Enlightened or Delusional?

Differentiating Religious,

Spiritual, and Transpersonal

Experiences from Psychopathology

Chad V. Johnson

Unviersity of Oklahoma

Harris L. Friedman

University of Florida

Psychological diagnosis faces unique challenges when used to differentiate

nonpsychopathological religious/spiritual/transpersonal (R/S/T) experiences

from those that might evidence psychopathology, particularly considering the

diversity of such experiences and the value-laden assumptions inherent in

most diagnostic practices. Theoretical and pragmatic problems related to the

diagnostic category, Religious and Spiritual Problem, as contained in the

Diagnostic and Statistical Manual of Mental Disorders are discussed.

Attention is paid to identifying potential biases and errors in using, or failing

to use, this diagnostic category, particularly as related to developing culturally

sensitive diagnoses. Specific methods, including psychometric approaches, for

evaluating R/S/T experiences that may range from healthy to psychopatho-

logical are reviewed and recommendations are presented for improving cur-

rent diagnostic practices and furthering needed research.

Keywords: religion; spirituality; transpersonal; diagnosis; DSM-IV; psy-

chopathology

erhaps one of the most perplexing arenas for fostering potential biases

and subsequent misuse of psychological diagnosis involves religious,

spiritual, and transpersonal (R/S/T) experiences that may appear as evi-

dence of psychopathology to unaware clinicians. For example, Fukuyama

and Sevig (1999) emphasized how cultural context can vastly shift a diag-

nosis in this area. Claims that one has encountered a vision of the Virgin

Mary may be acceptable (and even socially desirable) in some predomi-

nantly Catholic Latin American cultures, while claims of being possessed

by a spiritual entity may be highly rewarded in the context of Haitian

Journal of Humanistic

Psychology

Volume 48 Number 4

October 2008 505-527

10.1177/0022167808314174

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voodoo trance dance. However, in most U.S. psychological contexts, both

these claims would likely be denigrated as mere delusions or hallucinations

and used diagnostically as an indicator of psychopathology. In sum, deter-

mining whether a client is experiencing enlightenment (i.e., transformative

spiritual experience) or delusion (i.e., psychological disturbance) can be

wrought with challenges.

There are many studies suggesting that psychological diagnostic practices

are unavoidably value laden, subjective, and influenced by clinicians’ previous

assumptions—that is, they are inherently subject to bias. James and Haley

(1995) found that therapists diagnosed clients in poor physical health as more

pathological, less appropriate for psychotherapy, and less capable of establish-

ing a beneficial therapeutic relationship than clients in better physical health;

they also demonstrated similar biases related to client age. Other studies on

diagnosis and clinical judgment have found that client gender (Seem &

Johnson, 1998), therapist gender (Hansen & Reekie, 1990), therapists’ theo-

retical orientation and years of clinical experience (Daleiden, Chorpita,

Kollins, & Drabman, 1999), and therapists’ ethnicity (Atkinson et al., 1996)

all affect clinicians’ attributions of pathology, including ratings of severity and

type of diagnosis, as well as judgments of prognosis. And these are just a few

of the many research strands supporting that diagnosis is far from an objective

activity. Consequently, for these and many other reasons, humanistic psychol-

ogists have been prone to reject or minimize the importance of diagnostic

practices (e.g., Honos-Webb & Leitner, 2001; Siebert, 2000), though some

have defended the continued use of diagnosis within humanistic psychology

despite also recognizing it inevitably involves numerous limitations that can

be seen as biases (Friedman & MacDonald, 2006).

However, humanistic psychologists may be somewhat less likely to exhibit

such biases toward R/S/T experiences than would other psychologists. For

example, Allman, De La Roche, Elkins, and Weathers (1992) surveyed 286

APA psychologists’ attitudes toward clients who report mystical experiences.

Humanistic psychologists were less likely to consider clients with mystical

experiences as psychotic than behavioral, cognitive, and psychodynamic psy-

chologists. Moreover, psychologists who rated spirituality as important were

less likely to regard clients’ mystical experiences as simply evidence of psy-

chopathology. Taken as a whole, it appears that psychological practices in dif-

ferential diagnosis of R/S/T problems are especially problematic, but that

humanistic psychologists may be more open to these experiences than psy-

chologists from other orientations.

Nevertheless, many mainstream researchers, practitioners, and theo-

rists have recognized the importance of including R/S/T variables in

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diagnostic clinical work (e.g., Cashwell & Young, 2005; Chirban, 2001;

Johnson, Hayes, & Wade, 2007; Sperry & Shafranske, 2005), as have some

humanistic psychologists (e.g., Friedman & MacDonald, 1997, 2002). The

pertinent question is clearly not whether clinicians should assess these

variables, but why mental health professionals do not consistently do this.

A Word on Religion, Spirituality,

and Transpersonality

Many have argued that the terms religiosity and spirituality have quite dif-

ferent meanings, though they are frequently used in overlapping ways (e.g.,

Ho & Ho, 2007). Pappas and Friedman (in press) have conceptually delineated

not only these two terms, but also transpersonality, as three categories that

have distinctly important, though still overlapping, meanings. For consistency

of expression, R/S/T will be used as an overarching term encompassing expe-

riences having either a religious, spiritual, and/or transpersonal nature.

However, when a researcher or theorist specifically uses only one or two of

these terms without the overarching meaning seemingly being implied, the

more narrow term or terms are kept for consistency with the original author’s

intent.

Differentiating among Four Religious

and Spiritual Categories

The DSM-IV (APA, 1994) category “Religious or Spiritual Problem” has

increased the options and, potentially, the cultural sensitivity toward diagnos-

ing R/S/T concerns. Now that the field has a legitimate option for categoriz-

ing R/S/T problems, it is important for psychologists and other mental health

professionals to know how to make this diagnosis and distinguish it from psy-

chopathology, especially considering the iatrogenic harm that may occur

from inappropriate diagnoses. For example, clients may feel increasingly iso-

lated and misunderstood when their R/S/T experiences are misdiagnosed and

this may lead to adverse outcomes, including blocking any future attempts at

help seeking (Bragdon, 1993; Lukoff, Lu, & Turner, 1996). Lukoff, Lu, and

Turner (1992, 1996) suggested that the inclusion of this new category

requires differentiating among four types of problems: (a) purely religious or

spiritual problems, (b) mental disorders with religious or spiritual content, (c)

religious or spiritual problem concurrent with mental disorder, and (d) reli-

gious or spiritual problems not attributable to a mental disorder.

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Purely religious problems consist of concern over faith and doctrinal

matters and should be treated by appropriate clergy. For example, a reli-

gious person experiencing distress related to his or her religion’s doctrinal

view on salvation might consider consulting with clergy first or, if this is

too distressing, with a clinician familiar with his or her religion’s beliefs. In

contrast, they defined purely spiritual problems as involving “conflicts

about a person’s relationship to the transcendent or [that] arise from a spir-

itual practice” (Lukoff, Lu, & Turner, 1992, p. 677) that are not associated

with institutional forms of religion. Examples of this type include a person

who has an unusual perceptual experience while meditating or has questions

about proper yoga technique. Generally, they suggest that knowledgeable

spiritual directors or teachers be consulted for these types of problems.

Lukoff et al. (1992) defined mental disorders with religious and spiritual

content as identifiable Axis I disorders that manifest religious or spiritual sym-

bols and expressions. These include obsessive-compulsive disorder, manic

episodes, and psychotic episodes that possess religious or spiritual content.

Imperative in these instances is to differentiate whether these distressful expe-

riences are “true” expressions of R/S/T or the result of underlying pathology.

Lukoff et al. (1996) created an additional classification called religious or

spiritual problem concurrent with mental disorder that involves religious or

spiritual problems that are addressed in conjunction with an existing mental

disorder. For example, if a therapist addresses excessive religious rituals

associated with obsessive-compulsive disorder (OCD), then they argue that

both OCD and Religious or Spiritual Problem should be coded. This classi-

fication may increase the use of the new category and accentuate the impor-

tance of addressing R/S/T issues in mental health. Moreover, this category

may alert mental health professionals to the existence of spiritual issues and

help focus treatment to address these concerns.

The fourth category, religious or spiritual problem not attributable to

mental disorder, refers to experiences directly related to religiosity and spiri-

tuality but not psychopathology. Questioning one’s religious beliefs and val-

ues or distress related to changing one’s spiritual community fall under this

category as does near-death and mystical experiences (Lukoff et al., 1992). For

instance, mystical experiences are among the most frequently encountered

spiritual events in the clinical and research literature (e.g., estimates suggest

that 30% to 40% of the U.S. population report having had mystical experi-

ences; Hood, Spilka, Hunsberger, & Gorsuch, 1996). Thus, R/S/T experiences

are likely typical of normal human experience, rather than being inherently

abnormal and indicative of psychopathology (e.g., Johnson & Hayes, 2003).

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Validating the DSM-IV V-Code:

Religious and Spiritual Problem

At the current time, only two empirical studies have attempted to validate

the utility of the DSM-IV category of Religious or Spiritual Problem using

Lukoff et al.’s (1992) criteria. In the first study, Milstein, Midlarsky, Link,

Raue, and Bruce (2000) compared clergy and psychologists on their ability

to differentially diagnose presenting problems with religious and spiritual

content. A national, random sample of 111 rabbis and 90 clinical psycholo-

gists (whose theoretical orientations were not identified) were provided

three clinical vignettes representing a mental disorder (schizophrenia with

spiritual content), a spiritual problem without a mental disorder (mystical

experience), and a pure religious problem (client unclear about religious rit-

uals for mourning a parent). They were asked to rate the vignettes as to the

likelihood that the situation was caused by spiritual issues rather than psy-

chopathology per se, as well as the severity of the problem and the suitabil-

ity of psychiatric medication for treating the problem.

Both the clergy and psychologists evaluated the religious etiology of

schizophrenia as being less due to religious factors compared to mystical

experience, which in turn was attributed less to religious factors compared to

mourning a parent. Rabbis considered the etiology of schizophrenia as signif-

icantly more due to religious factors than did psychologists. In terms of sever-

ity, rabbis rated schizophrenia as more serious than mourning, and mourning

more severe than mystical experience. Rabbis also considered mourning a

parent as more problematic than psychologists did. In regards to the utility of

psychiatric medication, rabbis viewed medication as more useful for schizo-

phrenia than for mystical experience and more helpful for the mystical expe-

rience than mourning. Psychologists rated medication as more useful for

schizophrenia than both mystical experience and mourning. Psychologists

considered medication as significantly more helpful for schizophrenia than

the rabbis did.

The validity of these results is limited somewhat by a methodological

issue, namely that the vignette for mystical experience did not describe some-

one who was experiencing overt distress—a vital criterion for diagnosing a

religious or spiritual problem. Despite this shortcoming, this study showed

that both psychologists and clergy could distinguish among problems with

religious and spiritual content. Furthermore, it provided preliminary support

for the utility and validity of this distinct category of problems.

In the second empirical study attempting to validate the utility of the

DSM-IV V-code for Religious or Spiritual Problem using Lukoff et al.’s

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(1992) criteria, Hartter (1995) surveyed 100 psychologists (60 women and 40

men, 63% of whom had been in clinical practice at least 16 years and 84% of

whom were in private practice) as to their experiences with religious and spir-

itual problems in psychotherapy. Humanistic-existentially oriented psycholo-

gists were the largest represented (25%) followed by “other” (22%),

psychodynamic (15%), and cognitive (10%). She found 65% would use the

V-code if finances or third-party reimbursement were not a prohibiting issue.

Furthermore, 92% agreed that there was a qualitative difference between a

psychotic episode and spiritual emergency or spiritual problem. In most

cases, this had to do with level of daily functioning and reality testing.

Although both of these studies provide preliminary evidence for the validity

and utility of the V-code, additional empirical research is clearly needed.

Differential Diagnosis of Religious Problems

from Psychopathology

Beyond additional empirical research, there is also a need for further

conceptual clarification. Several authors have identified criteria for distin-

guishing between religious problems and pathology. For instance,

Barnhouse (1986) indicated that when differentiating between psychotic

disorders and other phenomena the content of religious language alone

rarely determines its pathological significance. She recommended that an

extensive religious history be included in every psychological evaluation.

Similarly, Greenberg and Witztum (1991) stressed that therapists must be

thoroughly familiar with the basic tenets of a client’s religion; otherwise,

identifying pathology will be extremely difficult. Based on several decades of

clinical experience with an ultra-orthodox Jewish sect in Israel, they proposed

the following criteria for differentiating between normative, strictly religious

beliefs and experiences from psychotic symptoms. Psychotic episodes (a) are

more intense than normative religious experiences in their religious commu-

nity, (b) are often terrifying, (c) are often preoccupying, (d) are associated

with deterioration of social skills and personal hygiene, and (e) often involve

special messages from religious figures.

Lovinger (1984) also offered guidelines for assessing religious problems to

distinguish them from pathology. First, he suggested determining if the reli-

gious issue is “idiosyncratic or is rather an expression of group attitudes, ideas,

or practices” (p. 177). For instance, speaking in tongues (glossolalia) should

probably not be considered pathological for someone from a Pentecostal

church community, but may be considered a problem for someone who is

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nonreligious. He concluded that clinical judgment and a thorough understand-

ing of a client’s background are required to make this type of distinction.

A concern with this criterion is that individuals may have atypical spir-

itual experiences for their particular cultural group and still these may not

be evidence of psychopathology. For instance, it is generally not considered

normal in mainstream U.S. culture to have directly heard the voice of God

or to have witnessed spiritual beings. Yet many people who are not actively

affiliated with any religious or spiritual movements that endorse these types

of experience may still claim to have had similar unusual experiences

(Bragdon, 1993; Grof & Grof, 1992; Hood et al., 1996). Though these

experiences may differ significantly from one’s cultural reference group,

they do not necessarily signify psychopathology, a determination that often

depends on the worldview of the clinician and his or her openness to non-

pathological altered states of consciousness. It may also be contingent on

other factors, including psychological history and amount of stress a person

is currently experiencing. All of these complexities make distinguishing

between religious experience and psychopathology challenging.

Second, Lovinger (1984) considered hallucinations and delusions with

religious content as indicative of psychopathology, in contrast to transper-

sonal perspectives that might consider them spiritual emergencies (Bragdon,

1993; Grof & Grof, 1989). A spiritual emergency involves a psychological

crisis as a result of unusual and/or intense spiritual or transpersonal experi-

ences (Bragdon, 1993). In this regard, Lovinger (1984) failed to explain

what he meant by hallucinations or delusions and seems to include all such

phenomena as inherently psychopathological. However, Lovinger believed

that hallucinations were similar in structure to dreams (i.e., consisting of

complex imagery and symbols) and could be treated as such.

Third, Lovinger (1984) emphasized assessing the quality of the religious

orientation. Although great strides have been made in shedding the pathologiz-

ing stigma championed by Freud (1907/ 1959) and Ellis (1980)

regarding

R/S/T experiences, there may be harmful features in a client’s religious beliefs

and practices (Helminiak, 2001): for example, practicing one’s religion in an

overly scrupulous or fear-based manner. Humanistic psychotherapists should

consider sensitively and mindfully identifying harmful beliefs and practices and

addressing them in diagnosis and psychotherapy.

Two Proposed Diagnostic Systems

Based on many years of clinical experience, Lovinger (1996) updated his

diagnostic criteria and delineated 10 markers of pathology (see Table 1).

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Lovinger’s markers are insightful and interesting, but caution should be used

in their application. According to Lovinger, clinicians should take a thor-

ough religious and psychological history to determine whether patterns of

pathology manifest themselves in other areas. That is, a person’s ability to

function at work, home, recreation, or in social settings should be consid-

ered. Questions to address at intake include whether a person’s pathological

religious expressions affect other psychosocial areas. If so, then psy-

chopathology is deemed likely. Furthermore, informed clinical judgment is

required to determine when the markers are, in fact, psychopathological and

when they are acceptable religious expressions. As previously noted, the

diagnostic process regarding R/S/T experiences is unavoidably subjective

and influenced by the clinician’s prior assumptions and world view. It

remains enigmatic how clinicians can determine when phenomena such as

Ecstatic Frenzy or a literal interpretation of the Bible as Guide are symptoms

of pathology rather than a reflection of value differences between the clini-

cian and client (see Table 1).

In one attempt to address this, Spero (1985) proposed eight diagnostic

criteria for differentiating healthy from unhealthy religious expression (see

Table 2). Spero intended these criteria to help determine when a person’s

512 Journal of Humanistic Psychology

Table 1

Lovinger’s (1996) Ten Markers of Pathology

1. Self-oriented display: Narcissistic displays of being religious

2. Religion as reward: Using religion to explain assistance with ordinary difficulties in life (e.g.,

God helping one find a parking space)

3. Scrupulosity: Intense focus on avoiding sin or error

4. Relinquishing responsibility: Feeling responsible for events beyond one’s control and

neglecting responsibility for manageable things

5. Ecstatic frenzy: Intense, erratic emotional expression often containing religious content or

occurring in religious contexts that may signal impending decompensation

6. Persistent church-shopping: Suggests difficulties in maintaining stable relationships

7. Indiscriminate enthusiasm: Religious enthusiasm frequently expressed to people who do not

welcome it

8. Hurtful love in religious practice: Expressions of love that unnecessarily cause harm to

oneself or others (e.g., setting unrealistic expectations for a child out of a notion of love

based on strict Biblical interpretations)

9. The Bible as moment-to-moment guide to life: Applying scripture in concrete ways to

direct one’s daily experiences (much like a daily horoscope)

10. Possession: May reflect underlying pathology such as hysteria, dissociative reactions,

paranoia, psychosis, and borderline disorders

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religious beliefs or behaviors reflect underlying intrapsychic needs and

conflicts rather than purely religious phenomena. Therefore, the utility of

Spero’s diagnostic scheme is limited to those who accept and understand

psychodynamic language and theory.

Like most of the diagnostic suggestions reviewed, both Lovinger (1996)

and Spero’s (1985) systems lack empirical support. This has resulted in a

serious lacuna in knowledge where research is sorely needed.

Differential Diagnosis of Spiritual Problems

from Psychopathology

Grof and Grof (1992) argued that clinicians must “accept the fact that

spirituality is a legitimate dimension of existence and that its awakening

and development are desirable” (p. 252), although not always without com-

plications. According to Lukoff and Turner (1996), “the clinician’s initial

assessment of powerful spiritual experiences can significantly influence the

eventual outcome” of any intervention (p. 243). Inappropriate diagnoses by

mental health professionals may intensify feelings of isolation and pre-

vent understanding, assimilation of the experience, as well as future help

Johnson, Friedman / Enlightened or Delusional 513

Table 2

Spero’s (1985) Criteria for Religious Pathology

1. Person integrates religious beliefs and practices into overall lifestyle (not pathological,

but a necessary criterion).

2. Relatively rapid and recent onset of religious affiliation or increased religious fervor with

associated severing of significant social and professional relationships.

3. Person’s religious history includes frequent and repetitive spiritual crises and changes in

religious affiliation or degree of belief.

4. Person demonstrates fixation or regression to early stages of object-relations

development marked by decompensation in psychosocial functioning, predominant

primitive thematic material in dreams, fantasy, and thinking, and conflict between

religious expression and adaptive ego functioning.

5. Person preoccupied with fear of backsliding (consciously or unconsciously) and reaction

formation of overly rigid and scrupulous religious expression.

6. Person displays continued depressed moods and lack of productivity following religious

conversion or awakening.

7. Person inappropriately idealizes religious leaders or movement and applies this to

resolving psychological issues such as autonomy, identity, and impulse control.

8. On occasion, an analyst’s carefully interpreted countertransference may indicate the

client is using religion to manage neurotic impulses.

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seeking (Lukoff & Turner, 1996). However, it is also important that clini-

cians accurately diagnose psychopathology and not ignore or minimize

problems that may have severe consequences. Even transpersonal psy-

chotherapists agree that medication and hospitalization are required in

some instances for severe decompensation (Grof & Grof, 1989; Lukoff, Lu,

& Turner, 1998). However, differentiating R/S/T experiences from psy-

chopathology can be extremely difficult because of similarities between

pathological symptom expression and the unusual behaviors and perceptual

characteristics found in these experiences (Lukoff et al., 1998; Lukoff &

Turner, 1996).

Spiritual Emergency

Bragdon (1993) indicated three primary ways people respond to spiritual

experiences: (a) gracefully integrate them into their lives and further develop

spiritually and psychologically; (b) become temporarily overwhelmed and

experience a spiritual and psychological crisis, but eventually accept the

experience as part of their reality; or (c) fail to integrate the experience

resulting in a chronic state of fragmentation. Bragdon argued that tradition-

ally trained clinicians might diagnose all three responses as pscyhopatholog-

ical based on the content of their experiences. For example, suppose a

woman encountered a vision of light accompanied by a voice calling her to

pursue a vocation in counseling. This calling may be integrated as a valid

sign from God without decompensation in terms of social and emotional

functioning. Nevertheless, if a mental health professional insensitive to

experiences of this kind were consulted, she might be categorized as delu-

sional or psychotic possibly leading to harmful consequences.

Distinguishing between R/S/T experiences and psychopathology

requires a thorough understanding of what characterizes spiritual emer-

gence and spiritual emergencies (Bragdon, 1993; Grof & Grof, 1992).

Spiritual emergence refers to integrating spiritual or transpersonal experi-

ences to achieve expanded consciousness and maturity whereas a spiritual

emergency may result if R/S/T experiences result in psychological crisis.

Significant work has occurred in identifying spiritual emergencies that

may technically meet the DSM-IV criteria for a psychotic episode but if

approached differently might promote recovery and possibly integration to

optimal levels of functioning (Bragdon, 1993; Cortright, 1997; Grof & Grof,

1992; Hendlin, 1985). First, clinicians should consider the intensity of the

spiritual experience and level of functioning in daily life. Those whose daily

functioning is significantly impaired by extremely intense R/S/T experiences

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are probably encountering a spiritual emergency. Second, people experienc-

ing spiritual emergence usually display an attitude of excitement contrasted

with the frightening and overwhelming stance found in a spiritual emergency.

Finally, a clinician should consider how the person copes with society’s reac-

tions to their experience. In a spiritual emergency, the person might lack dis-

crimination concerning who would be receptive to their experience and share

their experience with people who are not interested or uncomfortable with it.

In recognition of the need to distinguish between spiritual emergencies

that may lead to spiritual emergence if handled well or to psychopathology if

handled poorly, the Spiritual Emergence Network (SEN) (see http://www.spiri-

tualemergence.info/) was founded to create a national referral source providing

mental health practitioners sympathetic to this perspective. SEN assumes that

spiritual emergencies, as a specific type of spiritual problem, should be

approached quite differently from psychopathology to avoid further decom-

pensation or iatrogenic harm (Bragdon, 1993; Grof & Grof, 1989; Lukoff

et al., 1998). For example, a person in a spiritual emergency might benefit

from active social support, “grounding” (e.g., yoga or gardening) techniques,

and spiritual guidance and/or psychotherapy rather than hospitalization and

heavy medication (Grof & Grof, 1992).

Once it is determined that a person is experiencing a spiritual emer-

gency, it becomes paramount to distinguish it from psychopathology. Grof

and Grof (1992) recommended beginning with a complete medical evalua-

tion to rule out contributing physical conditions. If the results are negative,

they suggest diagnosing a spiritual emergency and treating it as such. If the

psychological and spiritual interventions help, they continue with psy-

chotherapy. If physical symptoms persist, however, they refer the client for

a more thorough medical and psychiatric evaluation. If this evaluation

excludes organic causes, then clinicians attempt to determine if the experi-

ence meets the criteria for a spiritual emergency or psychiatric disorder.

Many authors stress the importance of pre-episodic functioning

(Bragdon, 1993; Cortright, 1997; Grof & Grof, 1992) in making this deter-

mination. If the history demonstrates generally healthy social, psychologi-

cal, spiritual, and sexual functioning, then the person’s current experience is

viewed as psychospiritual and suggestive of a positive prognosis. In contrast,

a history of dysfunction, as well as strong evidence of manic symptoms,

poorly organized content within R/S/T experiences, self-destructive tenden-

cies, and the presence of persecutory delusions or hallucinations may be

indicative of psychopathology. In this case, traditional approaches to treat-

ment such as medication and/or hospitalization may result in better out-

comes (Grof & Grof, 1992).

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The DSM-IV simply does not differentiate psychotic hallucinations and

delusions from religious and spiritual phenomena, such as visions and

intense meditative experiences, and the DSM-IV does not discriminate

between the disorganized and incoherent speech of the psychotic from the

“noetic quality of spiritual experience” (Bragdon, 1993, p. 84). For example,

the DSM-IV does not distinguish psychotic disorganized behavior from the

unusual behaviors of a kundalini awakening. During a kundalini awakening,

a person may sense intense feelings of heat pulsating up the spine, experi-

ence overwhelming waves of emotions, find it difficult to control behavior,

and become extremely disoriented, all of which may appear as disorganized

psychotic behavior. Bragdon (1993) admitted that distinguishing spiritual

emergencies from psychopathology could be extremely difficult in people

who are highly dissociative. She recommended clinical expertise and an open-

minded stance that considers experiences of this kind as potentially repre-

senting spiritual emergencies rather than pathology.

Lukoff (1985) proposed several indicators for a positive prognosis fol-

lowing a spiritual emergency. The first indicator is good pre-episode func-

tioning demonstrated by a healthy social network, intimacy with romantic

partners, and an absence of prior psychotic episodes. The second is acute

onset of symptoms occurred during a 3-month period or less. The third indi-

cator included stressful precipitants to the psychotic episode such as

trauma, divorce, loss of job, or death of a loved one. Finally, evidencing a

positive exploratory attitude to the experience is often predictive of positive

outcomes. Lukoff and Turner (1996) maintained that individuals who meet

the criteria for a spiritual emergency should not be hospitalized and medica-

tion should be used minimally. They also recommended that helpers

employ transpersonal approaches in treatment.

In one of the few empirical studies in this area, Hartter (1995) found that

92% of psychologists surveyed believed there was a difference between a

psychotic episode and a spiritual emergency. In response to an open-ended

survey question asking how they differentiate between the two, the psychol-

ogists identified the following eight criteria listed in descending order by

prevalence: (a) Ability of client to function in reality or carry out daily life

activities, (b) previous history of mental stability, (c) content of thought

processes (conceptual organization or disorganization), (d) outcome that

leads to wholeness or integration—is transformative, (e) content and orga-

nization of hallucinations and delusions, (f) neurochemical imbalances, (g)

intact “religious belief system,” and (h) duration of crisis. These findings

closely resemble criteria found elsewhere in the literature (e.g., Bragdon,

1993; Grof & Grof, 1992; Lukoff, 1985). Given that these suggestions were

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given spontaneously in an open-ended format provides some validity to the

criteria previously discussed.

Psychosis and Spiritual Experiences

In a rare study comparing spiritual experience and psychosis, Jackson

(1991) compared five “undiagnosed” and five “diagnosed” participants, all of

whom interpreted their experiences in spiritual terms. Members of the undiag-

nosed group met the following criteria: they reported an intense experience

explained in religious or paranormal terms, the experiences were assessed as

possibly involving delusions or hallucinations, apparent absence of functional

deficits and evidence of positive social adjustment, and geographical proximity

to the research center. Members of the diagnosed group were individuals who

had recovered from major psychoses and interpreted their experiences in

strongly spiritual terms.

Results indicated significant phenomenological similarities between the

two groups. Each group manifested grandiose beliefs about their status,

positive and negative emotional experiences, true and “pseudo” hallucina-

tions, visual and auditory hallucinations, firm conviction in their “delu-

sional” beliefs, and a lack of insight into the possibility that their

experiences could be explained psychologically rather than spiritually.

However, visual hallucinations were reported more often in the diagnosed

group, as was the degree of symptom severity. For example, the diagnosed

group reported being completely overwhelmed by their experiences, during

which they lost contact with consensual reality and acted out their delusions

in bizarre behavior, in contrast to less severe manifestations in the undiag-

nosed group. The diagnosed group also differed in that they unanimously

indicated having had intensely negative experiences.

Subsequently, Jackson and Fulford (1997) investigated whether benign

spiritual experiences could manifest psychotic phenomena. They also sought

to explain the significance of this finding, if it occurred. They intensively

interviewed nine participants from a database of more than 5,000 accounts

of spiritual experience and strategically selected cases in which there

appeared significant overlap between spiritual experience and psychotic ill-

ness. The semi-structured interviews covered the participants’ background

and history, the context, phenomenology, and effects of their spiritual expe-

riences, and the interpretations that they and others placed on them.

Traditional psychopathology defines mental illness by the form, content,

duration, and intensity of symptoms and a lack of insight into their psycho-

logical origin (Jackson & Fulford, 1997). They found that the participants’

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spiritual experiences resembled the general form of psychotic phenomenon.

For example, some of the participants demonstrated delusions and first-

person auditory hallucinations. In terms of content, participants demon-

strated benign symptomatology that differed from malign symptoms such as

delusions of persecution. In addition, the participants described their experi-

ences as intense and enduring. Overall, the phenomena were broadly defined

as psychotic and likely to receive a diagnosis of psychoses in a traditional

psychiatric setting. However, in many cases the experiences resulted in

healthy and adaptive outcomes as interpreted by the participants and exter-

nal observers.

Jackson and Fulford (1997) concluded that the mental health profession

would benefit from reconceptualizing its notions of mental illness. They

proposed a more balanced model that considers the evaluative nature of

medical concepts and defines pathology as the patient’s experience of inca-

pacity (i.e., failures of ordinary intentional action). Jackson and Fulford

emphasized that pathology should be understood as “essentially embedded

within the framework of values and beliefs of the individuals concerned”

(p. 53). They also argued that mental health professionals must recognize

the value-laden nature of diagnosis and treatment.

In a comment on Jackson and Fulford’s (1997) study, Littlewood (1997)

stressed that mental illness and spirituality are always social or cultural

phenomenon—neither are objectively “real.” These concepts are “ ‘experi-

enced through cultural meanings’ not ‘influenced by’ culture” (p. 67). Storr

(1997) criticized Jackson and Fulford’s (1997) distinction between good

and bad psychotic experiences. For Storr (1997), whether an experience is

spiritual or pathological depends on the nature of the experience and the

social setting. For instance, most everyone has had at least one psychotic

episode (i.e., falling in love). Storr concluded his critique with the follow-

ing thoughts:

My own feeling is that the distinction “spiritual” versus “pathological”

should be dropped. Everyone is liable to have deeply irrational experiences

or hold deeply irrational beliefs that may be destructive or may be life-

enhancing. Psychiatric diagnosis must include reference to the subject’s per-

sonal relationships and his place in society as well as taking cognizance of

his beliefs and mental experience as an isolated individual. Otherwise, we

may condemn saints as psychotic, while treating serial killers as sane. (P. 84)

Thus, in all attempts at evaluating another human being’s experience, the

subjective, social, and cultural aspects of the evaluation process (including

the evaluator and evaluated) should be considered.

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Assessment Approaches

Most psychological diagnosis focused on differentiating R/S/T experi-

ences from psychopathology are based on using open-ended interview ques-

tions. Koenig and Pritchett (1998) suggested assessing religion and

spirituality using four “non-offensive and easily remembered” (p. 327) ques-

tions. Likewise, Anandarajah and Hight (2001) presented a simple qualitative

assessment approach, as have many others, but these are limited in useful-

ness. Some more sophisticated qualitative approaches to diagnose in this area

have been proposed by Hodge (2000, 2001), such as family genograms, and

may offer valuable data beyond using simple open-ended questions as part of

humanistic psychological assessment of R/S/T problems.

In addition to these qualitative approaches, there is quite a robust psycho-

metric tradition in the area of measuring R/S/T constructs. In one series of

review articles on such measures, more than 100 were discussed (MacDonald,

Friedman, & Kuentzel, 1999; MacDonald, Kuentzel, & Friedman, 1999;

MacDonald, LeClair, Holland, Alter, & Friedman, 1995). However, little has

been written on clinically using any of these measures for differential diag-

noses and we could locate none that specifically provided norms or other

essential information sufficient for responsible clinical applications.

One measure, however, has been explicitly discussed in terms of poten-

tial clinical utility, the Self-Expansiveness Level Form (SELF) (Friedman,

1983; Friedman & MacDonald, 1997, 2002). The SELF provides two sub-

scales, a personal (P) and a transpersonal (T) measure of level of identifi-

cation, which can be compared to each other to provide a sense of balance

between a person’s personal and transpersonal self-concept. Friedman (1983)

theorized that a high T score without a correspondingly high P score could

represent a psychopathological problem (i.e., a person who identifies more

with the spiritual level than they do with the level of the lived experiences

in the present). Friedman and MacDonald (1997) illustrated this with a

vignette of one of his former patients, as follows:

Millie is a commercial artist in her early 40s who also works as a minister in

a New Age church where she does psychic readings. She scored very low on

the Personal Scale of the SELF and very high on the Transpersonal Scale of

the SELF. She sought psychological treatment after having a number of dis-

sociative episodes that involved time loss and possible danger to herself,

when she ended up in compromising situations. She sought a neurological

examination but, after extensive medical workups, was referred for a psycho-

logical evaluation. The fact that she regularly dissociates when doing her psy-

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chic readings in a controlled fashion was not seen by her as related to the

episodes that she finds frightening. Her language is full of references to Spirit

guiding her and she lives her life in accord with her visions and dreams. She

gives short shrift, however, to her own personal needs and, in particular, has

a difficult time conceptualizing that it is good for a person to find ways to

meet their [sic] own personal needs; appropriate assertiveness, in particular,

occurs rarely. She does get angry on occasion, however, including inappro-

priate violent outbursts with her boyfriend, but these make no sense to her,

and embarrass her, in terms of her commitment to “Spirit” which she inter-

prets as without anger. (P. 118)

In contrast, another one of Friedman’s patients had both high T and P

scores on the SELF but was not judged as psychopathological per se,

though she had somewhat similar dissociative issues to Millie. Rather, she

was diagnosed as undergoing a spiritual emergency, though she had previ-

ously been diagnosed by another clinician as having a dissociative identity

disorder. Her concerns were expressed, however, in a quite different way

from a usual psychopathology, particularly in terms of its adaptive function,

as follows:

Jill, a member of a religious order, works as an administrator in a social

services agency. She is in her late 40s, dresses very conservatively, and

sought psychological treatment for work-related stress. She scored very

high on both the personal and transpersonal scales of the SELF. There were

many pressures on her at work regarding the dilemma between strictly

adhering to legal rules and providing sorely needed benefits available to the

poor and disabled served through her agency. She was frequently placed in

the situation where she would either have to do something improper (e.g.,

regarding how a form might be filled out) or let a family literally go with-

out food or shelter—and she had great difficulty reconciling this dilemma.

At times like this, she found herself “disappearing,” experienced as if some-

one else were doing the actions required. Though this was somewhat dis-

turbing to her, her sense was that, during these very stressful times, it was

an angel acting through her body. Her angel was viewed as a consummate

administrator who could “cut corners” when needed to save lives, as well

as could also deny services to those who might be needy but not in life-

threatening circumstances. The angel enabled her to achieve a balance in

her work that she could not personally manage. And her success as an

administrator who could get things done despite the overwhelming need of

her agency’s clients and the bureaucratic constraints placed on her was widely

admired. Nevertheless, she found the times when the angel was taking over

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to be somewhat disturbing, though she had implicit trust in the angel as an

ego dystonic entity, and sought help for her “problem.”

Contrasting these two cases, one previously published and one original to

this article, is quite interesting insofar as both showed signs of a dissociative

identity disorder but, in Millie’s case, this placed her in danger whereas, in

Jill’s case, it was not only benign but also positively adaptive for her and

those served by her agency.

What was apparently lacking in Jill, however, was the ability to see the

angel as part of her own self, the one who could make the incredible diffi-

cult decisions with aplomb. Although Jill identified highly with both the per-

sonal and transpersonal aspects of herself as measured by the SELF, it was

hypothesized that there was still room for her to grow in accepting her own

personal limits, such as in being a member of a society that mandates ignor-

ing the needy under certain legalistic circumstances, as well as in accepting

that the angel really could be her own higher Self, notwithstanding the pos-

sibility of something supernatural and more in accord with her religious

beliefs actually occurring here. In this sense, instead of psychopathologizing

Jill’s dissociativeness as a weakness, it was instead construed as a strength,

but one that allowed for more growth, which became the focus of further

psychotherapy.

The use of the SELF in differential diagnosis of R/S/T problems from

psychopathology has not been empirically investigated, but offers one poten-

tial avenue for exploring this area. It is our contention that a wide range of meth-

ods should be explored to address this important differentiation, including

qualitative interview and other qualitative methods, as well as psychometric

approaches. What is most crucial is that this extremely important area not be

ignored, as many people may be helped by further development in differen-

tial diagnosis in this area. And humanistic psychologists, being most open to

the prevalent biases in mainstream misinterpretations of R/S/T experiences

as only indicative of psychopathology should be in the forefront to develop

these.

Discussion and Conclusions

This article has highlighted several attempts at establishing criteria for

differential diagnosis of R/S/T experiences from psychopathology. Several

conclusions and corresponding recommendations can be drawn. To begin,

differential diagnosis requires openness, sensitivity, and knowledge about

various forms of R/S/T experience. Clinicians and their clients will benefit

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from mental health professionals possessing more than cursory knowledge

about common R/S/T experiences encountered in psychotherapy to aid in

such diagnoses (e.g., Richards & Bergin, 2000). Given the subjective nature

of diagnosis, diagnosticians and psychotherapists also require adequate self-

awareness concerning their own beliefs and assumptions concerning R/S/T

experiences. How these experiences are perceived will necessarily influence

diagnostic practices, so mental health professionals should consider explor-

ing potential sources of bias within their worldviews. Clinicians’ openness

to R/S/T experiences requires at the very least the ability to suspend judg-

ment by bracketing biases for effective diagnosis and treatment to occur

(Johnson et al., 2007; Morrow, Worthington, & McCullough, 1993).

In addition, it would be useful to develop sound empirical approaches,

based on both qualitative and quantitative research, to aid in differential

diagnosis in this area. The many research measures that have been devel-

oped demonstrate that this area is no less amenable to reliable and valid

psychometric approaches than other areas of psychology. The next step for

many extant measures would be to develop appropriate norms and explore

other psychometric properties necessary for the responsible clinical appli-

cation of these instruments, as well as the development of new measures

specifically useful for the differential diagnosis of R/S/T experiences from

psychopathology.

Furthermore, mental health professionals might familiarize themselves

with the diagnostic systems presented in this article, especially as summa-

rized in the article’s tables. From these systems, we can conclude several rec-

ommendations for “best practice” (see Table 3). For example, taking a

thorough R/S/T history as part of a holistic biopsychosocial history is a

necessity when determining whether unusual R/S/T experience may or may

not be psychopathological. Evidence of previous episodes of psychosis, dys-

functional relationships, or religious crises may be crucial in such a differen-

tial diagnosis. Also, knowing relevant markers of psychopathology (e.g.,

scrupulosity) found in religious expression may help determine whether a

client’s religious orientation is life enhancing or detracting. As a profession,

we should consider courageously and mindfully examining what benefits

whom and when.

Moreover, Lukoff et al. (1992, 1996) provide helpful criteria for deter-

mining more precisely the nature of religious and/or spiritual problems and

resulting treatment strategies. Is the problem purely a theological issue?

Then perhaps appropriate clergy should be consulted. Are there concurrent

mental or physical disorders that require attention or is the primary issue

distress of a spiritual nature sans mental or physical disorder? Increased

precision in diagnosis may increase sensitivity to clients and improve treatment

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outcomes. Finally, familiarity with spiritual emergence and emergency and

how they differ from psychopathology may prevent misdiagnosis and sub-

sequent iatrogenic harm. People in spiritual emergencies in particular may

greatly benefit from contextualizing their experiences in transpersonal

terms and treatment that includes grounding techniques and use of a spiri-

tual community, as opposed to psychiatric medication and hospitalization.

Note

1. Ellis (2000) later recanted his rejection of religious/spiritual/ transpersonal experiences

as inherently psychopathological and has recently even seen some value in exploring, rather

than merely debunking, these in psychotherapy.

Johnson, Friedman / Enlightened or Delusional 523

Table 3

Recommendations for Differential Diagnosis of

Religious/Spiritual/Transpersonal (R/S/T) Experiences

from Psychopathology

1. Accept reality of spiritual and transpersonal experiences.

2. Obtain thorough understanding of clients’ religious history and background.

3. Realize that psychopathology cannot be determined solely by content in clients’ R/S/T

experiences.

4. Assess adaptive functioning preceding and following R/S/T experience, whether symptoms

are acute or chronic, and level of openness to exploring spiritual experiences.

5. Assess quality of clients’ R/S/T orientation.

a. Does current behaviors/practices exceed religious injunctions?

b. Does client overemphasize certain practices or beliefs and neglect others?

c. Do beliefs and practices promote wholeness, relatedness and full humanness?

6. Compare idiosyncratic behavior and beliefs to normative practices in religious/ spiritual

community (e.g., speaking in tongues, hearing the voice of God).

7. Determine nature of religious or spiritual problem (Lukoff et al., 1992, 1996).

a. Purely religious or spiritual problem.

b. Mental disorder with religious or spiritual content.

c. Religious or spiritual problem concurrent with mental disorder.

d. Religious or spiritual problem not attributable to mental disorder.

8. Recognize and understand spiritual emergency versus spiritual emergence (Grof & Grof,

1992).

9. Recognize that psychopathology is often characterized by greater intensity, terror, and

decompensation than genuine spiritual experience.

10. Consider markers of religious psychopathology (Table 1).

11. Consider intrapsychic conflicts manifested as religious pathology (Table 2).

12. Consider assessment tools for identifying adaptive from maladaptive spirituality

(e.g., the SELF).

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Chad V. Johnson, PhD, is an assistant professor of human relations at the

University of Oklahoma (OU), a licensed psychologist, and a project

director in the Center of Applied Research for Nonprofit Organizations at

OU. He received his PhD in counseling psychology from Pennsylvania

State University. He has published in the areas of spirituality and psychology,

group psychotherapy, and social justice. His research and clinical interests

include social justice, the interface of spirituality and psychology, group

526 Journal of Humanistic Psychology

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psychotherapy, and body-oriented psychotherapies. Current research projects include

Community-Based Participatory Research with urban Native Americans, body-oriented inter-

ventions for trauma, and religious oppression for lesbian, gay, bisexual, and transgender/

transsexual individuals.

Harris L. Friedman, PhD, is a research professor of psychology at the

University of Florida and Professor Emeritus at Saybrook Graduate School

and Research Center, as well as interim Chair of the Clinical Psychology

Program at Walden University. He received his PhD in Clinical-Personality

Psychology at Georgia State University and is a Florida licensed psycholo-

gist. He is interested in scientific perspectives to transpersonal psychology,

especially as they pertain to epistemology and research methodology. He has

written or edited more than 70 publications, including books, book chapters,

and professional articles, as well as constructed the Self-Expansiveness Level Form, a measure of

transpersonal self-concept. Currently he serves as the editor of the International Journal of

Transpersonal Studies and the associate editor of The Humanistic Psychologist.

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