1. Introduction
Version followed: Śrīvidyā worship of the Śrīcakra (Śrī Yantra) and related deity yantras as taught today in the Devipuram Śrīvidyā course structure (lineage of Sri Amritananda Natha Saraswati, called "Guruji" by the institution), the yantra pūjā sequence documented ethnographically in a contemporary South Indian Śrīvidyā temple community (Hirmer 2022), and, for open meditative use, yantra trāṭaka (gazing) as published by Swami Satchidananda of Integral Yoga. Textual background: the Yoginīhṛdaya (Kashmir, 10th–11th c.) as the main textual source for Śrīcakra worship, with the Paraśurāmakalpasūtra and Tripurārahasya as related texts [source: Schwarz Linder handout; Hirmer 2022; Devipuram; Integral Yoga Magazine].
A yantra is a line-based geometric diagram used in Hindu Tantra and Vajrayāna Buddhism as a support for ritual and meditation; a more pictorial counterpart is the maṇḍala. Yantras may be drawn on the ground or paper and discarded after a rite, or carved in stone or metal for temples [source: Britannica]. The best known is the Śrī Yantra or Śrīcakra ("wheel of Śrī"): nine interlocking triangles, five pointing down and four pointing up, which the tradition reads as the interplay of the goddess (Śakti) and Śiva, expressing all cosmic manifestation from and back to the central point, the bindu [source: Britannica; Penn yantra page]. Around the triangles lie lotus petals, circles and an outer square "earthly house" with four gates [source: Penn yantra page].
How change happens, as the tradition holds it: in Śrīvidyā the yantra is the goddess's body and dwelling. The practitioner installs the deity in the diagram and in their own body (nyāsa), worships the retinue goddesses enclosure by enclosure from the outside in, and draws the deity's energy back into the self, aiming at "oneness between practitioners and divinities" (Hirmer 2022). Practitioners in that study describe gradual loosening of body-identification, ego and fear [source: Hirmer 2022]. In open yantra trāṭaka, the stated mechanism is simpler: "repeated concentration and meditation on a visual form" steadies the mind [source: Integral Yoga Magazine]. These are the tradition's own accounts, neither endorsed nor disputed here.
For the psychotherapist this is a contemplative and devotional practice of a living tradition, not a therapy. Most Śrīcakra worship is taught after mantra initiation (dīkṣā) by a guru, so this guide gives only the public outline of the ritual and refers clients to qualified teachers; the therapist's own work is client-led integration, safety and adverse-effect care [synthesis].
2. Framework
There is no therapeutic phase model; the frame below has two layers.
A. The tradition's path (as institutions publish it).
- Entry: Devipuram requires a "Starter Regime" and an application before its Beginner's course and calls Śrīvidyā "a lifelong intensive sadhana" [source: Devipuram courses].
- Beginner level (online): mantra initiations (Guru, Gaṇapati, Bālā, Caṇḍī), Gaṇapati yantra pūjā, basics of the chakra system, internal meditations, a simplified fire ritual [source: Devipuram courses].
- Mid level (residential): yantra pūjās of Śyāmā and Vārāhī, drawing the Śrīcakra, its structure and the placement of its deities and their link to the body [source: Devipuram courses].
- Advanced (residential): Lalitā Tripurasundarī with the Navāvaraṇa (nine-enclosure) pūjā and internal worship [source: Devipuram courses].
- Moving between levels: the institution states "44 days practice" of one level's worship before the next. In the community Hirmer studied, initiated practitioners worship Gaṇapati, Śyāmā, Vārāhī and Lalitā in turn, each for 44 days, and may then perform the pūjās singly as needed [source: Devipuram courses; Hirmer 2022].
- Format: daily individual worship at set times of day per deity (for example Gaṇapati and Lalitā in the morning), plus temple worship led by priestesses; the Navāvaraṇa pūjā is long [source: Hirmer 2022]. Course lengths were not found in the sources consulted [uncertain].
B. The therapist's work alongside (not a protocol) [synthesis].
- Assessment and consent: understand the practice's place in the client's life, lineage and teacher; screen for risk factors for adverse meditation effects; agree whether and how the practice will feature in therapy.
- Integration: work with the meaning the client finds in it (devotion, steadiness, identity, community), in the client's language; optionally use the openly taught gazing form as a client-chosen anchor.
- Monitoring: watch for challenging experiences, scrupulosity, and teacher-relationship concerns; adjust with the client and, if they wish, their teacher.
- Moving on: there are no source-given session counts. Shift focus when the client's goals change, when adverse effects need priority, or when questions are doctrinal or ritual (refer to the teacher).
3. Guiding principles
- The tradition owns the practice. Ritual and mantra questions go to the client's guru or priest; you do not teach or correct ritual [source: Vieten et al. 2013 on spiritual competencies; synthesis].
- Client-led, consented, in the client's own tradition. Bring the practice into sessions only if the client asks and agrees on how [synthesis].
- Restricted content stays restricted. Never ask for, write down or teach mantras, initiation content or the Navāvaraṇa sequence; Devipuram gives these within initiation [source: Devipuram courses; synthesis].
- Attribute concepts, do not adjudicate them. Speak of Devī, Śakti, the bindu, chakras and kuṇḍalinī as the client's tradition holds them; neither confirm nor dismiss [synthesis].
- Meditation can harm. Pooled adverse-event prevalence in a systematic review was 8.3%, including in people with no prior mental health history; ask about effects routinely [source: Farias et al. 2020].
- Same experience, different meaning. An experience may be valued by one person and distressing to another; let the client's appraisal and functioning guide you [source: Lindahl et al. 2017 via Brown News].
- Intensity and support matter. Practice intensity, psychiatric or trauma history and quality of supervision are teacher-identified influences (hypotheses, not established causes) [source: Lindahl et al. 2017 via Brown News].
- Devotion can mask OCD. Scrupulosity can look like "hyper-faithfulness"; screen for it in precise-recitation practices [source: IOCDF blog].
- Notice the power of the guru relationship. In the community studied, "it is not usual to question the guru"; help the client keep their own judgement without disparaging the bond [source: Hirmer 2022; synthesis].
- No health claims. Yantra worship is not a treatment for physical disease; route health questions to the client's doctor [synthesis].
- You are not the teacher. Avoid dual roles, guard self-disclosure of your own religious commitments, and refer [synthesis].
4. Intervention inventory
Items 4.1–4.3 describe the tradition's practice so you can understand what the client does; you do not teach 4.2 or 4.3. Items 4.4–4.13 are the psychotherapist's own work.
4.1 Yantra trāṭaka (gazing and visualisation), openly taught
- Purpose / when: A concentration practice published openly by Swami Satchidananda (Integral Yoga) for steadying the mind on a visual form [source: Integral Yoga Magazine]. Relevant when a client already practises it, or asks for a tradition-congruent anchor in therapy (see 4.5).
- Steps (as published, in own words): (1) Place a picture of the yantra roughly at eye level. (2) Gaze at it gently, with most attention resting on the central dot. (3) Keep the eyes relaxed; do not strain. (4) After a while, close the eyes and rebuild the image inwardly. (5) When the inner image fades, open the eyes and gaze again. (6) Begin with a few minutes and lengthen gradually. The source gives no fixed posture, distance or time [source: Integral Yoga Magazine]. The tradition reads the central dot as absolute consciousness and the circles as nature's forces expanding outward [source: Integral Yoga Magazine].
- Example language (illustrative): "You mentioned you gaze at the Śrī Yantra in the mornings. What happens for you when you rest your eyes on the centre?"
- Watch for: eye strain or headache (the source warns against strain); visual after-images or perceptual changes that frighten the client; striving or self-criticism about "holding" the image. Working: client reports steadier attention and practises without strain [synthesis for the last two points].
4.2 Yantra pūjā (initiated ritual worship): public outline only
- Purpose / when: The core devotional ritual of Śrīvidyā. Taught after mantra initiation by a guru; at Devipuram, yantra pūjās are given within staged courses [source: Devipuram courses]. Know the outline so you can follow what the client describes.
- Public outline (as documented by Hirmer 2022; no mantras, gestures or breath elements): the practitioner sits before the yantra; the principal deity is invoked into its centre; offerings are made to the deities of each enclosure, moving from the outermost inward; the deity is installed in the practitioner's body (nyāsa); further invocations and offerings of honour (upacāras) follow; at the close the practitioner draws the deity's presence back into the self, and the consecrated offering is shared. Practitioners stress that mantra, thought and action must correspond. The Navāvaraṇa pūjā to Lalitā on the Śrīcakra is the most elaborate form, performed daily in that temple by a priestess [source: Hirmer 2022]. The ritual's procedure, mantras and any breath elements are taught within initiation and are not given here.
- Example language (illustrative): "I won't ask about the mantras or anything you received in initiation. I'm interested in what the pūjā means to you and how it sits in your day."
- Watch for: fear of ritual error (in Hirmer's study some deities are said to be dangerous if not propitiated correctly, and one practitioner says that ignoring Śyāmā's advice brings "problems"): these are tradition beliefs, but in a vulnerable client they can feed scrupulosity (4.11); time demands of long pūjās on sleep, work and family; questions about correct procedure, which go to the teacher [source: Hirmer 2022; synthesis].
4.3 Inner worship and visualisation: public outline only
- Purpose / when: Advanced practitioners move toward internal worship. Devipuram's advanced level includes internal worship of the goddess Parā and internal meditative worship of Bālā; in Hirmer's community, the Lalitā stage includes concentrating at the third eye and meditating on the goddess as a rising sun, and samāyācāra practice involves visualising deities and letters within the body, aiming at union with Devī [source: Devipuram courses; Hirmer 2022]. Devipuram's beginner content includes basics of kuṇḍalinī and the chakra system [source: Devipuram courses].
- Steps: Not given; taught within initiation. Refer (4.7).
- Example language (illustrative): "When you do the inner worship, what do you notice in your body and mood afterwards?"
- Watch for: energy or kuṇḍalinī-type bodily sensations, altered sense of self, or unusual perceptions that the client finds distressing or that persist outside practice; respond with 4.8–4.9 [source: Lindahl et al. 2017 via Brown News; synthesis]. Some Śākta lineages include restricted ritual forms not described here [uncertain: not verified].
4.4 Assessment of the practice and its meaning
- Purpose / when: At intake for any client who mentions yantra worship or Śrīvidyā; repeat when practice changes (new initiation, retreat, new teacher).
- Steps: (1) Ask what the client practises, how often, since when, and with whom (lineage, guru, temple, online course). (2) Ask what it means to them: devotion, protection, steadiness, belonging, identity. (3) Ask about family and community views. (4) Ask about any difficult experiences linked to practice (4.8). (5) Ask what role, if any, they want it to have in therapy. A structured cultural assessment such as the DSM-5-TR Cultural Formulation Interview and its spirituality, religion and moral traditions module can frame this [uncertain: not verified]. Use the competency stance described by Vieten et al. 2013 (respect, knowledge of the tradition, skill in assessment) [source: Vieten et al. 2013, abstract].
- Example language (illustrative): "Tell me about your relationship with Devī and the yantra. What does your practice give you, and has it ever been hard?"
- Watch for: reluctance to speak because of fear of judgement or of breaking confidentiality vows; signal that you will not ask for restricted content. Working: client speaks freely about meaning and difficulties [synthesis].
4.5 Client-led integration in session (spiritually integrated psychotherapy)
- Purpose / when: When the client wants their practice to support therapy goals (steadiness, self-compassion, meaning in grief or illness). Cross-refer Domain VII (spiritually integrated psychotherapy) [synthesis].
- Steps: (1) Get explicit consent and agree the form: talking about the practice, the client bringing a yantra image as a visual anchor, or brief open gazing as in 4.1. (2) Let the client lead with their own words and images; do not introduce ritual elements, mantras or deities yourself. (3) Keep any in-session gazing brief, eyes-open-friendly, and end with orientation to the room. (4) Link the experience to the therapy goal in the client's terms (for example the bindu as a "centre" to return to when overwhelmed). (5) Review: did it help, feel intrusive, or feel like misuse of something sacred? [synthesis]
- Example language (illustrative): "Would it be useful to have your yantra image here while we work on the panic, or would you rather keep it for your own practice? Either is fine."
- Watch for: the client feeling the sacred is being instrumentalised; therapist drift into teacher role; increased ritual pressure. Working: client reports the practice feels more available and their own [synthesis].
4.6 Secular and clinical adaptations
- Purpose / when: For clients who want a concentration practice without devotional content, or where religious use is not appropriate.
- Steps: No published clinical adaptation of yantra worship or yantra gazing was found in the sources consulted. Use established secular programmes instead (Domain II: MBSR, MBCT, MSC, CFT; Domain IV: trauma-sensitive yoga), or a neutral visual-focus exercise that borrows only the structure of 4.1 (gentle gaze on a simple shape, eyes relaxed, short) without presenting it as yantra practice [synthesis].
- Example language (illustrative): "We can practise steadying attention on a simple image here. It's a secular exercise, separate from any religious practice you have."
- Watch for: blurring a sacred object into a technique without the client's agreement; the same adverse-effect signs as in 4.8 [synthesis].
4.7 Referral to and collaboration with a qualified teacher or priest
- Purpose / when: Any question of ritual correctness, initiation, mantra, progression between stages, or doctrinal meaning; when the client wants their teacher involved in managing difficulties.
- Steps: (1) Ask who their teacher or temple is. (2) With written consent, agree what may be shared. (3) Frame contact around the client's welfare (for example a temporary reduction in practice, or what the tradition says about pausing). (4) Keep clinical and religious roles distinct; you advise on mental health, they on practice. Institutions such as Devipuram offer structured courses and a volunteer forum for practice questions [source: Devipuram courses; synthesis].
- Example language (illustrative): "That question about how the pūjā should be done is one for your teacher. Would it help to plan what you'll ask them?"
- Watch for: a client using you to get around a teacher, or using a teacher to avoid clinical care; teachers who dismiss mental-health concerns. Do not encourage the client to seek restricted practices outside legitimate teachers [synthesis].
4.8 Screening and monitoring for adverse meditation effects
- Purpose / when: Before intensive practice (residential courses, long pūjās, retreats) and at regular review for any active practitioner.
- Steps: (1) Screen for risk factors teachers commonly name: high practice intensity, psychiatric or trauma history, limited supervision [source: Lindahl et al. 2017 via Brown News]. (2) Clients with serious psychiatric disorders should discuss intensive practice with their care team first (VA Whole Health advice as reported) [source: Psychotherapy Networker]. (3) Ask across the seven domains Lindahl et al. describe: cognitive, perceptual, affective, somatic, conative (motivation), sense of self, social [source: Lindahl et al. 2017 via Brown News]. (4) Note that the most commonly reported adverse events in a systematic review were anxiety, depression and cognitive anomalies [source: Farias et al. 2020]. (5) Record onset, duration and link to practice changes.
- Example language (illustrative): "Some people find that practice brings up difficult things: sleep changes, fear, odd perceptions, feeling unreal. Has anything like that happened for you?"
- Watch for: insomnia, involuntary movements, light or sound sensitivity, panic, loss of emotion, or positive states (oneness) that go on too long or disorient [source: Lindahl et al. 2017 via Brown News]. Effects can last days, months, or in some cases more than a decade [source: Lindahl et al. 2017 via Brown News].
4.9 Responding to challenging experiences: dose reduction, grounding, differential assessment
- Purpose / when: When 4.8 finds distressing or impairing effects.
- Steps: (1) Normalise without dismissing: such experiences are documented and not the person's fault [source: Lindahl et al. 2017 via Brown News]. (2) With the client (and teacher if wished), reduce intensity: shorter or fewer sessions, pause inner visualisation, keep eyes open [synthesis; eyes-open and external focus from Goodman in Psychotherapy Networker]. (3) Grounding: walking, talking, physical activity, external sensory focus [source: Psychotherapy Networker]. (4) Assess differentially for psychosis, mania, depression or dissociation using standard assessment, without pathologising spiritual experience; DSM-5-TR includes a code for a religious or spiritual problem, Z65.8 [source: ICD-10-CM Z65.8]. (5) Arrange urgent psychiatric review for psychotic or manic features, suicidality, or inability to function. (6) Offer specialist resources: Cheetah House provides consultations, support groups and crisis-help pages for meditators in distress [source: Cheetah House resources].
- Example language (illustrative): "What you're describing is something other practitioners have reported too. For now, let's see whether keeping your eyes open and doing a shorter pūjā settles things, and keep an eye on sleep."
- Watch for: improving sleep and day-to-day functioning (working); escalating perceptual changes, grandiosity, reduced need for sleep, paranoia or loss of reality testing (escalate) [synthesis].
4.10 Trauma-sensitive adaptation
- Purpose / when: Clients with trauma histories who practise yantra gazing or pūjā, or who want to.
- Steps: (1) Offer choice and control at every point (eyes open or closed, length, stopping). (2) Prefer eyes-open, external-focus practice; yantra gazing is naturally external, so keep the inner-visualisation phase short or optional. (3) Watch arousal and pause before overwhelm. (4) Be cautious with practices involving body touch (nyāsa) or bodily energy imagery if the body is a trauma site; discuss with the client how their teacher could adapt. (5) Avoid recommending intensive or residential practice during active trauma symptoms [source: Psychotherapy Networker, reporting Goodman on eyes-open practice and on not recommending intensive meditation to trauma survivors; synthesis]. Trauma-sensitive mindfulness (Treleaven 2018) is a published framework for these adaptations [uncertain: not verified].
- Example language (illustrative): "You're in charge here. Keep your eyes on the yantra, look around the room, or stop at any time."
- Watch for: flashbacks, numbing, dissociation, startle; working: client stays within a tolerable range and reports more choice [synthesis].
4.11 Scrupulosity and fear of ritual error
- Purpose / when: Practices built on exact recitation, correct sequence and correspondence of "mantra, thought and action" (Hirmer 2022), together with beliefs that wrongly performed worship can bring harm, can become a focus for religious OCD.
- Steps: (1) Screen: repeated re-starting of pūjā, checking, reassurance-seeking from the guru or priests, distress out of proportion to tradition norms, practice time expanding. Scrupulosity is often mistaken for devotion, and sufferers may seek constant reassurance from faith leaders [source: IOCDF blog]. (2) Distinguish tradition-normative care from compulsion by asking what the teacher and community expect. (3) If OCD is present, offer ERP; with consent, consult the client's religious authority to agree what the tradition actually requires, so exposures target the OCD and not the faith; clinicians and faith leaders working together is the IOCDF-endorsed stance [source: IOCDF blog; detailed ERP adaptation is synthesis]. (4) Exposures might include completing pūjā once without re-starting, or tolerating uncertainty about a minor error, only within what the teacher accepts [synthesis].
- Example language (illustrative): "Your teacher says one careful performance is enough. The urge to start again is the OCD. Can we practise letting the pūjā end and sitting with the doubt?"
- Watch for: the client experiencing ERP as an attack on faith; reassurance-seeking moving to the therapist. Working: shorter practice time, less distress, practice feels devotional again [synthesis].
4.12 The guru relationship, power and coercive control
- Purpose / when: Śrīvidyā is taught through a guru; in the community Hirmer studied, practitioners describe "sitting at Guruji's feet" and it is "not usual to question the guru" [source: Hirmer 2022]. Assess when the client's autonomy, finances, relationships or safety seem constrained.
- Steps: (1) Explore the relationship respectfully, including its value. (2) Ask about pressure on money, time, sexuality, contact with family, or secrecy beyond normal initiation confidentiality. (3) If concerns arise, support the client's own decision-making; do not label the group. (4) For clients leaving a group, address loss of community, identity and meaning, and any religious trauma [synthesis]. No independent investigation or court finding concerning the institutions named here was found in the sources consulted.
- Example language (illustrative): "How do you and your teacher handle disagreement? Is there room for you to say no?"
- Watch for: isolation, escalating demands, fear of spiritual punishment for leaving; working: client feels able to make choices and keep their practice on their own terms [synthesis].
4.13 Role boundaries and therapist competence
- Purpose / when: Throughout.
- Steps: (1) Build basic knowledge of Śākta and Śrīvidyā terms from reliable sources. (2) Use the 16 spiritual and religious competencies proposed for all licensed psychologists (attitudes, knowledge, skills) as a self-audit [source: Vieten et al. 2013, abstract]. (3) Do not act as guru, priest or ritual adviser; avoid dual relationships (for example attending the client's temple events in a role). (4) Limit self-disclosure of your own religious commitments to what serves the client. (5) Follow your professional ethics code on competence, boundaries and respect for religion [synthesis]. (6) Never endorse claims that yantras or their worship cure physical illness; such claims have no established evidence base [synthesis].
- Example language (illustrative): "I'm not a teacher of Śrīvidyā, so I'll learn from you about it, and your teacher remains the one to guide the practice itself."
- Watch for: curiosity turning into the client teaching you at their expense; your own enthusiasm or scepticism shaping the work [synthesis].
5. Handling problems
The sources used do not address therapy problems with yantra worship directly; the guidance below is synthesis unless tagged.
- Client wants you to teach or check the ritual. Decline warmly, explain your role, and help them prepare questions for their teacher (4.7) [synthesis].
- Client asks you to keep or read initiation material. Do not; it is given under the teacher's authority and stays with them [synthesis].
- Overwhelm during or after practice (panic, depersonalisation, intense energy sensations). Ground first (eyes open, external focus, movement, talking) [source: Psychotherapy Networker]; then reduce dose with the client and teacher; assess differentially and escalate if psychotic or manic features appear (4.9) [synthesis].
- Client fears that pausing practice will offend the deity or bring harm. Do not argue theology. Ask what their teacher and tradition say about pausing or simplifying worship, and support a conversation with the teacher; treat persistent, distressing fear as possible scrupulosity (4.11) [synthesis; belief context from Hirmer 2022].
- Stuck: the practice has become a duty without meaning. Explore what changed (life events, teacher, community); consider whether the client wants to revisit the meaning with their teacher, simplify practice, or step back. Respect any choice, including leaving [synthesis].
- Non-adherence to agreed limits (for example, a residential course despite active symptoms). Explore the pull of the course and what it represents; plan safety (sleep, contact with care team, warning signs, how to reach help) rather than prohibit [synthesis; screening advice from Psychotherapy Networker].
- Resistance to discussing the guru critically. Respect loyalty; ask about concrete experiences rather than the guru's character; return to the client's own goals and wellbeing [synthesis].
- Rupture: the client feels you dismissed or exoticised their faith. Acknowledge, repair, ask what respect would look like; check your own assumptions (4.13) [synthesis].
- Family conflict over practice (time, money, unfamiliar rituals). Treat as a family or couples issue; avoid taking sides on religion [synthesis].
- Health claims (a yantra bought to cure illness or bring fortune). Explore meaning and hope; route health questions to the client's doctor and do not suggest stopping medical care; the practice is not a treatment for physical disease [synthesis].
- Effects persist after stopping. Long-lasting effects are documented [source: Lindahl et al. 2017 via Brown News]; offer ongoing support and specialist resources such as Cheetah House [source: Cheetah House resources].
Sources
- Yantra, Encyclopaedia Britannica
- Hindu Tantric Diagrams (yantra), Patrick A. George, University of Pennsylvania
- Sri Vidya Courses, Devipuram
- Hirmer, M. (2022). The Self as Combination of Deities and Yantras: Divinisation Rituals among Contemporary Śrīvidyā Practitioners in India. Religions 13: 738 (SOAS repository)
- Schwarz Linder, S. (2021). Tantric Elements Embedded in a Purāṇic Context: the Example of the Māhātmyakhaṇḍa of the Tripurārahasya, lecture handout, Oxford Centre for Hindu Studies
- Tratak: Meditation on a Form or Yantra, Swami Satchidananda, Integral Yoga Magazine
- Study documents range of challenging meditation experiences, Brown University News, 2017 (on Lindahl, Fisher, Cooper, Rosen & Britton, PLOS ONE, doi:10.1371/journal.pone.0176239)
- Adverse events in meditation practices and meditation-based therapies: a systematic review. Acta Psychiatrica Scandinavica 2020;142(5):374–393 (PubMed abstract; Farias et al.)
- Cheetah House resources
- Lyford, C. (2022). Is Meditation as Safe as We Think? Psychotherapy Networker
- Discussing Faith and OCD, IOCDF blog, 2023
- Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5(3), 129–144 (Institute of Noetic Sciences page)
- Treleaven, D. (2018). Trauma-Sensitive Mindfulness [uncertain: not verified].
- American Psychiatric Association. DSM-5-TR, Cultural Formulation Interview [uncertain: not verified].
- ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances