CHALLENGES IN TRANSPERSONAL DIAGNOSIS Paul A. Jerry, Ph.D. Athabasca University Alberta, Canada

ABSTRACT: Distinguishing between diagnosis and differential diagnosis, the author explores some of the challenges faced by therapists who need to make differential diagnoses of transpersonal experiences and psychotic states. Numerous studies have explored the differences between these two experiences and many guidelines exist to distinguish psychosis from transcendence. Needed is a scheme to aid the clinician in both diagnosis/assessment and treatment. Following a review of this historical backdrop, and building upon this base, the author offers a framework specifically designed for use by clinicians that differentiates between transpersonal phenomena and co-occuring psychiatric diagnosis. The framework calls for attention to three areas of experience, that of: the clinician, the client, and the presenting issue(s). Central attention is given to how balanced use of the DSM may be embraced from a transpersonal perspective. Included is a brief self-assessment and reflection guide for the practice of transpersonal diagnosis.

The question of distinguishing between transcendent and psychotic states is not new. Since the inception of the Journal of Transpersonal Psychology, articles have been published that explore this issue (e.g., see Wapnick, 1969). In spite of over 30 years of exploration, a number of issues remain unresolved. Generally, the literature has focused on the question of whether an individual’s experience is evidence of transcendence or psychosis (Lukoff, 1985; Ossoff, 1993; Wapnick, 1969). Specifically, the question has been one of distinguishing symptoms of the schizophrenic and psychotic clusters from those that are experienced during intentional (and unintentional, see Krishna, 1972) work with techniques directed at raising the kundalini energy. Less common are authors who explore other symptom clusters such as depression (e.g., Lukoff, 1988; and Wolman, 1986) or dissociative states (Hughes, 1992; Pattison, Kahan, & Hurd, 1986). While helpful for theoretical issues, these contributions do not always directly address the ‘‘hands-on’’ needs of the clinician. When the literature does address clinical needs, it often reduces the transpersonal/psychosis question to a dichotomy (see Nelson, 1994 for a discussion of this split). Clients, however, rarely present with a ‘‘pure’’ problem. Generally, they experience a blend of symptoms that need to be addressed from multiple perspectives (Grof & Grof, 1989).

A NOTE ABOUT LANGUAGE AND LABELS One of the issues facing transpersonal theory today is the broad use of terms for describing phenomena that fall under the umbrella of transpersonal psychology (Woodhouse, 1996). In another work (Jerry, 2001) I have discussed the problems of working in a field where terms are often used interchangeably but which terms may not Email: [email protected] Copyright Ó 2003 Transpersonal Institute

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be covering the same phenomenological ground. My personal resolution to this dilemma is to adopt two general definitions of transpersonal psychology with which I have a particular resonance. These two definitions are those of Tart (1997) and Mohs, Valle, and Butko (1997). Tart states, in part, that ‘‘Transpersonal psychology is a fundamental area of research, scholarship and application based on people’s experiences of temporarily transcending our usual identification with our limited biological, historical, cultural and personal self . . .’’ and as a result, experiencing a ‘‘much greater ‘something’ that is our deeper origin and destination’’ (Tart, 1997, available http://www.paradigm-sys.com/display/ctt_articles2.cfm?ID¼25). Tart also notes that language will always be an imprecise means of communicating the transpersonal since these experiences move beyond the extensional world of language. Mohs, Valle & Butko (1997) present a description of transpersonal psychology that is both applied and resonant with my clinical experience. They suggest further that transpersonal psychology works at both ego integration and ego transcendence. They suggest that we have a drive towards wholeness that comes from a disconnection between our true essence and our ego-based sense of self. For Mohs et al., our true essence has misidentified with our body, thoughts, and emotions and they suggest that transpersonal psychotherapy (and all of human growth) be modeled after a yogic process where an individual’s task is to recall his or her true nature as a spiritual being. Much work has been done on labeling theory and how language mediates and defines our experience of reality (e.g., Lacan, 1968/1981; Hayakawa, 1964; Whorf, 1956). Diagnosis is a process of labeling. Transpersonal therapy is a process of freeing ourselves from labels. On the way to this goal, we need to engage responsibly with the labeling process, if only to point us in the ‘‘right’’ direction. ORDER OR DISORDER? One concern for the clinician is the fact that only a handful of articles (mainly those by Lukoff) have been published on the issue of psychosis versus transcendence since the advent of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV, American Psychiatric Press, 1994). Although not without its critics and its flaws, the DSM-IV remains the principal manual for diagnosing and classifying mental disorders in the North American clinic. Many clinicians who include transpersonal issues in their practice also work within a context where they need to interact with, and integrate, the dominant psychiatric paradigm in their work. I see transpersonal psychology as having to take a position in relation to established systems in order to maintain rigor as well as to highlight difference. Kason (2001) notes that the DSM-IV provides a coding for ‘‘Spiritual and Religious Problems’’ (diagnostic code V62.89; American Psychiatric Association, 1994) thereby legitimizing (for the mainstream clinician) exploration and treatment of what may be interpreted as transpersonal (or as Kason prefers, ‘‘spiritual’’) issues. THE DIAGNOSTIC PROCESS In clinical practice, diagnosis plays a central role. Diagnosis shows itself in a number of ways. A clinician might directly engage in a diagnostic session with the intent to

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assign a label based on the DSM-IV (or some similar classification scheme). The clinician might use a theoretical system to assess and categorize a client’s behavior such as McWilliams’ (1994, 1999) psychoanalytic case formulations. Likewise, the theories of Washburn (1994, 1995) or Wilber (1995, 1996) can be applied to an individual’s experience as a means of making a statement about their current state of being (see Nixon, 2001a, for an example of an application of Wilber to alcoholism diagnosis and treatment). Or, a clinician may gather information grounded in some form of pattern-matching process where symptoms are considered in their contexts and, depending on the pattern and context of these symptoms, the clinician then applies an intervention. Common to any of these approaches is the creation of a statement of meaning around symptoms and experiences that, up until the point of diagnosis, are perceived by the client (and others) with a certain degree of ambiguity, uncertainty, and distress. Generally, one makes diagnoses in the context of a set of symptoms that are said to be causing personal distress and disruption in daily functioning. The purpose of diagnosis is not simply the assigning of a label for the sake of assigning a label. Bateson (1972) calls this process ‘‘dormative’’ diagnosis. Once the label is reached, thinking stops. A person becomes ‘‘a schizophrenic.’’ The treatment that follows is mechanical and prescribed. I am not suggesting that all clinicians stop thinking about their clients after the diagnosis milestone has been passed. Rather, I am suggesting that diagnosis is a dynamic and on-going process with revisions and changes occurring throughout the therapeutic process. However, establishing a starting point is essential to therapy. As McWilliams (1994) notes, the intent of diagnosis is to lead to a treatment plan. Making the correct diagnosis then has implications for the next phase of clinical interaction. To the transpersonallyorientated clinician, distinguishing between a brief psychotic episode and an experience of kundalini becomes paramount. One would likely intervene with medication and hospitalization for the psychotic, a course of treatment that could be disastrous for the transcending client. Diagnosis also has more subtle implications for treatment. In psychoanalytic psychotherapy, it can be important to consider a client’s character structure when making a diagnosis. In this context, the reasoning is that different character structures will react or respond to a variety of treatment methods in different ways. Certain character types will respond to directive approaches, while others will respond to containment strategies. An accurate diagnostic profile will help by-pass therapeutic mismatches and make the treatment process more efficient and accurate. In transpersonal therapy, Wilber’s spectrum of consciousness model is one illustration of this idea (Wilber, 1999). An individual who is experiencing a sense of nothingness and great anxiety about his or her existence needs to be understood from a developmental framework (Nixon, 2001b). Is the source of anxiety a sense of falling apart due to a fragile ego structure (Wilber’s Fulcrum-2 pathology, 1999, pp. 118–120) or is it a manifestation of an existential crisis brought on by a deliberate search for meaning (Wilber’s Fulcrum-6 pathology, 1999, pp. 125–127)? Proper diagnosis of the client’s level of development will help distinguish the key issues to be addressed in treatment, resulting in an appropriate treatment matching. Embracing the void will be an appropriate intervention for the existentiallydistressed client (Nixon, 2001b) but would not be recommended for the individual

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with a fragile ego structure, where containment and ego integration methods would be a better fit (Wilber, 1999). Diagnosis or Differential Diagnosis? Without playing too much on semantics, the task facing transpersonal therapists (and others to be sure) is one of differential diagnosis, not just diagnosis. This distinction has been implied in the transpersonal literature up to this point but the full implications have not been teased out. Many articles and books (e.g., Nelson, 1994; Washburn, 1994, pp. 254–256) tend to make a comparative listing of symptoms with the intent of demonstrating that transpersonal phenomena are categorically distinct from those of psychosis. This is a necessary and clinically useful approach since it gives a clinician a set of criteria from which to work. Other sources advocate for the inclusion of spiritual material in the assessment process, but more as an inclusive process for those new to spiritual counselling rather than as a discriminatory function regarding the type of experience in question (Faiver, Ingersoll, O’Brien, & McNally, 2001). In some sense, this latter approach is a far cry from Lukoff’s (1985) demand for a ‘‘well-trained diagnostician’’ who is able to work in both the psychiatric and the transpersonal worlds when addressing the needs of a client. It is this bridging of these two worlds where the process of diagnosis becomes the task of differential diagnosis. An example of the challenge to differential diagnosis is illustrated by a former client of mine. He was a 40 year-old male referred for an assessment/consultation by his massage therapist. He presented with a number of issues including a work-related injury, a tentative diagnosis of schizophrenia made at the local mental health clinic, a tentative diagnosis of psychosis made by a local psychiatrist, and his own selfdescribed experiences of ‘‘energy’’ and the presence of an animal totem that seemed to overlap with his experience of physical pain from his injury. The purpose of the consultation was to determine how much of what the client was experiencing was due to a genuine psychiatric condition, a transpersonal experience (the ‘‘energy’’ and animal totem), and the traumatic aftermath of a physical injury. The core challenge for this clinical consultation was working through the differences between his description of his experience and the possible diagnoses proposed for him by a number of professionals. This situation highlighted for me the need for further research on distinguishing between the DSM-IV diagnosis of Schizotypal Personality Disorder, [with its inclusion of criteria for diagnosis such as the ‘‘belief in clairvoyance, telepathy, or sixth sense,’’ and ‘‘unusual perceptual experiences,’’ (p. 645)] and some manifestations of transpersonal states that may include perceptual distortions, telepathy or clairvoyance. Having gathered information from the client (and likely others) regarding signs and symptoms, it is likely that the list of the client’s experiences will match a number of different possible diagnoses, or none at all. Here, the clinician moves into a phase of differential diagnosis. Following the DSM-IV, there are inclusion criteria and exclusion criteria for every diagnosis in the book. Implicit in this is a structural hierarchy that suggests that some categories of classification hold greater weight (or are more severe pathologies) than others. While the DSM allows for multiple diagnoses on a variety of dimensions, there is an expectation that a clinician needs to

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choose which of the symptom clusters is the primary disorder (First, Frances, & Pincus, 1995). While perhaps implied by the quantity of articles on kundalini and psychosis, transpersonal psychology does not yet appear to be in a position to model the American Psychiatric Association’s apparent certainty that one ‘‘transpersonal diagnosis’’ holds more weight than another.1 First et al. (1995) propose six steps which guide the process of differential diagnosis according to the DSM. These are: 1. Is the presenting symptom real? 2. Rule out substance etiology (including drugs of abuse, medication, toxin exposure) 3. Rule out a disorder due to a general medical condition 4. Determine the specific primary disorder(s) 5. Differentiate Adjustment Disorder from Not Otherwise Specified 6. Establish the boundary with no mental disorder These six steps give the clinician a model for critical thinking about a client’s symptoms. They also provide a sense of what is considered primary in this system. Specifically, body-based disorders (including medical conditions and substance intoxication) are considered to be more vivid data, as they can mimic symptoms that might otherwise be interpreted as psychological. Also, there does appear to be an attempt (whether put into practice or not is another issue) to attribute the least intrusive, that is to say, the least pathologizing, diagnosis appropriate to the symptoms. Steps five and six consider the severity of the symptoms, suggesting that (step five) if one has a series of symptoms which do not meet the criteria for a full diagnosis (often these are relegated to the ‘‘Not Otherwise Specified’’ category) that one needs to consider the diagnosis of Adjustment Disorder (often considered a ‘‘mild’’ diagnosis compared to, for example, an Affective Disorder such as depression, or an Anxiety Disorder). Step six asks a question that might be naturally found at the forefront of the minds of many transpersonal therapists, ‘‘is there really anything wrong here at all?’’ Given the history of transpersonal psychology and its move to define itself as different from other approaches to human experience (Harman, 1988), this question becomes a double-edged sword. On the one hand, in the quest for a transformative and health-based view of clients’ experience, transpersonal psychology places itself in the center of a movement and a world view which favors health, growth, and change as a positive process (Cortright, 1997). At the same time, it is possible that in our hopefulness and our quest to facilitate our clients’ growth and health, we might mis-diagnose (or under-diagnose) a genuine psychopathological condition. Apart from the harm this might do to a client (as great a harm as the mainstream psychiatric community mis-diagnosing a mystical experience as schizophrenia), this kind of loose practice is, in part, what leads the mainstream clinician to consider our work suspect (Lukoff, 1985; Nelson, 1994).

CLASSIFICATION IN TRANSPERSONAL THEORY Transpersonal psychology has not been lax in the areas of classification and differential diagnosis. Pattison, Kahan, and Hurd (1986) present a general nosology for

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some of the trance-based altered states of consciousness. While their work is primarily theoretical, they propose a classification scheme for altered (trance) states based on a division between ‘‘naturalistic’’ and ‘‘supernaturalistic’’ explanations. Unfortunately, their scheme is not designed to aid the clinician in assessment and diagnosis of client experience. I mention them here to show that attempts have been made to make sense of the universe of experience related to altered states of consciousness. White presents a more recent cataloguing of altered states, which she terms ‘‘Exceptional Human Experiences’’ (EHE) (White, 2000; Palmer & Braud, 2002). White’s list appears to be more inclusive than the work of Pattison et al. and includes experiences familiar to the transpersonal literature (e.g., kundalini awakening) as well as experiences that may be more common (e.g., ‘‘psychotherapeutic resonance’’) or may represent categories of experiences or study (e.g., psychoneuroimmunology). Ken Wilber, perhaps one of the best-known transpersonal theorists, presents a developmental model for organizing experience, both personal and transpersonal. His spectrum of consciousness (Wilber, 1999, pp. 65–72) and its related spectrum of psychopathology (Wilber, 1999, pp. 117–133) serve as models for mapping human experience in a systematic manner. He proposes that human beings develop through a series of stages of consciousness and that at each stage, it is possible for the developmental process to ‘‘go wrong,’’ leading to ‘‘specific and characteristic pathology’’ (Wilber, 1998, p. 68). Wilber’s model is comprehensive and lends itself to the broad categorization of a client’s position. It also suggests a direction for therapeutic intervention in a given case. However, the clinician who is looking for specific therapeutic strategies will be disappointed in Wilber’s model. Wilber often appears to leave the development of the details to others—his strength being found in his ability to conceptualize the grand view, and integrate diversity into it. Fans of Wilber will need to search for, or better yet, develop on their own, details of diagnosis and treatment based on his model. Ingersoll (2002) proposes that the current psychiatric disease model limits the clinician’s view of his or her client because the essence of its application is descriptive. Diagnosis based on the DSM describes clusters of symptoms and proposes that the relief of these symptoms is the goal of treatment. Ingersoll notes that there has been an emphasis in the field of psychiatry to incorporate a biopsychosocial approach to diagnosis but that pressures such as the reimbursement patterns of thirdparty payers tend to influence the training and behaviour of clinicians in a manner that does not easily support the use of potentially richer dimensional models of diagnosis. Ingersoll presents Wilber’s Integral Model as an approach to diagnosis. This model is ‘‘dedicated to integrating body, mind, soul, and spirit in self, culture, and nature’’ (Ingersoll, 2002, p. 118). He presents a case example of the use of both the DSM multi-axial approach as well as Wilber’s model of the four quadrants and levels of reality (the three ‘‘eyes’’) in the diagnosis of a woman who is experiencing a variety of psychological, relational and spiritual issues. This application of Wilber’s work allows the clinician to organize a variety of human experiences in a manner that avoids clinical reductionism. Lukoff (1985, p. 163) presents a ‘‘flow chart for guiding decision-making regarding diagnoses and treatment of cases with psychotic features.’’ This work is concerned with differentiating psychosis from mystical experience, and the development of an

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understanding (and diagnosis of) the ‘‘mystical experience with psychotic features’’ (MEPF). Lukoff presents a diagnostic decision tree not unlike those found in the DSM itself. He suggests an order (like First, et al., 1995) to the diagnosis of a mixed psychotic/mystical state. The process involves determining the presence of psychosis according to the DSM, the presence of mystical experience(s), and a determination of the severity of each subset of symptoms as a way of determining which of the two (psychosis or mystical state) takes precedence in the final diagnosis. Lukoff is the first to clinically consider psychological disorder and transpersonal phenomena as overlapping states, and not as discrete phenomena. Lukoff is also one clinician/researcher who has taken the exploration of transpersonal experience beyond the psychotic/mystic dichotomy, employing transpersonal therapy with bipolar disorder (Lukoff, 1988a, 1988b). His recent work describes the development of linking religious and spiritual issues and the DSM diagnostic system (Lukoff, Lu & Turner, 1998) and updates his previous work with diagnostics. Included in this contribution is a listing and description of a variety of spiritual problems including questioning of spiritual values, meditation-related problems, mystical experience, near-death experience, leaving a spiritual teacher/path, and spiritual emergence. These descriptions (often with short case examples) enhance the clinician’s diagnostic ability by providing concrete criteria with which to evaluate a client’s experience.

A FRAMEWORK FOR TRANSPERSONAL DIAGNOSIS Transpersonal diagnosis involves accounting for three areas of experience, that of the clinician, that of the client, and that of the presenting issue(s). The Clinician In this category, I suggest that there are three main points of which the clinician needs to be aware. The first is the clinician’s own assumptions and beliefs about transpersonal phenomena. Cortright (1997) suggests a list of working assumptions that he sees as underlying the field of transpersonal psychotherapy (pp. 16–21). Briefly, he suggests that much of what is considered transpersonal psychotherapy today can be seen to rest on assumptions that our essential nature is spiritual; that consciousness is multidimensional and as such will manifest in ways within and beyond our experience; that human beings have a drive to spirituality; that contact with a ‘‘deeper source of wisdom’’ is both possible and desirable, and that following this path of contact is health-promoting. He notes that altered states of consciousness are one pathway to the goal of spiritual awareness but that these experiences can be seen in the context of a meaningful life and that all of these (and other) values that the clinician holds will shape our view of the client. While these are not exhaustive assumptions, the clinician will hold beliefs and values about the nature of transpersonal experience (ranging from ‘‘it doesn’t exist’’ through to a wholly inclusive, and hence non-discriminative belief). Awareness and acknowledgement of their influence on the clinical setting is essential to the process of turning to diagnoses that move beyond simple observation of behavioral symptomology.

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The second point is an awareness of the nature of the transpersonal experiences of the clinician. Many therapists come to transpersonal practice because of their own experiences with these phenomena (Kason, 2000). How might these experiences influence the clinician’s view of the client? Are there phenomena which the clinician knows/believes to be real based on direct experience? Are there phenomena which the clinician knows/believes to be false? A colleague at a meeting of psychologists interested in exploring transpersonal psychology was quite negatively vocal when a participant suggested we look at UFO abductions as part of the content for discussion. My (unvoiced-at-the-time) response was that this individual would be better, clinically and ethically, to refer any client who presented with this issue to another clinician since my colleague had (to my knowledge) never been abducted, nor did he believe that this was a legitimate area for exploration. The third point is how familiar the clinician is with both formal diagnostic schemes such as the DSM, and similar models of transpersonal experience to the extent that they exist. Does the clinician have access to current knowledge and understanding about the varieties of transpersonal experience in the same way that they might have a knowledge and understanding of diagnostic schemes such as the DSM? The clinician has a role as one who may be an active and knowledgeable agent and/or facilitator in the process of understanding a client’s current state and their potential need or desire for transformation. In order to fulfill that role, the clinician requires a framework for understanding the experiences presented by the client.

The Client The second category of experience is that of the client. To a large degree, the issues in this domain of experience are typical of any diagnostic process. What exactly is the client asking for or presenting with? What is the client’s orientation to the experiences? Nelson (1994, p. 398) suggests that an understanding of how the client perceives his or her symptoms and experiences is an important diagnostic consideration. This is, to a degree, a clinicalinterpretive process on the part of the clinician. Following the work of McWilliams (1994) on psychoanalytic character types, it is possible to consider the characterological structure of the client’s relation to his/her symptoms. The role of personality structure has also been explored in the context of spiritual growth (Welwood, 1986). In the context of diagnosis and treatment of mental disorders and transpersonal experiences, two questions need to be considered. First, how do the clients’ psychological/characterological structures of personality affect their interpretation of their experience? This is primarily understood from the way a client communicates their distress as opposed to the kind of distress they have. Nelson asks us to consider ‘‘how the person feels about his shift in consciousness. Is he frightened, enlightened, confused, fascinated and so forth’’; and ‘‘how the person defends himself against the inflowing energies of the growing paranoia, denial, grandiosity, religiosity, occult beliefs, simple bewilderment, denial that anything is wrong’’ (p. 398). These manifestations of psychopathology are just that. As the energy of a transformational

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experience or a spiritual discipline flows through the client, it encounters blocks and barriers (often the distortions of our conscious and unconscious mind). These are not transpersonal. These are psychological and are best mapped with psychological means. The second question is one for treatment planning: Given the constellation of symptoms, interpretations and orientation to the experience, which of these psychological distortions will become the grist for the therapeutic mill? In other words, having a sense of the nature of the reaction to the experience (say, paranoia), will this become the focus of therapy because it is the most likely to transform itself (say from paranoia to security)? It is conceivable that in our zeal to explore the fascinating and interesting world of our, and our clients’, transpersonal experiences that these phenomena are, for the client, only peripheral to the issues which motivated him/her to seek therapy. For example, I interviewed a young woman who had been having profound feelings and intrusive memories which she could only make sense of as issues from a past life. Without any obvious links in her heritage or community, she had been having nightmares about the Holocaust and her role in surviving it. In her visions, she survived the war only to die a few years later. Her recollection of these events was detailed and very disturbing to her. She also had a history of recalling in vivid, trance-like states, life-experiences which pre-dated her current life. In the present context, she was approaching the age at which she remembers dying in the apparent former life. She reported an increase in anxiety as her birthday approached and was articulating fears and feelings which others have termed ‘‘survivor guilt’’ (see for example Matsakis, 1999). While some understanding of the theory and mechanics of current and past life experiences was helpful to her (she lived in a small community where this kind of information was not readily available), her main concern was in obtaining relief for her insomnia. Our therapeutic interaction was centered on nonchemical strategies and techniques for sleeping through the night. Apart from an initial assessment and interpretation of her issues in the context of past-lives theory, the main focus of the therapy was an intervention for insomnia. The important questions become ‘‘What does the client want?’’ and ‘‘How can we provide that without ourselves getting in the way?’’ This leads to a second point, that of readiness to change. Much has been written in the past two decades about the concept of stages of change (Prochaska & Norcross, 1999). The authors suggest that regardless of one’s theoretical perspective, clients seeking to change aspects of their behavior progress through identifiable stages of change. These range from a state of not being ready to change (called precontemplation), a state of considering change (called contemplation), a state of making ready to change (called preparation), a state of active change (called action), and a state of maintaining changes made (called maintenance). While a wholesale accounting of this model is beyond the scope of this presentation, I suggest the use of what Prochaska and Norcross call the ‘‘transtheoretical model’’ as one aspect of transpersonal diagnosis for two reasons. One, it is descriptively useful. The model is fairly direct in its aim to describe the process of change. It is easily applied by a clinician. Two, because it does not derive from any particular psychotherapeutic theoretical orientation, it has the potential to be applicable to most (if not all) transpersonal/clinical experiences. The model evaluates a process of change, and

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not the client’s experience. In the last example, the young woman was satisfied with minimal focus on the details of past-life theory but was compelled to find relief for her insomnia. One could suggest that she was ready for the stage of action with regard to her sleeplessness but perhaps at contemplation with respect to the past-lives discussion. This evaluation of the different aspects of the presenting issue can help clarify the diagnostic picture. (See McConnaughy, Prochaska, & Velicer, 1983, for a paper-pencil psychometric tool for establishing a client’s stage of change vis-a`-vis a specific problem.)

The Clinical Issues The third category of experience is that of the presenting issues. At this point, the clinician is ready to explore the details of the phenomena in question and begin the process of applying a model or models of understanding to what is being presented by the client. This stage of analysis includes the process of differential diagnosis, essentially asking the questions ‘‘what is this phenomenon?’’ and ‘‘what isn’t it?’’ Under the rubric of ‘‘what is it?’’ the clinician may list the client’s symptoms as they appear in the context of mental disorder according to some established diagnostic scheme such as the DSM-IV. The clinician may then list the client’s symptoms as they appear in the context of transpersonal experience either according to some established model, or according to the client’s report. Next, the clinician will want to determine areas of overlap and uniqueness in these lists of comparative symptoms. Such comparative symptom lists have the advantage of being experience-based (with greater or lesser degrees of positivist rigor). The clinician who is able to refer to such lists (including lists embodied in the DSM) and thus make an informed and empirical accounting of the clinical situation will not only increase the accuracy of his/her work (Gambrill, 1990, pp. 53–61, 74), but will also be in alignment with the various ethical codes which may govern the individual’s clinical practice [see for example, Ethical Principles of Psychologists and Code of Conduct (APA, 1992); Canadian Code of Ethics for Psychologists (Canadian Psychological Association, 2000)]. Finally, in spite of lists of symptoms of both mental disorders and transpersonal experiences, clients’ reports of these experiences will not always use the same language to which we are accustomed in our theoretical and clinical work. Careful listening on the part of the clinician, with a view to finding the best fit of symptom/experience to category (mental disorder, transpersonal experience, both, none) is key to any successful diagnostic practice. Other considerations include timing of the onset of symptoms (including the presence of any deliberate practices such as meditation prior to the symptoms), whether this is a first experience or one of many, and other information typically gathered in a complete history. Under the rubric of ‘‘what isn’t it?’’ the clinician will want to pay careful attention to a number of issues in order to clarify the diagnostic picture. These issues include recent or habitual use of drugs and/or alcohol. In spite of the existence of practices which use chemical media to induce transpersonal experiences, individuals who have used alcohol or drugs as an on-going coping mechanism to address serious

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psychopathology are more likely reporting painful withdrawal than transcendence (Nixon, 2001a). A rule of thumb in this context is to determine the purpose of the client’s drug or alcohol use. Obviously one would interpret ritual and deliberate use differently than chronic use marked by the typical signs and symptoms of addiction (Frances & Miller, 1998). Medical conditions can mimic psychological disorders (Taylor, 2000). It is important, from both the ethical and clinical perspectives, to be clear about the difference between a medical disorder that calls for specific intervention and other experiences that are only cursorily related to the body. My own bias and assumption in this area places a priority on the physical vehicle in which we dwell. Not unlike the conceptual challenges to physiological studies of transpersonal states, the body appears to exert a significant effect on states of consciousness. Notwithstanding clinicians who work in the very rich fields of palliative care, mind-body interaction in chronic medical conditions, and end-of-life issues, research on the normal and non-normal effects physical health on transpersonal experience is still open territory for explanation and the clinician is faced with balancing client health and safety with emerging theory and empirical data. While not a usual topic for transpersonal psychology, a thorough differential diagnosis needs to consider the question of confabulation and/or malingering. There are two reasons for this. The first is clinical. Is there some benefit (external or internal to the person) for having these experiences? Clinical work in this area often centers around ego needs (the so-called ‘‘spiritual materialists’’). How does it help the client to be seen, or to see themselves as being ‘‘more and more spiritual’’? While not out of the realm of possibility, less common is the situation where litigation hinges on the assessment of a client’s purported transpersonal experiences. In any case, the question of a client ‘‘faking’’ symptoms is necessary for a complete ruling out of alternative explanations for a diagnosis. Of course, clients who regularly ‘‘fake’’ these experiences may be very interesting to work with in and of themselves. The second reason is empirical. In a sense, asking this question leads to a process of accounting for one’s clinical reasoning. In the context of self-evaluative practice, it may be helpful to the clinician, the client, and the field of transpersonal psychotherapy generally to be able to explain and describe logically, consistently, and coherently what reasoning and what conclusions were used to understand this client’s experience. My rule of thumb here is to ask whether or not I could explain this diagnostic process to another transpersonally-orientated clinician, to a colleague who does not share an interest in transpersonal psychology, and to a friendly member of my profession’s Discipline Committee. Hypothesizing. The process of hypothesizing is divided into two categories: the theoretical model and the diagnostic model. The theoretical model provides a consistent language and framework for explaining a phenomenon and, more importantly, suggests what else may be present or not yet accounted for by an initial observation. The diagnostic model provides a listing of known and generally accepted clusters of symptoms as well as decision rules for prioritizing symptoms and inclusion/exclusion criteria. The process of integrating each of these models might include a process of evaluating each symptom, as well as the Gestalt of

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symptoms its relative membership in a psychiatric versus transpersonal category. Clarity about one’s understanding of transpersonal theory and its assumptions will help the clinician frame his or her view of clients and their experiences, both personal and transpersonal. The result of this step would be a concise description of the client, their symptoms, and the proposed explanation for those symptoms. This statement would lead directly to some plan for intervention, be that psychotherapy or support, guidance or counselling. Intervening. Diagnosis becomes outcome-based, not in traditional psychotherapeutic (or managed care terms) but in terms of the spirit. In my teaching context (with graduate students in counselling) I have had the opportunity to continually focus on the necessary link between diagnosis and intervention. A label for the sake of a label may have administrative utility but does not always serve the immediate clinical needs of the client. My position is that a diagnosis should propose within itself the next step towards relief or change or transformation. Goodwin and Guze (1989) note that ‘‘Classification has two functions: communication and prediction’’ (p. xi). Communication serves the administrative utility I noted above. Clinically, the main issue with diagnosis is prediction. Goodwin and Guze further describe their dictum of ‘‘diagnosis is prognosis’’ in this way: There are many diagnostic categories in psychiatry, but few are based on a clinical literature where the conditions are defined by explicit criteria and follow-up studies provide a guide to prognosis. Lacking these features, such categories resemble what sociologists call labeling. (p. xi) They suggest that current classification schemes are not yet comprehensive enough to capture all possible human phenomena and suggest that in the absence of data, no diagnosis is better than ‘‘a label incorrectly implying more knowledge than exists’’ (p. xi). Vaughan (1998) presents a set of outcomes and indicators for spiritual development. Some of these outcomes include markers of self-awareness, awareness of others, and authenticity. Emotional changes may include compassion replacing judgment, forgiveness replacing anger, and the experience of an expanding circle of empathic identification. Motivations may change from fear to love, from ignorance to understanding. A client’s sense of purpose may change to desires to relieve suffering, awaken new perceptions, intentional self-realization and self-transcendence, and connecting one’s life of mind and spirit with action in the world. My proposal is that the transpersonally-orientated clinician incorporate these outcomes as part of the diagnostic process, reframing a client’s symptomology (both psychiatric and transpersonal) as progress along a road toward these goals. This is not to suggest that the clinician need impose a model for growth on the client but rather that he/she be guided by what is known about the process of spiritual development from a variety of sources. CONCLUSION American psychology has observed a small but important revolution in recent years. While not new, the focus of what Seligman has termed ‘‘positive psychology’’

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shows that there is an interest to explore the ‘‘up side’’ of human experience (Seligman & Csikszentmihalyi, 2000). As Walsh (2001) noted in his reply to Seligman and Csikszentmihalyi, transpersonal psychology has been dealing with the essence of positive psychology for the past 30 years. We are now faced with the need to continue a balanced application of this field of study in the clinical setting. I conclude with a final caution when undertaking transpersonal diagnosis, in the form of a re-phrasing of a comment made by Malan (1979). Originally, he stated that, ‘‘There is no greater enemy of a psychiatric diagnosis than a psychodynamic diagnosis.’’ Malan was a psychiatrist and psychoanalyst who trained therapists. He commented that ‘‘it is a frequent observation that when a psychiatrist becomes a psychotherapist, his knowledge of psychiatry tends to disappear out the window, and he progressively forgets its extreme relevance to psychotherapy’’ (p. 224). In other words, Malan saw a clinical value in placing psychiatric knowledge before psychotherapeutic knowledge, a value in placing potentially biological/somatic issues before psychological. This presages First et al.’s (1995) steps two and three in differential diagnosis. In the present context, I would re-write Malan’s statement thus: ‘‘There is no greater enemy of a psychiatric diagnosis than a transpersonal diagnosis, and vice-versa.’’ In other words, the clinician cannot afford to defend either side of the (likely false) transpersonal/psychiatric dichotomy when the lives of clients hang in the balance.

NOTES 1 Whether or not it is appropriate for the field of transpersonal psychology to match the kind of diagnostic model portrayed by the DSM is a question in and of itself. Some of my colleagues disagree with me that transpersonal psychology needs to model itself after another paradigm—especially the medical model. My response is that for those of us who need to (clinically) bridge the gap between science and spirituality on a daily basis, there needs to be a system or model which meets the apparent rigor of the dominant paradigm while taking into account that our field of endeavor is existentially different from the medical domain. Hutchins (2002) provides an expansion of the DSM to include, in parallel fashion, redefinitions of each Axis to include an individual’s strengths and abilities.

REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION (1994). Diagnostic and statistical manual of mental disorders (4th ed.). American Psychiatric Press, Inc.: Author. AMERICAN PSYCHOLOGICAL ASSOCIATION (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47(12), 1597–1611. BATESON, G. (1972). Steps to an ecology of mind. New York: Ballantine Books. CANADIAN PSYCHOLOGICAL ASSOCIATION (2000). Canadian Code of Ethics for Psychologists (3rd ed.). Retrieved Feb. 1, 2001 from the World Wide Web: http://www.cpa.ca/ ethics2000.html CORTRIGHT, B. (1997). Psychotherapy and spirit: Theory and practice in transpersonal psychotherapy. Albany, NY: SUNY Press. FAIVER, C., INGERSOLL, R. E., O’BRIEN, E., & McNally, C. (2001). Explorations in counselling and spirituality. Belmont, CA: Wadsworth/Thompson Learning. FIRST, M. B., FRANCES, A., & PINCUS, H. A. (1995). DSM-IV handbook of differential diagnosis. Washington, D.C.: American Psychiatric Press, Inc. FRANCES, R., & MILLER, S. (Eds.) (1998). Clinical textbook of addictive disorders (2nd ed.). NY: The Guilford Press.

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GAMBRILL, E. (1990). Critical thinking in clinical practice. San Francisco, CA: Jossey-Bass Publishers. GOODWIN, D. W. & GUZE, S. B. (1989). Psychiatric diagnosis (4th ed.). New York: Oxford University Press. GROF, S., & GROF, C. (Eds.) (1989). Spiritual emergency: When personal transformation becomes a crisis. NY: Jeremy P. Tarcher/Putnam Books. HARMAN, W. W. (1988). The transpersonal challenge to the scientific paradigm: The need for a restructuring of science. ReVision, 11(2), 13–21. HAYAKAWA, S. I. (1964). Language in thought and action (2nd ed.). New York: Harcourt, Brace & World, Inc. HUTCHINS, R. L. R. (2002). Gnosis: Beyond disease and disorder to a diagnosis inclusive of gifts and challenges. The Journal of Transpersonal Psychology, 34(2), 101–114. INGERSOLL, R. E. (2002). An integral approach for teaching and practicing diagnosis. Journal of Transpersonal Psychology, 34(2), 115–127. JERRY, P. (2001). The journey of the ‘‘everyday mystic’’: A phenomenological-empirical exploration of transpersonal experience. Unpublished doctoral dissertation, University of Calgary, Calgary, Canada. KASON, Y. (2000). Farther shores: Exploring how near-death, kundalini, and mystical experiences can transform ordinary lives (rev. ed.). Toronto: HarperCollins Canada. KASON, Y. (2001). Counselling patients with spiritual experiences: Fundamentals of diagnosis and treatment. Spirituality and Health Conference, University of Calgary Faculty of Medicine, May 24–26, 2001. KRISHNA, G. (1972). Kundalini: The evolutionary energy in man. Boston, MA: Shambala Publications. LACAN, J. (1968/1981). The language of the self. Baltimore, MD: JohnsHopkins Press. (Tr. A. Wilden.) LIESTER, M. B. (1996). Inner voices: Distinguishing transcendent and pathological characteristics. Journal of Transpersonal Psychology, 28(1), 1–29. LUKOFF, D. (1985). Diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology, 17(2), 155–181. LUKOFF, D. (1988a). Transpersonal therapy with a manic-depressive artist. Journal of Transpersonal Psychology, 20(1), 10–20. LUKOFF, D. (1988b). Transpersonal perspectives on manic psychosis: Creative, visionary, and mystical states. Journal of Transpersonal Psychology, 20(2), 111–139. LUKOFF, D., LU, F., & TURNER, R. (1998). From spiritual emergency to spiritual problem: The transpersonal roots of the new DSM-IV category. Journal of Humanistic Psychology, 38(2), 21–50. MALAN, D. (1979). Individual psychotherapy and the science of psychodynamics. London, UK: Butterworths. MATSAKIS, A. (1999). Survivor guilt: A self-help guide. Oakland, CA: New Harbinger Publications, Inc. MCCONNAUGHY, E.N., PROCHASKA, J.O., & VELICER, W.F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368–375. MCWILLIAMS, N. (1994). Psychoanalytic diagnosis. New York: The Guilford Press. MCWILLIAMS, N. (1999). Psychoanalytic case formulation. New York: The Guilford Press. MACDONALD, D., LECLAIR, L., HOLLAND, C., ALTER, A., & FRIEDMAN, H. (1996). A survey of measures of transpersonal constructs. Journal of Transpersonal Psychology, 27(2), 171– 235. MOHS, M., VALLE, R., & BUTKO, A. (1997). Transpersonal perspectives in the nature and treatment of substance abuse. Brentwood, CA: Awakening Press. NELSON, J. E. (1994). Healing the split: Integrating spirit into our understanding of the mentally ill. Albany, NY: SUNY Press.

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NIXON, G. (2001a). Using Wilber’s transpersonal model of psychological and spiritual growth in alcoholism treatment. Alcoholism Treatment Quarterly, 19(1), 79–95. NIXON, G. (2001b). The transformational opportunity of embracing the silence beyond hopelessness. Voices, (Summer), 55–66. OSSOFF, J. (1993). Reflections of shaktipat: Psychosis or the rise of kundalini? A case study. Journal of Transpersonal Psychology, 25(1), 29–42. PALMER, G. & BRAUD, W. (2002). Exceptional human experiences, disclosure, and a more inclusive view of physical, psychological, and spiritual well-being. Journal of Transpersonal Psychology, 34(1), 29–61. PATTISON, E. M., KAHAN, J., & HURD, G. Trance and possession states. In B. B. Wolman and M. Ullman (Eds.). (1986). Handbook of states of consciousness. Ch. 9. New York: Van Nostrand Reinhold. PROCHASKA, J. O., & NORCROSS, J. C. (1999). Systems of psychotherapy: A transtheoretical analysis (4th ed.). Pacific Grove, CA: Brooks/Cole Publishing Co. PSYCHOLOGISTS ASSOCIATION OF ALBERTA (1994). The Professional Practice of Psychology: Self-Evaluation. Practice Review Committee, Psychologists Association of Alberta: Author. SELIGMAN, M., & CSIKSZENTMIHALYI, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14. TART, C. (1997). Transpersonal Psychology: Definition of. Journal of Consciousness StudiesOnline. Retrieved June 21, 2003 from the World Wide Web: http://www.paradigm-sys. com/display/ctt_articles2.cfm?ID¼25 TAYLOR, R. (2000). Distinguishing psychological from organic disorders: Screening for psychological masquerade. New York: Springer Publishers. VALLE, R., & MOHS, M. (1998). Transpersonal awareness in phenomenological inquiry: Philosophy, reflections, and recent research. In W. Braud and R. Anderson (Eds.), Transpersonal research methods for the social sciences: Honoring human experience, pp. 95–113. VAUGHN, F. (1998, August). Spiritual development: Outcomes and indicators. Council on Spiritual Practices. Retrieved July 7, 1999 from the World Wide Web: http://www.csp.org/ development/docs/vaughn-spiritual.html WALSH, R. (2001). Positive psychology: East and West. American Psychologist, 56(1), 83–84. WAPNICK, K. (1969). Mysticism and schizophrenia. The Journal of Transpersonal Psychology, 1(2), 49–67. WASHBURN, M. (1994). Transpersonal psychology in psychoanalytic perspective. Albany, NY: SUNY Press. WASHBURN, M. (1995). The ego and the dynamic ground (2nd ed.). Albany, NY: SUNY Press. WELWOOD, J. (1986). Personality structure: Path or pathology? Journal of Transpersonal Psychology, 18(2), 131–142. WHITE, R. (2000). List of Potential EE/EHEs Retrieved June 16, 2003: http://www.ehe.org/ display/ehe-page.cfm?ID¼3 WHORF, B. L. (1956). Language, thought, and reality: Selected writings of Benjamin Lee Whorf. Cambridge Mass.: MIT Press. (Ed. J. B. Carroll.) WILBER, K. (1996). A brief history of everything. Boston, MA: Shambala Publications. WILBER, K. (1995). Sex, ecology, spirituality: The spirit of evolution. Boston, MA: Shambala Publications. WILBER, K. (1999). The collected works of Ken Wilber (Vol. 4: Integral psychology; Transformations of consciousness; Selected essays). Boston: Shambala Press. WOLMAN, B. B. (1986). Protoconscious and psychopathology. In B. B. Wolman and M. Ullman (Eds.), Handbook of states of consciousness. Ch. 10. New York: Van Nostrand Reinhold. WOLMAN, B. B., & ULLMAN, M. (Eds.) (1986). Handbook of states of consciousness. New York: Van Nostrand Reinhold.

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WOODHOUSE, M. (1996). Paradigm wars: Worldviews for a new age. Berkeley, CA: Frog Books Ltd.

The Author Dr. Paul Jerry is an Assistant Professor of Applied Psychology with the Centre for Graduate Education in Applied Psychology, Athabasca University, and an Adjunct Assistant Professor of Applied Psychology, University of Calgary. His teaching responsibilities are in the Campus Alberta Applied Psychology Counselling Initiative, a three-university partnership that provides a blended face-to-face and on-line program for training counselling psychologists at the master’s level. Dr. Jerry’s research interests include single case clinical research models, counsellor education, transpersonal psychology in clinical practice, assessment practice, adult web-based distance learning and the development of virtual communities. In addition to his academic appointments, he maintains a private practice in clinical and forensic psychology.

The following self assessment is modeled on a self assessment tool originally developed by the Psychologists Association of Alberta (1994). The tripartite framework of clinician, client, and issues is my own.

Appendix A BRIEF SELF-ASSESSMENT FOR THE PRACTICE OF TRANSPERSONAL DIAGNOSIS The Clinician Have I examined my own assumptions and beliefs about transpersonal phenomena?





What are my experiences? How might they color my view of my client? Are there phenomena that I believe to be real? Are there phenomena that I believe to be false?

Have I taken stock of my own knowledge of:
The DSM and/or other formal diagnostic schemes?
The varieties of transpersonal experiences?

The Client What exactly is my client asking for? How well do I know the limits of my client’s belief systems? (How should I frame my explanations/interventions for ‘‘best fit’’ with my client?) Can I apply a basic stages of change model to my client’s situation (i.e., assess their ‘‘readiness’’ for the likely interventions I may need to propose?)

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The Issues Can Can Can Can

I I I I

frame the client’s issues in a consistent language? apply a diagnostic model to the issues my client presents to me? account for experience at the levels of body, mind, and spirit? categorize experience into psychopathological, transpersonal or mixed?

Differential Diagnosis.

What it isn’t (. . . can I rule out):


Drug/alcohol (except for situations where chemical use is part of an established spiritual practice)
Medical condition(s) known to mimic other symptoms
Confabulation/malingering What it is:
Can I list symptoms according to some established diagnostic scheme such as the DSM?
Can I list symptoms according to some established model of transpersonal experience?
Can I determine areas of overlap and uniqueness in these lists? Why now?
Was the client recently engaged in a spiritual/transformative practice that might be the cause of the current issues? (look for both the type—e.g., meditation, or an event—e.g., recent retreat or workshop)
Is the client in therapy for other issues?
Is this the first experience or one of many? Hypothesizing. Can I frame the whole diagnostic picture in a consistent language? Does my formulation include (or is it guided by) the client’s attempts to make meaning? Does my understanding of ‘‘what’’ lead to ‘‘how’’? Intervention. Have I considered the appropriateness of my models of intervention for the issues at hand? Do my proposed interventions address diverse levels of experience?
Body: (e.g., breath work, body therapies, yoga, energy therapies, medication, diet changes, etc.)
Mind: (e.g., depth psychotherapy, meditation, other approaches such as EMDR, etc.)
Spirit: (e.g., meditation, prayer, community, etc.) Evaluation. client to:

Can I explain logically/consistently/coherently what I did with this


Another transpersonally-orientated clinician?
A colleague who does not share an interest in transpersonal psychology?
A member of my profession’s discipline or practice review committee?

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