anything, has opened up?"
Watch for: Never interpret faith itself as neurotic. The course cites a case where that preceded a suicide attempt.

D2. Changes in membership, practice or belief, including conversion and intensification

Purpose / when: Intermarriage, relocation, conversion, or sudden intensification after a religious experience, guilt or trauma. [source: course PDF, Lesson 2.3]
Steps: (1) Screen with Greenberg and Witztum's features (A4). (2) For the newly religious, identify and work through conflicts between the former and current lifestyle, beliefs and attitudes. (3) Work on identity and family relationships. In Spero's case of a 16-year-old's sudden turn to Orthodoxy, no disorder was found and therapy addressed identity. (4) Where conversion affects medical decisions (the course cites a dialysis-refusal case), assess decision-making capacity in the usual way.
Example language (illustrative): "What did you leave behind when you took this path, and what do you still miss or feel conflicted about?"
Watch for: Family conflict, and reflexive pathologising by family or professionals.

D3. New religious movements and high-demand groups

Purpose / when: A client in, joining, or leaving a group. The course notes over 90% of recruits leave new religious groups within two years (Post), and that most such groups are harmless while some are destructive. [source: course PDF, Lesson 2.4]
Steps: (1) Assess vulnerability factors the course lists from Curtis and Curtis, including ego weakness, dissociative tendencies, weak family support, severe childhood abuse or neglect, substance use and unmanageable stress. (2) Check for Wellwood's signs of a pathological group: a leader with total power over members' self-worth, cohesion held by ideology, manipulation of hope and fear, groupthink, and self-styled prophets without substantial training. (3) Use reflective questions adapted from Vaughan: what attracts you, is it fear or love, what are you giving up, are you moving toward something or running from your life? (4) Provide client-centred, non-judgemental therapy focused on psychological consequences. (5) Prefer voluntary exit counselling to deprogramming. The course criticises coercive deprogramming and involuntary hospitalisation. (6) For someone separating from a spiritual teacher, address the loss of spiritual connection and support (Bogart, cited in the course).
Example language (illustrative): "I'm not here to judge the group. I'm interested in what being part of it is doing to you: what it gives you and what it costs."
Watch for: Physical neglect; the course cites an adolescent with anaemia in a dietary-restrictive group. Also watch for abuse, coercion and child-safeguarding concerns, which trigger your usual reporting duties. [synthesis]

D4. Terminal and life-threatening illness

Purpose / when: Fear of pain and death, threats to integrity, afterlife questions, anger at God, guilt over "sins", lapsed practice. [source: course PDF, Lesson 2.5]
Steps: (1) Ask about "why me?" questions and take a religious/spiritual history. (2) Support spiritual thinking and notice whether the person's spiritual striving helps or hinders coping (Millison). (3) Consult a religious professional or chaplain. Hospice standards require spiritual care. (4) Consider "religious prescriptions". In the course's spinal-injury case the consultant recommended psychotherapy on her beliefs, religious music and clergy visits, and the authors judged this ethically sound. (5) Offer compassion, acknowledge anger and guilt, and be present (Penson et al., "Losing God").
Example language (illustrative): "Many people find this illness raises questions about God or meaning. Is that happening for you?"
Watch for: Spiritual withdrawal combined with refusing treatment or food. The course's case S., 58, stopped church after a diagnosis, became depressed and stopped eating. Assess depression and capacity.

D5. Mystical experiences

Purpose / when: Transient states of unity, felt relation to the divine, euphoria, a sense of revealed knowledge (noesis), loss of ego boundaries, altered time and space, and loss of control. [source: course PDF, Lesson 3.3]
Steps: (1) Recognise and diagnose correctly (A3, A6). (2) Avoid hospitalisation or medication when less restrictive options suffice. (3) Normalise (B1) and integrate (C1–C3). (4) Watch for ego inflation.
Example language (illustrative): "What you describe resembles what mystics in many traditions have written about. Let's understand what it means for you."
Watch for: Psychotic features (A3); inflation.

D6. Near-death experiences (NDEs)

Purpose / when: After an NDE, distress such as depression over losing the state, conflict with prior beliefs, over-identification with the experience, fear of losing one's stability, ridicule, isolation, role strain. Some distressing NDEs meet criteria for adjustment disorder. [source: course PDF, Lesson 3.4]
Steps: (1) Distinguish from ICU delirium or "ICU psychosis". Greyson notes such reports are no longer routinely treated with antipsychotics. (2) Avoid antipsychotics for the NDE itself. (3) Use the Lesson 6 interventions: normalise, tell the story, integrate.
Example language (illustrative): "Many people who come close to death report something like this, and it's common to struggle afterwards to fit back into ordinary life."
Watch for: The course's case of a student with anxiety, years later, as life-review scenes seemed to come true. The course framed this as a spiritual problem, not a disorder.

D7. Meditation- and practice-related problems; kundalini

Purpose / when: After intensive practice (many hours daily for weeks) with frightening perceptions or "false enlightenment". The course describes the Tibetan concept sokrlung as a disorder from straining for awareness. Kundalini is described, in the yogic tradition's terms, as energy rising through the chakras. Signs include heat, tremors, involuntary laughing or crying, glossolalia, GI symptoms, rigidity or limpness, and animal-like movements. [source: course PDF, Lesson 3.5]
Steps: (1) Pause practice (B4) and ground (B5–B7). (2) Following Greenwell's guidance in the course, consider a kundalini-type process when there is a description of awakening, regular practice, or deep meditative states. (3) Arrange medical evaluation. The course notes these symptoms can mimic conversion disorder, epilepsy, MS, heart attack and pelvic inflammatory disease, and the emotional symptoms can mimic anxiety, depression or organic syndromes. (4) Integrate (C1–C3).
Example language (illustrative): "Some traditions describe exactly these sensations. Before we go further, let's rule out anything medical with your doctor."
Watch for: Psychosis risk in people with a history of schizophrenia (A3, B4).

D8. Psychic experiences

Purpose / when: Spontaneous apparent telepathy, clairvoyance, precognition, poltergeist-type events or synchronicities that cause fear ("I'm going crazy") and isolation. Yoga and Buddhism call such experiences siddhis and treat them as distractions. [source: SCRC Lesson 3.6]
Steps: Arthur Hastings' (1983) counselling sequence, paraphrased in the course: (1) have the person describe the experience; (2) listen fully and without judgement; (3) where appropriate, reassure them it is not a sign of insanity; (4) identify the type of event; (5) share what is known about that type; (6) where possible develop reality tests to check whether there is a non-psychic explanation; (7) address the psychological reactions. Goal: balance, integration and judgement.
Example language (illustrative): "Let's look at this carefully together, both what it felt like and whether there are ordinary explanations, without deciding in advance."
Watch for: Psychic experiences also occur in psychotic and dissociative states, so they are not diagnostic alone. Assess (A3).

D9. Visionary experiences (Perry's approach, described historically)

Purpose / when: In Perry's account, intense activation of archetypal material with grandiose delusions and hallucinations. [source: SCRC Lesson 3.7]
What the source describes: At Diabysis, Perry gave no antipsychotics, encouraged expression ("work with what the psyche presents"), saw one patient three times a week, used drawing, and allowed about six weeks for the episode plus integration time. Kingsley Hall, Diabysis and Soteria are named as models, and the course notes none is still open.
Steps for today: (1) Assess safety and judgement (A7), since judgement may be impaired. (2) Arrange a safe level of care, which may mean residential or round-the-clock supervision. (3) Provide frequent contact and creative work (B8). (4) Make medication decisions with a psychiatrist (B9). [synthesis: adapting the Perry model to current standards of care]
Example language (illustrative): "Tell me about the images. Would you draw them?"
Watch for: Do not withhold standard psychosis treatment on the strength of this model. [synthesis]

D10. Possession experiences

Purpose / when: An altered state in which the person feels taken over by a spirit, deity or other person, often without later recall. This is valued in many religions' rituals but not normative in Western settings, where it risks misdiagnosis. DSM-IV listed possession trance under Dissociative Disorder NOS, problematic when it impairs functioning or causes marked distress. [source: SCRC Lesson 3.10]
Steps: (1) Apply the Lesson 5 differential criteria (A3–A4), with special attention to the person's religious community and its practices. (2) Prioritise discernment (Cook). (3) Ground the physical aspects (B5). (4) If the person belongs to a group whose practices include possession, include its leaders in the treatment plan. (5) Support integration of the experience within the community.
Example language (illustrative): "In your tradition, how is this understood, and who would usually help someone through it?"
Watch for: Choking, vomiting, frantic movement and contortions are frightening for everyone present. Assess physical safety. Check dissociative disorders and trauma history; the course notes theories linking ritual trauma to identity dissociation. Exorcism is not addressed in the course. [synthesis: see §5 on requests for exorcism]

D11. Shamanic and alien-encounter experiences

The course has lessons on these (3.8, 3.9), but they are not drawn on in this guide. [uncertain] Apply the general sequence: differential (A3), acute interventions (B), integration (C).

5. Handling problems

The course addresses few of these directly. Items marked [synthesis] are my own guidance and are not attributed to Lukoff, Lu or Turner.

Client fears they are "going crazy". Very common with psychic and mystical experiences (Tart, cited in the course). Respond with B1 normalising and Hastings' steps 1–5 (D8), after the differential (A3). Say honestly what you have and have not ruled out. [source: SCRC Lessons 3.6, 6.1]
Overwhelm or flooding in session. Stop exploring and ground (B5): voice, eye contact or other anchors, affirmation, creative channelling. Afterwards, reduce stimulation (B3) and pause practices (B4). Return to the story (C1) only once the client is oriented. [source: SCRC Lesson 6.1] Agree a between-session plan: walks, regular meals, a named support person, and crisis contacts. [synthesis]
Signs of disorder emerge after you framed it as spiritual. Re-run A3. Rising disorganisation, persecutory non-mythic content, onset longer than three months, poor premorbid functioning, terror and preoccupation, declining self-care, or risk all point toward psychosis or mania. Say so openly and code both if both apply. Medication can sit alongside the spiritual frame (B9). [source: SCRC Lessons 4, 5] Tell the client the change is a revision, not a betrayal: "I'm not taking back that this is spiritual. I'm adding that your mind also needs some protection right now" (illustrative). [synthesis]
Client refuses psychiatric evaluation or medication, insisting it is purely spiritual. Without imminent risk, keep the alliance, give information, involve trusted religious figures who may support evaluation, and agree on warning signs that would change the plan. With imminent risk, follow standard emergency procedures; the course treats danger as overriding (criterion 3). [source: SCRC Lessons 5, 6.1] [synthesis on the negotiation]
Family or other professionals push for hospitalisation; or dismiss real risk. Educate the family (B10). Share your risk formulation in a way tied to the support system (A7). Write the spiritual content into the record so other teams do not simply label it delusional (the course's case finding). [source: SCRC Lessons 6.1, 6.2] [synthesis on liaison]
Grandiosity and ego inflation. Do not argue with it directly. In C2, separate valid spiritual elements from inflated ones, and turn "I am X" into "X as a model" (Perry's "ideal model"). Handle later embarrassment gently. [source: SCRC Lesson 6.2; course PDF Lesson 3.3] If grandiosity comes with reduced sleep, pressured speech or risky spending, assess for mania; the course notes religious delusions in about a quarter of hospitalised bipolar patients in one study. [source: SCRC Lesson 4] [synthesis on the mania screen]
Client wants you to confirm metaphysical claims (that the spirit, past life or prophecy is real). The framework works phenomenologically and through meaning. Use Hastings' reality-testing step where the claim is checkable (D8), and otherwise explore what the belief does for the person. Do not affirm or deny the metaphysics. [source: SCRC Lesson 3.6] [synthesis]
Client wants to resume intensive meditation or retreats too early. Agree a gradual reintroduction schedule with their teacher, with stop rules: return of agitation, insomnia, or perceptual change. [source: SCRC Lesson 6.1 (temporary pause, reintroduce as stabilising)] [synthesis on the stop rules]
Rupture from a dismissive or interpretive remark. Course cases show the harm: a devout patient whose beliefs were called neurotic later attempted suicide. If you have pathologised or minimised, name it, apologise, and return to the client's own framing. [source: course PDF Lesson 2.2] [synthesis on repair]
Therapist countertransference (devout, sceptical, or enthusiastic about the experience). Gellerman and Lu warn of bias from one's own religious or cultural background. Seek consultation, and use the cultural formulation to slow your judgement. [source: Stagno 2011] Over-enthusiasm is also a risk: romanticising psychosis as awakening can delay needed care. [synthesis]
Clergy, healer or community leader disagrees with your plan. Clarify roles: they guide the spiritual meaning, you assess mental health and risk. Seek a shared plan and keep the client's consent central. [source: SCRC Lessons 4, 3.10 (involve leaders)] [synthesis on role-split]
Scrupulosity resists change because rituals feel religiously required. Involve the religious leader to set what the religion actually requires (A5), and use that as the target for standard OCD treatment. [source: SCRC Lesson 4] [synthesis on treatment]
Request for exorcism or deliverance, or a group performing one. The course does not address this. [uncertain] Assess physical safety and coercion. Do not perform or endorse religious rites yourself. Support involvement of the client's own legitimate religious authority if the client wishes, and keep providing mental-health care. Treat restraint, deprivation of food, water or sleep, or harm to children as safeguarding matters. [synthesis]
Client in a high-demand group or leaving one. Stay non-judgemental (D3). Do not collude with coercive deprogramming. Address grief, identity loss and practical needs after exit. [source: course PDF Lesson 2.4] [synthesis on post-exit work]
Crisis after psychedelic, plant-medicine or other substance use. The course compares hallucinogen narratives (A6) but gives no protocol. Treat it as harm reduction and integration: rule out medical and substance-induced causes, assess risk, give general education about risks and interactions without dosing, use B and C interventions, and refer as needed. Do not facilitate illegal use. [synthesis]
Non-adherence to homework (writing, timeline, myth work). Shorten the task, write it together in session, or switch to drawing or recording (B8). [synthesis]
Stuck in integration (a coherent story but no change in life). Move to C3 step 5 (vocational, social and ideological directions) and set small concrete actions. [source: SCRC Lesson 6.2] [synthesis on action steps]
Limits of the framework. The criteria in A3 are hypotheses that have not been validated (the course says so). The course's evidence base leans on the author's own sources, and some acute-care advice (diet, Perry's no-medication model) is tradition or historical practice, not tested treatment. Use it as a framework for stance and integration within current standards of care. [source: SCRC Lesson 5; course PDF] [synthesis]

Sources

Sources

Further reading (not drawn on): the SCRC detailed-history page and Lesson 2.1; Lessons 3.8–3.9 and the spiritual-history lesson. [uncertain]

Books and papers cited (not drawn on unless listed above)

Lukoff, D., Lu, F., & Turner, R. (1992). Toward a more culturally sensitive DSM-IV: Psychoreligious and psychospiritual problems. Journal of Nervous and Mental Disease.
Lukoff, D., Lu, F., & Turner, R. (1998). From spiritual emergency to spiritual problem: The transpersonal roots of the new DSM-IV category. Journal of Humanistic Psychology.
Lukoff, D. (1985). The diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
Peteet, J. R., Lu, F. G., & Narrow, W. E. (Eds.) (2011). Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-V. American Psychiatric Publishing.
Hastings, A. (1983). A counseling approach to parapsychological experience. Journal of Transpersonal Psychology.
Greenberg, D., & Witztum, E. (1991). (cited in SCRC Lessons 4–5 on religious OCD and psychotic vs religious experience).
Grof, S., & Grof, C. (Eds.) (1989). Spiritual Emergency.
Perry, J. W. (1974). The Far Side of Madness.
Cortright, B. (1997). Psychotherapy and Spirit.
Feinstein, D., & Krippner, S. The Mythic Path; Keen, S. Your Mythic Journey.

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