Hesychasm, nepsis and the Philokalia

1. Introduction

Version followed: the Byzantine–Slavic Eastern Orthodox hesychast tradition as the Orthodox Church in America (OCA) presents it in its catechetical text "The Jesus Prayer" (The Orthodox Faith, vol. IV, Spirituality). This is supplemented by Kallistos Ware, The Power of the Name (SLG Press), by the pastoral teaching of Hieromonk Irenei (Pikovsky) of Sretensky Monastery (Moscow), and by Encyclopaedia Britannica for the history. Oriental Orthodox (non-Chalcedonian) churches have their own monastic prayer traditions. This guide does not describe them [uncertain: not verified].

What it is. Hesychasm (Greek hēsychia, "stillness, quiet") is a tradition of Eastern Christian monastic prayer. Practitioners seek divine quietness through uninterrupted prayer that involves the whole person. This prayer is often called "pure" or "intellectual" prayer, or the Jesus Prayer [source: Britannica]. Its usual form is "Lord Jesus Christ, Son of God, have mercy on me a sinner", also called the "prayer of the heart" [source: OCA]. Nepsis (watchfulness, sobriety) means guarding attention and the heart against distracting and tempting thoughts. The OCA links it to a "sober invocation" of the Name and to Nikephoros's Discourse on Sobriety [source: OCA]. The Philokalia is an anthology of hesychast writings. It was published in Greek at Venice in 1783 and in Slavonic at St Petersburg in 1793 [source: Britannica]. Its compilers are usually given as Nikodemos of the Holy Mountain and Makarios of Corinth [uncertain: not verified]. Sources also differ on the Greek date (1782 or 1783) [uncertain].

How change happens, as the tradition holds it. The tradition does not frame the practice as psychological change. Ware presents invoking the Name of Jesus as a sacramental act, an effective sign of Christ's presence and action, with which the person co-operates through faith and ascetic effort; in his account mechanical repetition achieves nothing and the prayer is no magic charm [source: Ware, Power of the Name, paraphrased]. Attentive, frequent repetition is said to make prayer more unified and more inward [source: Ware]. The aim is union with God and the service of others. It is not a technique, and the tradition does not regard it as a route to experiences [source: OCA; Irenei]. These are religious claims. They are attributed here, neither affirmed nor dismissed. The practice is not presented as a treatment for any physical or mental disorder.

The psychotherapist's role. This is a contemplative practice taught openly within a living church. The therapist does not teach hesychasm. They support an Orthodox (or Eastern Catholic) client who already prays, or wishes to pray, in their own tradition. They also refer the client to the client's priest or spiritual father, watch for adverse effects and scrupulosity, and keep their own role clear.

2. Framework

The tradition's three uses of the prayer [source: OCA]

Unceasing prayer for all Christians. The prayer is repeated throughout daily activity, with no special posture or breathing. The OCA says anyone may practise this, whatever their occupation. Gregory Palamas taught it, and The Way of a Pilgrim illustrates it.
Brief invocation against temptation. The Name is called on at the moment a temptation or troubling thought arises. The OCA cites John Climacus, who held the Name to be a stronger weapon against temptation than any other.
The hesychast method (silent, concentrated prayer of the heart, including the "psychophysical method"). The OCA reserves it for people of genuine humility and sound judgement, under a spiritual guide "always and without exception", within the total life of the Church.

How the tradition describes progression [source: Ware; OCA]. Early practice is hard. Ware describes it as a hidden, martyr-like struggle, marked by temptation to give up. Over time the prayer is described as becoming more inward and continual. The fathers speak of the mind "descending into" or being united with the heart, bringing joy and freedom from distraction [source: OCA]. Common teaching divides the path into stages: oral, then mental, then prayer of the heart, then "self-acting" prayer. This guide does not give these stages from a primary text [uncertain: not verified]. In the tradition, moving to the hesychast method is decided by the person's spiritual father, not by the practitioner and not by a therapist [source: OCA; Irenei].

Psychotherapy framework [synthesis]. No published protocol integrates hesychasm into psychotherapy as such. A practical sequence is:

(a) Spiritual assessment and consent. Include a spiritual history and the DSM-5-TR Cultural Formulation Interview, including its spirituality, religion and moral traditions supplementary module [uncertain: not verified].
(b) Agree a role for prayer in therapy. Decide whether the prayer has a role at all, how much, and who guides it (usually the priest or spiritual father).
(c) Client-led integration. Bring the prayer into coping and values work in the client's own words.
(d) Monitor continuously. Watch for adverse experiences, scrupulosity and over-reliance on technique.
(e) Review and refer. Review regularly and refer to clergy when needed.

Move from (a) to (c) only when consent is explicit, the client already has or is seeking guidance in their church, and no red flags are present (see 4.10 to 4.12). Session numbers depend on the client's main treatment. No source gives a count for this integration.

Published adaptation. Knabb and Frederick (2017), Contemplative Prayer for Christians with Chronic Worry: An Eight-Week Program (Routledge), gives the Jesus Prayer its own chapter (ch. 4). It sits between chapters on Ignatian prayer and Centering Prayer. Each chapter has goals, techniques, homework and downloadable guided audio [source: Routledge]. It is a broadly Christian (not specifically Orthodox) adaptation. Cross-refer to Domain II (MBSR, MBCT, MSC, CFT) and Domain VII (spiritually integrated and contemplative psychotherapy).

3. Guiding principles

The client's tradition owns the practice. Use the client's words (Jesus Prayer, komboskini or chotki for the prayer rope, spiritual father, prelest) and follow their church's teaching. Do not teach it as a generic mantra. OrthodoxWiki states that the prayer "should not be used as a mantra" [source: OrthodoxWiki].
No technique without a guide. The OCA requires a spiritual guide for the hesychast method "always and without exception". Practical meaning: never coach posture, gaze or breath linkage, and refer such questions to the client's priest or spiritual father [source: OCA].
Quality, not quantity. Irenei teaches "what actually matters is not the number of prayers but their quality". Practical meaning: do not set repetition targets or track counts. Notice when counting becomes compulsive [source: orthochristian.com].
Not a technique, not a talisman. Practical meaning: do not frame the prayer as an anxiety-reduction tool. If the client values calm as a by-product, let them say so in their own terms [source: Ware; OCA].
Do not chase experiences. The OCA warns against accepting visions, images or light experiences, because they can lead to pride and delusion. It calls fixation on pleasant feelings "spiritual hedonism" (Theophan) or "spiritual gluttony" (John of the Cross). Practical meaning: do not encourage or interpret unusual experiences spiritually. Refer them to the client's guide, and assess them clinically when they cause distress [source: OCA].
Embedded in Church life. The tradition places the prayer within sacraments, liturgy, humility and life with others [source: OCA; Irenei]. Practical meaning: ask how the prayer sits within the client's wider church life, and notice isolation.
Concepts are attributed. God, grace, the Name, the uncreated light, demons and prelest are described as the tradition holds them. They are neither affirmed nor dismissed in clinical work.
The therapist is not a spiritual father, confessor or teacher. Practical meaning: no spiritual direction, absolution or rule of prayer from the therapist. Collaborate with clergy when the client wishes [synthesis].
Consent and client lead. Practical meaning: the client decides whether prayer enters therapy at all, and can withdraw that permission [synthesis].
Safety first. Adverse effects of contemplative practice are not rare, and they can occur in people with no prior mental health history [source: Farias et al. 2020]. Practical meaning: screen, monitor and reduce the amount of practice when needed.

4. Intervention inventory

Items 4.1 to 4.6 describe what the tradition teaches openly, so the therapist can understand and respect it. The therapist does not teach these. Items 4.7 to 4.14 are the therapist's own work alongside the practice.

4.1 The Jesus Prayer in daily life (unceasing prayer), as the tradition teaches it

Purpose and when it is used: remembrance of God at all times, open to every Orthodox Christian whatever their occupation, without special posture or breathing [source: OCA].
Publicly taught outline (in summary): The person repeats the prayer (usual form above; shorter forms are used in practice [uncertain: not verified]) inwardly or quietly through ordinary activities. They keep attention on the words and on the One addressed, with what Ware describes as recollection and inner watchfulness [source: Ware, paraphrased]. Many use a prayer rope [uncertain: not verified]. A personal "rule" of prayer is normally agreed with the person's priest or spiritual father [source: Irenei, on obedience and guidance; detail synthesis].
Example language (illustrative): "You said the Jesus Prayer has been part of your day since you were young. How does it fit into your days at the moment?"
Watch for: repetition turning mechanical or anxious; counting as a ritual; prayer used to avoid tasks or relationships. The OCA notes that idleness can be used as a pretext for "praying without ceasing". Signs it is going well (as the client sees it): they describe the prayer as connecting them to God and others, not as a performance.

4.2 Brief invocation in temptation or distress

Purpose and when it is used: a short call on the Name when a temptation or troubling thought arises. John Climacus valued this highly, as cited by the OCA [source: OCA].
Outline: the person turns from the thought to the Name, rather than arguing with the thought [source: OCA, "ejaculatory prayer"; wording synthesis].
Example language (illustrative): "When those thoughts come at night, you said you turn to the prayer. What happens next, in your mind and in your body?"
Watch for: the invocation becoming a neutralising compulsion. Signs are saying it until the thought feels "cancelled", rising distress if it is not said "right", and growing frequency (see 4.12). Note also whether it is being used in place of needed help, such as for suicidal thoughts.

4.3 Nepsis (watchfulness) and attention to thoughts

Purpose: guarding the mind and heart, staying clear-minded and free of images, and keeping attention within the words of prayer [source: OCA; Ware].
Outline: the tradition speaks of sobriety and vigilance. The person notices thoughts as they arise and does not follow or entertain them. They return to the Name and set aside images and imaginings [source: OCA]. The Philokalia's authors develop this theme at length [source: Britannica on the Philokalia; detail not verified].
Example language (illustrative): "In your tradition, watchfulness means noticing a thought before it carries you off. Would it help to look at the worry thoughts that way here, in your own terms?"
Watch for: watchfulness sliding into self-surveillance and moral hypervigilance, with constant checking of thoughts for sin (see 4.12). Notice harsh self-judgement presented as "sobriety". There are conceptual parallels with decentering in MBCT (Domain II), but keep the client's theological frame [synthesis].

4.4 The hesychast method and the "psychophysical method" (public outline only)

What it is: silent, concentrated prayer of the heart. In the late 13th century Nikephoros the Hesychast advised novices to centre their attention within the body during prayer and to join the prayer to breathing [source: Britannica]. Texts later gathered in the Philokalia describe a seated, inward-turned bodily setting. The mind, in their phrase, is placed "in the heart". Rational thoughts and images are set aside, and the fathers report light and joy [source: OCA]. Barlaam the Calabrian mocked the practice in the 14th century. Gregory Palamas defended it, holding that the sanctified body shares in prayer and that the uncreated light of Tabor may be seen. Councils in Constantinople (1341, 1347, 1351) confirmed his teaching [source: Britannica].
Status in the tradition: reserved, guided, and secondary to humility and Church life. The OCA records that the method's abuses were already a concern in Byzantium. It also records that by Bishop Theophan's time bodily postures and breathing techniques were largely discouraged, because people harmed themselves instead of gaining the Spirit [source: OCA]. OrthodoxWiki quotes Theophan on people "ruining their lungs" [source: OrthodoxWiki]. Irenei says "it isn't the rhythm of inhale-exhale that matters" [source: orthochristian.com].
Steps: none given here. This guide gives no posture, gaze, breath-linking, breath-holding or timing instructions. Who teaches it: a spiritual father or experienced monastic guide within the Orthodox Church, typically in a monastic setting [source: OCA].
Example language (illustrative): "That sounds like something your tradition says should be learned with a spiritual father. Is that someone you have, or could ask?"
Watch for: a client self-teaching the bodily method from books, videos or apps; breath-holding or forced breathing; dizziness, chest discomfort or headache. Gregory of Sinai, as reported by Ware, mentions aching shoulders and head pain as discomforts to endure [source: Ware]. Route physical symptoms to the client's doctor and technique questions to the guide.

4.5 Reading the Philokalia and related spiritual writings

Purpose: formation in the tradition. Irenei recommends St Ignatius (Brianchaninov) and St Theophan the Recluse's writings on prayer [source: orthochristian.com]. The Way of a Pilgrim is the popular narrative of a layman learning unceasing prayer [source: OCA].
Outline: reading is usually done with guidance from a priest or spiritual father [synthesis, consistent with OCA and Irenei].
Example language (illustrative): "What have you been reading lately in the Philokalia? What do you take from it for this part of your life?"
Watch for: reading texts written for monastics as rules for lay life, leading to austerity, isolation or harsh self-judgement. Notice especially compulsive reading for reassurance. Irenei criticises The Way of a Pilgrim for linking prayer to counting, posture and breathing [source: orthochristian.com].

4.6 Spiritual guidance and Church life

Purpose: the tradition locates the prayer within confession, Holy Communion and liturgy, and under obedience to a spiritual father [source: OCA; Irenei].
Outline: the client brings their prayer life to their priest or spiritual father, who sets or adjusts the prayer rule [source: Irenei; detail synthesis].
Example language (illustrative): "Who in your church do you talk to about how your prayer is going?"
Watch for: an absent guide, or a guide relationship that seems controlling (see 4.14).

4.7 Spiritual assessment and consent

Purpose: to learn what the prayer means to the client and agree whether and how it enters therapy. Use at intake or whenever the client raises prayer [synthesis].
Steps: (1) Ask open questions about tradition, parish, practice and guidance. (2) Where available, use the DSM-5-TR Cultural Formulation Interview and its spirituality, religion and moral traditions supplementary module [uncertain: not verified]. (3) Ask how the client hopes faith will figure in therapy, or not. (4) Record explicit consent, including what the therapist will and will not do: no teaching of method, no spiritual direction. (5) Screen for adverse-experience risk (4.11) and scrupulosity (4.12).
Example language (illustrative): "Some people want their faith to be part of therapy and others prefer to keep it separate. Either is fine. What would suit you?"
Watch for: the client feeling judged, or assuming the therapist shares or rejects their faith. A sign it is working: the client speaks freely in their own religious vocabulary.

4.8 Client-led integration in session

Purpose: to let the client draw on their own prayer as a resource for coping, values and meaning, within spiritually integrated psychotherapy (cross-refer Domain VII) [synthesis].
Steps: (1) The client chooses whether and when to pray. Examples: silently at the start or end of a session, or as their own response when worry rises. The therapist neither leads nor joins unless the client asks, and even then stays non-directive. (2) Link the prayer to treatment goals in the client's words, for example as a way of returning from rumination to what the client values. (3) Agree any between-session use in the client's own terms, with no counts or durations set by the therapist. (4) Review its effect, the client's sense of closeness to God, and any distress. For a structured Christian-contemplative format that includes the Jesus Prayer, see Knabb and Frederick (2017), chapter 4 of an eight-week programme for chronic worry [source: Routledge]. It is a non-Orthodox adaptation, so check that it fits.
Example language (illustrative): "When the worry spirals, you said turning to the prayer helps you hand it over to God. Shall we include that in your plan for evenings, in whatever way you and your priest think is right?"
Watch for: the therapist drifting into teaching or prescribing prayer; the prayer becoming a symptom-control tool against the client's own theology; reduced practice being experienced as spiritual failure.

4.9 Referral to, and collaboration with, a priest or spiritual father

Purpose: the tradition requires guidance, and the OCA states it is essential for the hesychast method [source: OCA]. Use when the client asks about method or rule of prayer, reports unusual experiences, has scrupulosity, or wants spiritual direction.
Steps: (1) Ask whether the client has a confessor or spiritual father. (2) With written consent, offer a joint conversation or a letter limited to agreed content. (3) Clarify roles: clergy for spiritual guidance and the prayer rule, the therapist for mental health. (4) Agree how to respond to warning signs.
Example language (illustrative): "Questions about how to pray belong with your spiritual father, not with me. Would it help if we thought together about what you want to ask him?"
Watch for: the client being pulled between therapist and clergy; confidentiality limits; a guide who discourages all mental health care. Explore this respectfully and do not set yourself against the church [synthesis].

4.10 Trauma-sensitive adaptation

Purpose: inward-turning, interoceptive or silent practice can heighten traumatic arousal or dissociation. Trauma-sensitive mindfulness (Treleaven 2018) is a published adaptation of meditation [uncertain: not verified]. Cross-refer Domain IV (trauma-sensitive yoga) and Domain II.
Steps (synthesis): (1) Prefer the tradition's lay form (4.1), said aloud or with eyes open, in short periods, during ordinary activity. Avoid inward bodily focus. (2) Offer external anchors such as the prayer rope in the hand, an icon, or the feet on the floor. (3) Agree stop signals and grounding options. (4) Watch for theological themes ("sinner", "mercy") that touch on shame or religious trauma, and explore their meaning with the client. Do not edit the prayer for them; any change belongs to the client and their priest.
Example language (illustrative): "If silent prayer brings up the old memories, would it feel right to say it aloud while holding your prayer rope, with your eyes open?"
Watch for: dissociation (glazed look, loss of time), flashbacks, panic, shame spirals. A sign it is working: the client can pray and stay oriented to the room.

4.11 Recognising and responding to adverse experiences

Purpose: a systematic review of 83 studies found adverse events in meditation reported in 65% of studies. Pooled prevalence was 8.3%. The most common were anxiety, depression and cognitive anomalies, and they occurred even in people with no prior mental health history [source: Farias et al. 2020]. The Varieties of Contemplative Experience study (Lindahl et al. 2017, PLOS ONE) documented challenging experiences in Western Buddhist meditators. These included energy-like bodily sensations, light experiences, changes in sense of self, fear and terror, and delusion-like ideation [source: Cheetah House]. No equivalent study of Orthodox hesychasts was found in the sources consulted [uncertain]. The tradition itself warns against visions and pleasant sensations, and against prelest (spiritual delusion and pride) [source: OCA].
Steps: (1) Before intensive practice or a monastic stay, screen for psychosis, bipolar disorder, recent trauma, dissociation and suicidality [synthesis]. (2) If problems arise, reduce the amount of practice, shift to the lay oral form, and use grounding: sleep, meals, activity, people [synthesis; Cheetah House offers support and clinician training]. (3) Assess carefully. Tell spiritual experiences apart from psychosis, mania, depression or dissociation without pathologising faith and without missing illness. DSM-5-TR has a code for a religious or spiritual problem (Z65.8) when the focus of care is religious or spiritual. (4) With consent, coordinate with the spiritual father, whose tradition already counsels caution about such experiences.
Example language (illustrative): "Your tradition says not to chase or trust experiences like that light. I'd also like to check your sleep and mood, so we can see the whole picture."
Watch for: sleep loss, grandiosity, special-mission beliefs, voices, rising fear, depersonalisation. Arrange urgent psychiatric assessment if there is risk.

4.12 Scrupulosity and religious OCD

Purpose: the prayer's repetition and its confession of sinfulness can be drawn into OCD. IOCDF lists compulsions such as excessive or repeated prayer, "saying a prayer over and over again until it is done 'just right'", over-confessing and reassurance-seeking [source: IOCDF].
Steps: (1) Assess whether the prayer is driven by fear and distress and narrows onto one practice, which IOCDF calls typical of scrupulosity, or whether it fits the client's faith. (2) Treat with ERP, the first-line treatment, aiming to "disentangle OCD from the religious and moral values" of the client [source: IOCDF]. (3) Design exposures that do not ask the client to break their faith. Examples are saying the prayer once without repeating it, or postponing confession-seeking. (4) With consent, consult the priest or spiritual father so the client hears their tradition's position from their own authority [source: IOCDF, on consultation with faith leaders].
Example language (illustrative): "Your spiritual father has said one attentive prayer is enough. Let's practise saying it once and letting the 'not right' feeling be there, without repeating."
Watch for: the therapist being used for reassurance; the client experiencing ERP fear as sin. IOCDF frames that fear as fighting OCD, not breaking faith.

4.13 Role boundaries, self-disclosure and competence

Purpose: to avoid becoming a spiritual father, confessor or teacher, and to manage dual relationships, for example a therapist in the same parish [synthesis].
Steps: (1) Decline to teach methods or set a prayer rule. (2) Disclose your own religious position only when it serves the client. (3) Seek consultation or training in religious and spiritual competencies (Vieten et al. 2013 [uncertain: not verified]). (4) Follow your profession's ethics code on competence, multiple relationships and respect for religion [synthesis].
Example language (illustrative): "I'm not a spiritual guide, and I don't want to step into your priest's role. My part is helping with the anxiety alongside what he offers."
Watch for: your own enthusiasm for or discomfort with hesychasm steering the work.

4.14 The elder relationship, power and coercive control

Purpose: obedience to a spiritual father is central to the tradition [source: Irenei; OCA]. Most such relationships are healthy, but any relationship of obedience carries power [synthesis].
Steps (synthesis): (1) Ask neutrally how guidance works for the client. (2) Watch for signs of coercive control: isolation from family, control of medical or mental health decisions, financial demands, shaming, secrecy, or punishment for questioning. (3) If these appear, support the client's autonomy and safety, and offer information on other clergy within their church and on religious-trauma support. (4) Avoid pejorative labels for the community. No independent investigation of misconduct was found in the sources consulted, so no individual is named.
Example language (illustrative): "How free do you feel to disagree with your spiritual father, or to ask another priest?"
Watch for: fear, secrecy, deteriorating health or functioning linked to the guidance.

5. Handling problems

The sources say little about psychotherapy. Unless a line is tagged otherwise, the guidance below is [synthesis].

"I can't keep my mind on the prayer, so I'm failing." The tradition expects early difficulty: Ware likens it to a hidden martyrdom [source: Ware, paraphrased]. Normalise this within their frame. Explore any perfectionism, and refer the question of how to persevere to the spiritual father.
Pressure to make the prayer a calming technique (from the client, the therapist or a programme). Revisit the client's own theology. The OCA warns against treating the prayer as a technique rather than a means of union with God [source: OCA]. Use secular skills (Domain II) for symptom control if the client prefers to keep prayer separate.
The client is self-teaching the bodily method from books, video or apps. Name the tradition's own caution: guidance "always and without exception", and Theophan's warnings about harm [source: OCA]. Encourage them to bring it to their priest. Check for breath-holding, dizziness or chest symptoms and send physical complaints to their doctor. Do not correct the technique yourself.
Overwhelm, panic or dissociation during prayer. Stop, ground, and switch to the oral, eyes-open, everyday form. Reduce the amount of practice. Assess for trauma and dissociation (4.10, 4.11). Resume only as the client chooses, with their guide.
Unusual experiences (light, warmth, voices, sense of mission). Do not interpret them spiritually. The tradition itself says not to accept visions [source: OCA]. Assess sleep, mood and reality testing. Arrange urgent psychiatric care if there are signs of psychosis or mania. With consent, involve the spiritual father.
Compulsive repetition, recounting prayers, over-confession. Assess for scrupulosity and offer ERP with consultation with clergy (4.12) [source: IOCDF].
"Have mercy on me, a sinner" intensifies shame or depression. Explore what "sinner" and "mercy" mean to the client. Within Orthodox teaching the petition expresses confident trust in mercy (the publican of Luke 18) [source: OCA]. The client may wish to talk with their priest about this. Do not alter the prayer for them. Assess depression and suicide risk.
Non-adherence to agreed plans involving prayer. Treat it as information, not failure. The client decides their own practice, and a change of plan may reflect advice from their guide.
Rupture around faith (the client feels judged, or suspects the therapist is "secular" or "New Age"). Name it, repair it, restate the boundaries in 4.13, and offer a referral to a therapist of the client's tradition if they prefer.
Conflict between the guide's advice and clinical need (for example, discouraging medication or therapy). Seek a joint conversation with consent. Keep to your clinical duties, and route health questions to the doctor. Watch for coercive-control signs (4.14).
Fasting, vigils and monastic visits alongside prayer. Do not prescribe or set limits. Ask about sleep, eating and health. Coordinate with the client's doctor and priest. Orthodox practice is known to allow pastoral adjustment (oikonomia) of such disciplines for illness [uncertain: not verified].

Sources

Books and papers cited:

Ware, Kallistos. The Power of the Name: The Jesus Prayer in Orthodox Spirituality. SLG Press.
Knabb, J. J., and Frederick, T. V. (2017). Contemplative Prayer for Christians with Chronic Worry: An Eight-Week Program. Routledge.
Farias, M., et al. (2020). Adverse events in meditation practices and meditation-based therapies: a systematic review. Acta Psychiatrica Scandinavica, 142(5), 374–393. doi:10.1111/acps.13225.
Lindahl, J., et al. (2017). The varieties of contemplative experience. PLOS ONE, 12(5).
The Philokalia (Greek, Venice, 1783; Slavonic, St Petersburg, 1793, per Britannica).
Treleaven, D. (2018). Trauma-Sensitive Mindfulness [uncertain: not verified].
Vieten, C., et al. (2013). Spiritual and religious competencies for psychologists [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

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