Diagnostic: History of the Proposal
For full account, see Lukoff, D., Lu, F., and Turner, R. From spiritual emergency to spiritual problem: The transpersonal roots of the new DSM-IV category. Journal of Humanistic Psychology, 38(2), 21-50, 1998.
The initial impetus for this proposal came from the Spiritual Emergence Network (then called the Spiritual Emergency Network) which was concerned with the mental health system's pathologizing approach to intense spiritual crises. The auhtors decided to propose a new diagnostic category for the then-in-development DSM-IV as the most effective way to increase the sensitivity fo mental health professionals to spiritual issues in therapy. A previous article in the Journal of Transpersonal Psychology (Lukoff, 1985) had proposed a new diagnostic category entitled Mystical Experience with Psychotic Features (MEPF) for intense spiritual experiences that present as psychotic-like episodes. An analogy was drawn between MEPF and the DSM-III-R category of Uncomplicated Bereavement, which is a V Code--a condition not attributable to a mental disorder. The definition for this category notes that even when the period of bereavement following a significant loss meets the diagnostic criteria for Major Depression, this diagnosis is not given because the symptoms result from "a normal reaction to the death of a loved one" (p. 361). Similarly, individuals in the midst of a tumultuous spiritual experience (a "spiritual emergency") may appear to have a mental disorder if viewed out of context, but are actually undergoing a "normal reaction" which warrants a non-pathological diagnosis (i.e., a V Code for a condition not attributable to a mental disorder) (Lukoff, 1988a).
Following this precedent of bereavement in DSM-III-R of a nonpathological category for a distressing and disruptive experience, we notified the American Psychiatric Association's Task Force on DSM-IV in early 1991 of our intention to submit a propsoal for a new V Code category entitled "Psychospiritual Conflict." We contacted other experts in the field, including several members of APA's Division 36 (Psychology of Religion), to obtain their support and suggestions for relevant research and case studies. We also conducted several literature searches on PsychINFO, Medline and Religion Index to obtain references to clinical and research literature (Lukoff, Turner & Lu, 1992; Lukoff, Turner & Lu, 1993)
At the 1991 and 1992 Association for Transpersonal Psychology Conferences, we presented our ideas for the new category and received useful suggestions from other transpersonally-oriented psychologists and psychiatrists. As the proposal evolved, we substituted "problem" for "conflict" to be more in line with the terminology employed in the V Code section of DSM-III-R (e.g., Parent-Child Problem, Phase of Life Problem). To obtain greater support for the proposal and to acknowledge the many areas of overlap between spirituality and religion, we expanded our proposal to include both psychospiritual and psychoreligious problems. The literature review established the most prevalent and clinically significant problems within each category, enabling us to arrive at the following definition for a proposed V Code:
Psychoreligious problems are experiences that a person finds troubling or distressing and that involve the beliefs and practices of an organized church or religious institution. Examples include loss or questioning of a firmly held faith, change in denominational membership, conversion to a new faith, and intensification of adherence to religious practices and orthodoxy. Psychospiritual problems are experiences that a person finds troubling or distressing and that involve that person's relationship with a transcendent being or force. These problems are not necessarily related to the beliefs and practices of an organized church or religious institution. Examples include near-death experience and mystical experience. This category can be used when the focus of treatment or diagnosis is a psychoreligious or psychospiritual problem that is not attributable to a mental disorder.
In December 1991, the proposal for Psychoreligious or Psychospiritual Problem was formally submitted to the Task Force on DSM-IV. The proposal stressed the need for this new diagnosis to improve the cultural sensitivity of the DSM-IV since this was one of the priorities established for the revision (Frances, First, Widiger, Miele, Tilly, David, & Pincus, 1991), and also argued that the adoption of this new category would result in the following benefits: 1) increasing the accuracy of diagnostic assessments when religious and spiritual issues are involved; 2) reducing the occurrence of iatrogenic harm from misdiagnosis of religious and spiritual problems; 3) improving treatment of such problems by stimulating clinical research; and 4) improving treatment of such problems by encouraging training centers to address religious and spiritual issues in their programs. Support for the proposal was obtained from the American Psychiatric Association Committee on Religion and Psychiatry and the NIMH Workgroup on Culture and Diagnosis. The proposal in its entirety was published in the Journal of Nervous and Mental Disease (Lukoff, Lu & Turner, 1992) . In January 1993, the Task Force accepted the proposal but changed the title to "Religious or Spiritual Problem" and shortened and modified the definition to read:
V62.89 This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of other spiritual values which may not necessarily be related to an organized church or religious institution. (American Psychiatric Association, 1994, p. 685)
Articles on this new category appeared in The New York Times (Steinfels, 1994), San Francisco Chronicle (Lattin, 1994), Psychiatric News (McIntyre, 1994), and the APA Monitor (Sleek, 1994) where it was described as indicating an important shift in the mental health profession's stance toward religion and spirituality. What did not receive attention in the media is that this new diagnostic category has its roots in the transpersonal movement's attention to spiritual emergencies.
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