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The following chapter is from my book, The Comprehensive Mental Status Exam, a primer for mental health interns.







The presentation of spiritual or religious problems are rare, or a small minority in a psychiatric secular setting. Religious and spiritual problems are addressed in the chapter, “Other Conditions That May Be a Focus of Clinical Attention” in DSM IV. This category receives no statistics under the heading of ‘prevalence.’ The presentation of a spiritual or religious problem during the course of a mental status examination will be unlikely unless it is introduced as the presenting problem. This may happen if the person has suffered a traumatic event or a loss and they are asking, “Why did God do this?”, or, “Where is God?”


There are conservative denominations in the Christian church that does not think much of psychology and psychiatry. Members from these groups with a spiritual problem would more likely take their issue to their minister, or pastor, if they were so inclined. However, the realization the local church is not always the best place to reveal one’s foibles, may prevent them from seeking help there. A common fear is that, because churches are not the best place to keep a secret, everyone in the church will know, and you will be looked on with scorn, or perhaps shunned. In addition, some individuals do not like being preached at - or corrected. People resent having bible verses and platitudes shoved down their throat by individuals who are as vulnerable and human like everyone else, and yet claim to be righteous and upstanding. This is often referred to as hypocrisy. While these fears may be baseless for a majority, the few who do not seek out a minister from another congregation, or a secular psychologist, have no recourse but to suffer from whatever problem they have.


If, and when, a client with a religious problem does appear in the secular setting they may be reluctant to mention any spiritual issues until they have a well-established relationship with the clinician. Likely, they may present with an anxiety or depressive disorder, or a family relationship problem. The anxiety and depression profiles will apply to individual with these signs and symptoms. The ‘Religious and Spiritual Problem’ profile on the following pages is more specific, with inventories related to individual needs associated with spiritual issues.


When meeting someone with religious and spiritual problems, tread lightly. Nothing will turn a client off quicker then an air of superiority, and speaking as if you, or your particular denomination, has the supreme truth. If you did have the supreme truth, everyone in the world would be following you and the conversation you are having with the client would be unnecessary. Let the client decide what the truth is for them, and what their relationship with the cosmos will be.


“As a spiritual midwife, the director’s task is to pay attention, to listen to what is not being said – or to what is being said but minimized. Those seeking a spiritual director for the first time are almost invariably apologetic and quick to minimize their experience of annunciation, at least until they are reassured of its validity. So our conversations often begin with a disclaimer: “I’m not really sure of why I am here. I shouldn’t be taking up your time. But....” Talking about God is difficult, and many of those yearning for spiritual direction lack the vocabulary to describe their symptoms and – alas! – the imagination to envision the fruit of their travail. They just know they are experiencing inner changes, sometimes alarmingly joyful and sometimes profoundly disturbing. Spiritual distortion, imbalance, and nausea are no more pleasant than the analogous physical phenomena, even when they are signs of life and fruitfulness.”

Margaret Guenther (1992) Holy Listening, The Art of Spiritual Direction



Though it is rare, you may be presented with someone who has lost his or her way. Someone that was once a believer is now blaming God for the problems they have. If they are not blaming God, they have at least given up the idea that God is of any help. They may stop going to church, start drinking or do things they would not normally do, ethically, or morally. They may not have attended church at all, or did so rarely. Now something has gone wrong and they no longer believe as they once did. The idea that “I no longer believe” may never be expressed, yet may lie at the root of their current problem, or is a result of their current difficulty. Losing one's sense of self and place in the world is an insult to self-integrity. The thought of God abandoning us is the final rejection. This would send anyone into despair. Why pray for help if we never get an answer?


“All the unhappiness of human beings springs from the hope that tempts them from the silence of the citadel and exposes them on the ramparts in expectation of salvation. Unreasonable aspirations have no other effect than to reopen carefully bandaged wounds. That is why Epicurus does not deny the gods: he banishes them, and so precipitately, that men have no alternative but to retreat once more into the citadel. “The happy and immortal being has no preoccupations of his own and no concern with the affairs of others.” Lucretius goes even further: “It is incontestable that the gods, by their very nature, enjoy their immortality in perfect peace, completely unaware of our affairs, from which they are utterly detached.” Albert Camus, The Rebel, (1951)

“Then if man does not wish to perish in the coils that strangle him, he will have to cut them at a single blow and create his own values” (Camus, 1951).


Existential psychotherapy is concerned with existence and the uniqueness of humans as they emerge or become. The primary need of existence is to fulfill potential. Western civilization has two fundamental influences concerning existence, one that is Greek, and the other Judeo-Christian. Greek thought emphasizes the impersonal and the universal. This is the meaning of science and theory. In defining 'you' Greek philosophy will define you by what you share with everyone else. This is the universal, the impersonal; it is that which applies to everyone. Truth in Greek thought means the universal. The Judeo-Christian tradition is just the opposite. Truth in the Judeo-Christian traditions means a single event, a single event that will never reoccur. For the Jews, it was, according to Kierkegaard, Abraham's pact with God. For the Christians it was the birth, life, death, and resurrection of Jesus. These are not repeatable events. They happen only once. Only once does God make a pact with man. Only once does he give a Son to the world. The truth, therefore, in the Judeo-Christian tradition means a single event, an intersection of the divine with the mundane (Peter Kostenbaum, lectures, Institute of Clinical Philosophy, 1976)


Existential philosophy is a Judeo-Christian reaction against Greek science, which the existentialist believes is too limited in discovering the nature of man as a being-in-the-world because it rules out man's own experience, phenomenology. When you think of a human being as only one part of a universal system then you lose the essence and meaning of the person that has only occurred once. This 'me' that you are has occurred only once in the history - and this 'me' will never happen again. This is the supreme truth about you, and this is the existentialist application of a philosophy to the healing process. To develop a sense of being-in-the-world that is not only unique, but has happened only once.


Death is an abstraction that applies to everyone. You, me, and everyone else is going to die someday. But your death is an entirely different thing. It is unique and applies only to you. Here, we emphasize the word ‘you.’ You are different simply by the virtue that you are you and not someone else, and you are irreplaceable. There is never going to be another you. When your current 'you' is dead, your done.


The intentional theme of this philosophy is a search for security and meaning in a world full of suffering, guilt, and death. Existentialism does not view suffering in the Buddhist sense that 'all life is suffering,' but existentialism has a particular meaning by challenging the individual to seek new values in becoming, in a life that offers possibilities for growth. Life is only meaningful to the degree that I participate in it. Life is a risk in search of possibilities, moving forward to greater potentials. Existential psychotherapy is about discovering possibilities. The purpose of psychotherapy is to help people grow up. It would be wonderful if we could grow up before we die. What is the philosophical foundation of this growing up?


We are one; we are total being with the world when we are born. When we begin our thinking, we look at the world in a pre-predicative way, without assumptions, with no sense of 'me.' The child is the cosmos. This is the child's experience of being-at-one with the world, and this is the same mystical experience of being-at-one with God. Before we have learned consensual language, before we have learned common sense, before we have learned to organize the world in a consensual way, we are being, we are everything. There is nothing but the world and we are the world. In this state, which is the primordial philosophical state, totally deconstituted, presuppositionless, we are being with no sense of individuality. This is the ultimate state of peace, tranquility, and security.


If you are being, you are tranquil. The only thing that can upset this tranquility is to try to be an individual, to separate one's self from the world. To be an individual you must constantly fight the environment, and this makes you nervous and anxious. If you are the environment, if you are the world, you are in the total flow of reality; you are tranquil, which is the earliest experience of being a child.



“Originally, the ego includes everything, later it detaches from it-self the external world. The ego feeling we are aware of now is thus only a shrunken vestige of a far more extensive feeling - a feeling that embraced the universe and expressed an inseparable connection of the ego with the external world.” Sigmund Freud, Civilization and Its Discontents.



This is Alpha, the beginning of philosophical wisdom, the beginning of your life on earth, and Omega, the last insight of phenomenology, totally free of assumption. This sense of unity with the world is the experience of peace, tranquility, and security. These are the religious views in which somehow, we are unified with God. This is Omega, the ultimate state of philosophic self-disclosure. It is Alpha to the extent that this is what the world looks like when we are born.


This is peace, the ultimate tranquility sought after by world religions. Why would we want to leave this tranquility to be an individual? We have to leave because we are going to die, and before we die, we must grow up.


The mechanism of discrimination is used from moving from this cosmic tranquil state to the anxiety of wanting to be an individual. First, we must have the security of this sense of being tranquil. If we do not have this, we cannot move to phase two. Premature individuality does not work. We must have peace and oneness with the world, and then we move to risk taking, carving out a small section and saying “This is me.” Then we say “Everything else is not me.” When we do this, we create a sense of individuality. Becoming an individual is ultimately a choice.


“I shall henceforth cease to experience myself as a cosmic divine being. I shall experience myself as an isolated individual.” This fundamental transition involves a choice, discrimination, a decision to be human.


Inherent in this decision is also the realization of death. One cannot rest in cosmic tranquility with the specter of one's own mortality being lost to oblivion. Death, my own individual mortality, this dominant experience of what it means to be me is the way in which I invent myself as an individual. I choose myself. Metaphorically, in truth, I am god. In a cosmic sense, in truth, I am god. Now, I choose to experience myself as an individual - not as a god. This is the most difficult of all cosmic choices. This is the fundamental symbolism of the Christian church. God becomes man through the cross, through death.


By inventing the idea that I am going to die the sense of being an individual enters meaningfully. Christianity is the one religion that has really grasped that idea. God choosing to become man through death. This fundamental process is deeper than psychology that pervades all of us. It is the underlying philosophic dynamic of counseling that will help a person become an individual, to grow up. This is not adjustment or natural maturation. This is a cosmic event symbolized in death. God choosing to be man. This is the fundamental meaning of the psychological theme of being an individual, of growing up, of becoming human. This idea of becoming human is serious. We are destined to live, and in this living, we are obligated to discover ourselves. We have no choice but to consent to this discovery.


To live is to find one obligated to be-in-the-world. The world is not something given to us already complete, it is not here like a thing to be used. Rather the world is to be discovered in our doing, in our tasks, in our choosing to participate, in our choosing to grow up, in our choosing to be human.


The existentialist view of man says “You are hooked into reality, irrevocably.” Moreover, “You must make a total commitment to reality, irrevocably.” This is engagement. This is the place where you are human. You are vulnerable when you are committed and attached. This is the source of your pain, your anxiety, your guilt, and your despair. To be human is to say “Yes” to whatever life presents to you. The Christian will say “Only God will save you from your sins.” Existential psychotherapy is just the reverse - “Only you can save yourself.” You decided to be who you are. God will not change you into something you are not. The truth is to 'be human,' and to be human is to be hooked into reality. To be hooked is to be who you are.  Not being hooked is schizoid, split from reality.



“The only truth is the world, to which man must be faithful and in which he must live and find his salvation. The world is divine because it is inconsequential. One must consent to the world in order to participate in its divinity, to accept the unacceptable and hold to the untenable. To be free is to abolish ends. The primordial sea indefatigably repeats the same words and casts up the same astonished beings on the same seashore. But at least he who consents to his own return and to the return of all things, who becomes an echo and an exalted echo, participates in the divinity of the world.”  Albert Camus, 1951



“Regardless of contrary claims, the only problems are the patient's inadequacy in, or resistance against, taking charge of his or her own life, and lack of contact with the world or not reaching toward the future” (Koestenbaum, 1978).


Even more so with problems defined as ‘spiritual.’ The expectation on the patient’s part is that God is somehow going to get them out of their current situation. The second scenario is that God has somehow failed them, either because they have committed an unpardonable act, or because they are no longer in God's favor. In either case, they are going to be miserable while they wait for a turn of events, or to accept what is, and go on with their life.

The solution is, in part, to make an archetypal decision for finitude and establishing contact with the world. To be authentic is to participate in the world as-it-is, not as, how one wishes it to be. The Greek word ‘metanoia’ translated throughout the New Testament as repentance, means 'change of mind.' It does not mean to feel sorry for one's actions, or to beg for forgiveness. It simply means to change your mind about how you see and act in the world. It refers to the acquiring of a new idea in light of a possible individual evolution. It is, first, the recognition that meaning is not to be found in external life, but in the idea of an inner transformation, from god to man. Second, transformation must mean engagement, an active commitment towards self-creation, by consent, in an imperfect world. Finally, transformation is the denial of absolutes, a deliberate rejection of enculturation and the universal, e.g., ”I am like everyone else”; and acceptance of finitude. It is the continuous choice of dying to what one wishes, so one may live as a being in a divine world, as it is.


All of those desperate thoughts. If I could have only danced them.

                                                  Nikos Kazantzakis, Zorba the Greek

The New Image of the Person: The Theory and Practice of Clinical Philosophy, Peter Kostenbaum,  1978


Religious and Spiritual Problems, chapter from, The Comprehensive Mental Status Exam, A Primer for Counseling Interns © James Sparks

, (1980), Theredone Press, San Francisco, Ca.

The Rebel, Albert Camus, 1951

Being religious or spiritual, what is the difference?


Religions based on fear vs Spirituality based on love

Some religious views are based on fear and the consequences of your actions if you do not follow their rules, e.g., going to hell if you commit sins. Spirituality knows that fear is not reality. Spirituality encourages you to base your actions on love for one another and the common good.

Religion is based on rules vs there are no rules in Spirituality

Spirituality opposes specific ideology's based on fear. Follow your heart and intuition, harm no other living being, animal or human, do what you will that is right for yourself and others. Instead of thinking about karmic punishment, a person on a spiritual path knows that Karma is the Law of Attraction, you get back what you give out.


Religion describes the truth – Spirituality lets you discover yourself

Religion tells you the truth according to their interpretation and scripture, e.g., how the universe was created, why you are here, genealogy of the actors and their message. Spirituality lets you to discover these questions and answers for yourself, empowering you to find the truth that works for you.


Religion differentiates – Spirituality unites

Religious denominations insist and preach their version of reality is the only story. Spirituality accepts and recognizes the differences and uniqueness in all religions and unites them all as sharing in one common goal.


Follow your own path

There is only One God and many forms of worship. No form is any more or less important than any other form. Know all the forms and then invent your own form. Follow your heart and intuition, you are the only one that knows the way to your homeland.

Spiritual Direction and Spiritual Life Coaching is offered by email  or Skype. Contact us with your details. 

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