Spiritualizing psychiatry: Transpersonal psychology,DSM,and Brazilian research about spirituality

Abstract

This article analyzes the trajectory of the diagnostic category ‘Religious or Spiritual Problem’, included in 1994 in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, the main diagnostic manual of North American psychiatry. Three moments of this trajectory are highlighted here: the beginning with transpersonal psychology, the debate around its inclusion in the DSM-IV, and the mobilization of the category in psychiatric research about spirituality in Brazil. Drawing on an array of material gathered through archival, bibliographical, and ethnographic research, I point out that the trajectory of ‘Religious or Spiritual Problem’ mirrors the shifts in spirituality scholarly debates in social sciences, from New Age practices to their institutionalized forms. Although psychiatry is known to historically pathologize religious or spiritual experience, I argue that the mobilization of such category acts toward legitimizing contemporary psychiatric research about spirituality.

Introduction

In recent years, the way scholars understand spirituality has transformed. Notably associated with studies on the New Age movement, spirituality has traditionally been discussed from its interpretation as an individual, autonomous, and non-institutional dimension of the experience of the sacred, in contrast to the institutional and mediating organization of religions (Amaral, 2000; Carozzi, 1999; Heelas, 1996). Several works have increasingly addressed the appearance of the theme of spirituality in more institutional forms or linked to centers of power (see Van der Veer, 2013). In this literature, the healthcare field has been fruitful in the study of institutionalized forms of spirituality. Such works approach the topics of the insertion of traditional and alternative medicines into public health systems (Toniol, 2018), the analysis of ‘spiritual care’ in hospitals (Sullivan, 2014), and even the debate at the World Health Organization around the importance of spirituality for human health (Peng-Keller et al., 2022; Toniol, 2022).

This article intends to contribute to the debate concerning the appearance of spirituality in institutionalized health discourses and practices. More so, the event analyzed here can be seen as mirroring the shifts in part of the spirituality scholarly debates in social sciences, from New Age practices to their institutionalized forms. This work is based on part of my master’s thesis in Social Anthropology (Baccetto, 2021), in which I analyzed the creation in the 1990s of two diagnostic categories about religious and spiritual experiences in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV). I was invested in comprehending how contemporary psychiatry understands these experiences that were historically understood by the medical field as fundamentally pathological, such as the religious trance and the visionary spiritual experiences.

This article is about the creation of the psychiatric diagnostic category ‘Religious or Spiritual Problem’ and its trajectory from the (New Age) transpersonal psychology to contemporary medical research about spirituality in Brazil. Before the inclusion of ‘Religious or Spiritual Problem’ in the DSM-IV, published in 1994, there were already mentions of religion and spirituality in the manual. However, until then, the appearances of religion in the DSM were embedded with a negative and even stereotypical perspective. In these cases, the manual exemplified symptoms of mental disorders, such as hallucinations, delusions, and irrational or magical thoughts, through religious experiences (Post, 1992).

The DSM replicated and updated a long and troubled history of the relationship between psychiatry and the themes of religion and spirituality. Perhaps the most known case is the French school of physiological psychiatry of the second half of the nineteenth century, headed by Jean-Martin Charcot, and its interest in the analogies between demonic possessions and the hysterical women under his care (Andriopoulos, 2014 [2008]). But such concerns continued to exist throughout the more recent history of the medical discipline, with examples such as the use of the category ‘religious insanity’ throughout the nineteenth century in the United States (Geppert, 2019); the emphasis on the perception of mysticism as a pathological manifestation (Deikman, 1977); and, notably, the opening of Civilization and Its Discontents, in which Sigmund Freud (1989) claims that the ‘oceanic feeling’ of religions was a type of narcissistic regression.

In Brazil, the pathological emphasis was dominant in most mainstream psychiatric discourse at the beginning of the twentieth century, with Afro-Brazilian religions and Kardecist Spiritism being psychiatrists’ central targets. The psychiatrists diagnosed these religious practitioners as mentally ill and understood possessive and mediumistic practices of these religions as symptoms of mental illness (Dantas, 1988). From the 1930s onward, the topic began to be addressed more and more by anthropologists from a cultural perspective, starting a process that would displace the possessive and mediumistic practices from the medical pathological discourse to the anthropological one (Giumbelli, 1997). At the same time, although there was a parallel development of Kardecist psychiatric practice starting in the 1950s, with the creation of medical Spiritist associations and hospitals that apply a conventional psychiatric treatment with complementary mediumistic practices nowadays (Aureliano and Cardoso, 2015), this ‘spiritualistic medicine’ did not find its way to universities and medical scientific research in Brazil.

It was in this context that ‘Religious or Spiritual Problem’ reached the public debate with its official inclusion in the DSM-IV, in 1994. The category was included in the manual’s section named ‘other conditions that may be a focus of clinical attention’, dedicated to life problems that would not be psychiatric disorders. ‘Religious or Spiritual Problem’ was centered on life problems associated with religion or spirituality that may be the focus of clinical attention. Its description includes ‘distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution’ (American Psychiatric Association, 1994: 685). Today, the category is still part of the last published version of the manual (DSM-5).

I came to know the existence of this category through the constant mention in the works of Brazilian psychiatrists as a way to legitimize their studies in what we could call the medical ‘spiritual field’. While attending scientific conferences and academic meetings regarding the psychiatric research of spirituality in Brazil, I noticed how ‘Religious or Spiritual Problem’ was also a constant presence on these occasions. Furthermore, I came to know that ‘Religious or Spiritual Problem’ inspired the creation in 2000 of a pioneer research group on religion and spirituality in psychiatry at the renowned University of São Paulo, guiding its first goals and interests.

I am aware of the implications of how certain actors and devices in psychiatry are producing specific knowledge about what is generically called spiritual and religious experiences. Even though they offer a non-pathological perspective, psychology, and psychiatry are technologies that inscribe distinct phenomena into a supposedly universal register of ‘psy’ disciplines, whether it be the register of the psychologized subject or the neural one. In this process, psychiatrists and psychologists become the experts authorized to speak and deal with the theme, to the detriment of the local actors involved (Rose, 1996). A fruitful path in this direction would be to analyze how the category is mobilized in clinical practice, or how the production of a psychological or psychiatric understanding of ‘spiritual’ phenomena erases the cultural particularities of these phenomena, establishing interpretations that conflict with local conceptions and practices (Baccetto, 2021: 82–86).

Although possible, I will not invest in this path in this article. Instead, I am taking a pragmatic stance by turning my attention to the ways in which the category has circulated through particular areas of psychiatry, producing concrete institutional effects in the network of academic knowledge production about so-called spiritual experiences. I am interested in the contingent aspects of the elaboration of the ‘Religious and Spiritual Problem’ (such as the biography of its main proponent) and how the category circulated beyond its original sphere of creation, passing through the cultural critique of the DSM and helping to legitimize the debate on spirituality in academic psychiatry in Brazil.

The analyzed data were gathered through archival, bibliographical, and ethnographic research. Special attention was given to written accounts and scientific articles, as well as to publicly available recorded interviews. I will rely on the methodological propositions of the field known as Science and Technology Studies (STS). In particular, since this work focuses especially on scientific articles and other written productions of psychiatrists and psychologists, I will draw from the work of Bruno Latour (1987) to analyze the chains of referencing and mobilization of categories, concepts, and theories in scientific literature. From this methodological approach, a statement becomes more ‘true’ based on its chain of allies – categories, other scientific articles, authors, and schools of thought – through which we can see how each act of referencing involves certain positioning in the face of a posed question. In the particular case analyzed here, we will see how the reference to categories such as ‘religion’ and ‘culture’ allows ‘Religious or Spiritual Problem’ to connect to more consolidated discussions in psychiatry, facilitating its entry into the diagnoses manual and its circulation in other countries and scientific fields. However, we will see how the category ‘Religious or Spiritual Problem’ begins to be mobilized as a stabilized and accepted statement that does not need to be explained, justifying the scientific endeavors of Brazilian psychiatrists. As I will argue at the end of the article, we will see how the mobilization of chain allies strengthens and transforms the category itself.

My argument is that this category contributes to legitimizing the general theme of spirituality in the psychiatric and psychological field. More importantly, it does so through a quite peculiar trajectory, that begins from the transpersonal field and its New Age praise of spiritual experiences; results in a quite neutral and bland diagnostic category of psychological problems, legitimized by a cultural critique of the DSM; and establishes as an effect the legitimating of the psychiatric studies of spiritual experiences in Brazil. The article is organized as follows: I will first retrace the historical background of ‘Religious or Spiritual Problem’ based on the narrative of its main proponent, the transpersonal psychologist David Lukoff; then, I will explore the conditions in which the category was accepted by the organizer committee of the DSM-IV; finally, I will talk about its uses and effects in the academic psychiatric field in Brazil.

Religious or Spiritual Problem and its New Age roots

It was only in a scientific article published in 1998, 4 years after the release of the DSM-IV, that the original proponents, the psychologist David Lukoff and the psychiatrists Francis Lu and Robert Turner, made clear their background and inspirations in creating the category ‘Religious or Spiritual Problem’ (Lukoff et al., 1998). As they manifest in this article and public speeches in the next decades, the proponents formed a group of psychiatrists and psychologists heavily influenced by the so-called transpersonal field. However, at the time of the creation of the category, the works of the transpersonal field were only referred to as good examples of care and respectability to spiritual experiences (Lukoff et al., 1992).

This previous concealment of their relation to the transpersonal professional field is not surprising. The DSM is the main psychiatric manual of diagnostics in North America, organized by the chief association in the field, the American Psychiatric Association. In a sense, as many scholars have stated (Mayes and Horwitz, 2005; Russo and Venancio, 2006), we can assume the manual constitutes the mainstream in psychiatry. ¹ However, the so-called transpersonal field has been historically marginalized by psychologists and psychiatrists. Created by the prominent psychologist Abraham Maslow in the 1960s California, the main interest in spiritual practices and the close relation with places like the Esalen Institute would qualify the field as a counterpart for the New Age movement (Alexander, 1992). For example, in his now-classic work, the historian Wouter Hanegraaf (1996: 50) remarks that ‘transpersonal psychology can be regarded as the theoretical wing of the Human Potential Movement’ – the predecessor of the New Age movement. Concurring with this statement but assuming a more critical than analytical position, the humanist psychologist Rollo May would refer pejoratively to the field as a ‘New Age psychology’ (Hoffman, 2009).

Within the group of proponents of the category ‘Religious or Spiritual Problem’, David Lukoff is probably the most well-known. He is still an active clinical psychologist in California and an advocate of the life-changing potential of spiritual experiences. Lukoff worked with Francis Lu and Robert Turner on the original proposal of the category for the DSM-IV (Lukoff et al., 1992). Some years before, Lukoff (1985) also published an early version of a diagnosis to differentiate spiritual experiences from mental disorders. Besides actively participating in the original proposal of the diagnostic category, Lukoff can be considered its greatest advocate. Over the years, he has given several public speeches around the world and has taught courses and written more than 100 pages of course material devoted to the category and its clinical uses (Lukoff, n.d.).

As I have addressed elsewhere (Baccetto, 2021; Toniol and Baccetto, 2022), Lukoff describes himself as a ‘spiritual seeker’, in a language quite familiar to spiritual practitioners nowadays. When invited to talk about his work and the importance of attending to spirituality in psychological care (see Lukoff, 1990), he always recalls his experience of ‘spiritual awakening’ as a decisive event in his life. Moreover, the personal event appears to condense his view on struggles related to spiritual experiences. In his narrative, Lukoff accounts for when he had a ‘psychotic crisis’ during a trip around the United States in his early 20s in 1971. He identified himself as Jesus Christ and Buddha and started to have grandiose ideas about how to change the world. After months, his ideas and identification started to fade away, and he started feeling depressed and lonely. It was at this moment that he heard a ‘calling’ to ‘become a healer’ (Lukoff, 2018: 5). This pushed him to learn a full array of alternative therapeutic practices and to join a Human Potential Movement center, and finally, to decide to become a psychologist.

Although Lukoff tried to work on his memories with a Jungian psychologist, it was only through neo-shamanic practices that he felt like diving into his experience. Furthermore, this would also allow him to reframe it from the earlier psychotic understanding. For him, this reframing was decisive because transformed a traumatic and pathologized experience into a spiritualized and powerful one. Within this new framework, his earlier so-called psychotic crisis was transformed into a spiritual crisis, a journey into the depth of his psyche, in which the self is connected with the spiritual realm of the collective unconscious.

Due to his spiritual crisis and the importance it had in his path to be a mental health professional, Lukoff started to work with key persons in the transpersonal field and in the topic of ‘spiritual emergency’. Coined by Stanislav Grof and Christina Grof (1989: X), the term refers to spiritual experiences in which there is ‘both a crisis and an opportunity of rising to a new level of awareness, or ‘spiritual emergence’. Similar to Lukoff’s account, the creation of this category was deemed important for them because many of the spiritual experiences that were followed by a personal crisis were treated by psychiatrists as mental disorders. In place of medication and a pathologized interpretation, they call for the embracement of these experiences due to their innate possibilities for personal improvement. In short, they argue that ‘[w]hen these states of mind are properly understood and treated supportively rather than suppressed by standard psychiatric routines, they can be healing and have very beneficial effects on the people who experience them’ (Grof and Grof, 1989: X).

According to Lukoff et al. (1998), the proposal of ‘Religious or Spiritual Problem’ is directly tributary to the work of the Grofs and of this concept in particular. Not surprisingly, the initial impetus for creating a category in the DSM came from the activities carried out in the Spiritual Emergence Network, founded at Esalen Institute in 1980 by Christina Grof after she experienced a spiritual crisis. The Network was created to provide support to people in ‘spiritual emergency’ by supplying them with ‘information that gives them a new understanding of their process, and advises them on available alternatives to traditional treatment’ (Grof and Grof, 1989: xiv). As Lukoff reports, ² it was as board members of the network that he and Francis Lu began to work together and came up with the idea of proposing the category for the DSM. This was a way to include the debate about spiritual emergence crises in the academic mainstream, acknowledging the existence of these phenomena.

This kind of attention given to the notion of ‘spirituality’, and its praise as a ‘positive’ and even desired phenomenon for human beings, is a hallmark of the literature on transpersonal psychology (e.g. Walsh and Vaughan, 1993). However, by attempting to constitute itself institutionally as a subfield of psychology, this characteristic has been taken negatively by the rest of the disciplinary field (Hartelius et al., 2007). Thus, in its history, transpersonal psychology has faced several resistances from the mainstream of North American psychology. That is the case of the failed attempts to create an independent transpersonal division in the American Psychological Association during the 1980s (Aanstoos et al., 2000), as well as the open criticism made by renowned psychologists such as Rollo May (1986) regarding the ‘religious’ character involved in some praise of spirituality.

Despite the difficulty encountered by transpersonal psychology to consolidate itself in the psychiatric and psychological mainstream, something worked out. It is noteworthy that less than 10 years after May’s criticism and the failure of the creation of a transpersonal division, ‘Religious or Spiritual Problem’ was included in DSM-IV. It is not possible to ignore the claim made by the proponents of the category about its origin, even if the DSM-IV does not present in its text something that can be recognized as ‘transpersonal’, beyond its concern with spirituality (Maraldi and Martins, 2016). To understand how this was possible, we must go through not only the process of creating the category but also the organization of the 4th edition of the diagnostic guide itself.

DSM, spirituality, and culture

For ‘Religious or Spiritual Problem’ to be accepted by the organizing committee of the DSM-IV, the proponents had to claim its importance in a particular way. They made it from two positions: (1) the inclusion of ‘religious problems’, leaving aside the praiseworthy transpersonal emphasis on the issue of spirituality; and (2) the claim that the creation of ‘Religious or Spiritual Problem’ would be important to correct the ‘cultural insensitivity’ of the DSM.

As psychologists and psychiatrists interested in transpersonal experiences, the central focus of the proponents of the ‘Religious or Spiritual Problem’ category was on the person’s spiritual experience rather than religion itself. Such asymmetry of interest is evident in one of the proponents’ texts on the DSM category, in which they define the notions of ‘religion’ and ‘spirituality’ (Turner et al., 1995). For the authors, while ‘religion’ would refer to adherence to a set of beliefs or practices of an institution, ‘spirituality’ would be the subject’s relationship with the transcendent. They resort to a definition by the transpersonal psychologist Frances Vaughan (1991), for whom spirituality would be a subjective ‘experience’ of the sacred, not a ‘theology’ about it. More than that, spirituality would be valued as universal, since it would be ‘an innate capacity that exists in every human being’, not being ‘limited to anyone set of doctrines or practices’ – that is, to any religion (Vaughan, 1991: 116).

As Lukoff et al. (1998) tell us in a post-DSM-IV article, the category was intended to refer only to ‘spiritual problems’. However, after the initial dialogue with psychologists of religion and other professionals linked to the Association for Transpersonal Psychology, they decided to include ‘religious problems’ in the proposal. This was to ‘obtain greater support for the proposal and to acknowledge the many areas of overlap between spirituality and religion’ (Lukoff et al., 1998: 26). However, the DSM-IV Task Force also made some changes to the initial proposal. In addition to removing two examples of ‘religious problems’, the two originally proposed examples for ‘spiritual problems’ were replaced by the ‘less specific ‘questioning of other spiritual values which may not necessarily be related to an organized church or religious institution’ (Turner et al., 1995: 436). Thus, despite the proponents’ transpersonal background and main interest in spirituality over religion, attention to the spiritual dimension was not only equalized to religion to increase the chances of category inclusion but was also marginalized by the DSM-IV Task Force itself.

As for the second position, referring to the ‘cultural’ issue, the debate is wider. In the article in which the original proposal is publicized, the proponents argue that the negative view of spirituality and religion held by psychiatry is due to a ‘cultural insensitivity’ on the part of psychiatrists and psychologists regarding these phenomena (Lukoff et al., 1992). As the title of the article emphatically suggests (‘Toward a more culturally sensitive DSM-IV’), the inclusion of ‘Religious or Spiritual Problem’ would assert the importance of taking into account, during clinical care, the cultural particularities of the collectivity to which the patient belongs.

The claim by Lukoff, Lu, and Turner around the ‘cultural’ importance of including a category on religion and spirituality in the DSM was somewhat new. As we have seen concerning transpersonal psychology, the dimension of spirituality and its intrinsically positive aspect is the central element that would justify any initiative. Added to this, when we go back to the article written by Lukoff in the 1980s, where he first mentions the proposal of creating a category, we do not find any mention of ‘cultural sensibility’. This strategic shift in the way the claims were made makes sense as we realize it is connected to the broader dispute in the organization of the DSM-IV.

When analyzing the debates in the development of the DSM-IV, we notice the concern of one group in particular regarding the ‘cultural’ dimension of the diagnostic manual. The group’s main characteristic was a dialogue between psychiatry and the medical anthropology practiced in North America, and a critical position regarding the then-latest edition of the manual, the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III). As the specialized literature argues (Mayes and Horwitz, 2005; Russo and Venancio, 2006), the DSM-III was thought to be ‘atheoretical’, designating only what would be noticed by any observer. This marked a rupture of the previous alignment with psychoanalysis and the psychodynamic approach. Such a change involved a greater affinity with a biological and physical perspective of mental disorders, following the deeper changes that were occurring in North American psychiatry, with the rise of biologically based psychiatry (Luhrmann, 2000).

The dialogue between psychiatry and anthropology took on a character with a greater emphasis on the social and cultural conditioning of mental disorders, following a major tradition of North American anthropological studies on mental health that had begun at least in the first decades of the twentieth century with Ruth Benedict works (Good, 1994). The organization of an event held in Pittsburgh, in the United States, in 1991, reflected this dialogue, which included the psychiatrist and anthropologist Horacio Fabrega, the psychiatrist Delores Parron, and the renowned anthropologist and psychiatrist Arthur Kleinman. The institutional movements started with an event held in Pittsburgh, in the United States, in 1991. A national working group was then formed around the issues addressed, named the Culture and Diagnosis Group. Thanks to the strong institutional links of some of its organizers, the group received funding from the Office for Special Populations, a division of the National Institute of Mental Health (NIMH). Led by psychiatrist Juan Mezzich et al. (1999), more than 50 ‘cultural experts’ remained active during the 3 years following the original event. Despite the group’s organizers’ efforts to institutionalize the initiative to the American Psychiatric Association, the DSM-IV task force refused to grant the working group an official status. However, some changes were implemented in the design of DSM-IV (Baccetto, 2021). ³

It was from this culturalization movement of the DSM that ‘Religious or Spiritual Problem’ could be included in the manual. In addition to the title of the article containing the original proposal, the proponents make this clear when referring to other human dimensions that started to be taken into account with the concern for ‘culture’: ‘Clinicians have begun to address gender, ethnic, and racial issues. It seems that psychiatry would also benefit from giving the same consideration and emphasis to religious and spiritual issues in treatment’ (Lukoff et al., 1992: 680). They also report that the proposal received support from the APA Committee on Religion and Psychiatry and from the NIMH Workgroup on Culture and Diagnosis (Lukoff et al., 1998). One effect of this process is that, in addition to officially supporting the proposal, psychiatrists concerned with the cultural issue in the DSM were able to frame the issue of religion and spirituality on their own terms. At least, this is what is clear from an excerpt from the New York Times article reporting the creation of ‘Religious or Spiritual Problem’. In the article, the vice chairman in charge of revising the manual, Harold Pincus, called the new entry on religion ‘a sign of the profession’s growing sensitivity not only to religion, but also to cultural diversity generally’ (Steinfels, 1994). In this case, the complimentary and prioritized transpersonal emphasis on spirituality becomes encompassed by cultural concerns, becoming one among other elements of the agenda. ⁴

The effects of Religious or Spiritual Problem in Brazil

As we have seen with reports in psychiatric journals and major newspapers, it did not take long for the ‘Religious or Spiritual Problem’ category to achieve some recognition in the United States. Within a few years after the publication of DSM-IV, several articles in specialized North American scientific journals already mentioned the category in some way (e.g. Greyson, 1997; Hawkins and Bullock, 1995). This trend continues, with more recently a London-based psychiatrist proposing the creation of a similar category in the World Health Organization’s manual of diseases, the International Classification of Diseases (Abdul-Hamid, 2011). In Brazil, during my research, I witnessed moments in which the category appeared in different ways in psychiatric and psychological academic events. Despite the diversity of ways in which it is mobilized for different purposes, what is evident is that the category was used as a powerful ally: both in claiming the possibility of certain religious and/or spiritual experiences not being pathological, and in legitimizing research fields or areas in psychiatry and psychology.

One of the times I heard about the category was in 2019, in an event called Rethinking Madness (Repensando a Loucura), organized by a group of transpersonal psychologists with the support of the Program on Health, Spirituality, and Religiosity (Programa de Saúde, Espiritualidade e Religiosidade – ProSER), of the Psychiatry Institute of the University of São Paulo, where the meeting was held. On that day, there was a presentation of a lecture recorded by Lukoff for the event. During his talk, the psychologist recounted part of the history of the proposition of ‘Religious or Spiritual Problem’ and the unfolding in his professional trajectory, emphasizing its transpersonal roots. In that event, the creation of the category in the diagnoses manual of the main psychiatric association in the United States was taken as an institutional recognition and victory of transpersonal psychology.

Despite this proposal of ‘Religious or Spiritual Problem’ as a legitimizing category of the transpersonal field and its praiseworthy understanding of spirituality, in other moments, I could also witness how the category was spreading in Brazil in different ways and beyond transpersonal psychology. The category was mentioned in the Second International Congress on Health and Spirituality (Congresso Internacional de Saúde e Espiritualidade), held in 2019 in the city of Juiz de Fora, and organized by the Center for Research in Spirituality and Health (Núcleo de Pesquisa em Espiritualidade e Saúde – NUPES) of the Medical School of the Federal University of Juiz de Fora. The Congress was the main Brazilian event on the subject in the medical field, bringing together hundreds of people in the audience and dozens of speakers from all over the world. On that occasion, an important Brazilian researcher spoke about how the inclusion of the category in the DSM was an important step toward the depathologization of the understanding of trance experiences by psychiatry and psychology, not necessarily meaning the recognition of transpersonal psychology.

Through a bibliographical survey, it was possible to find citations to the category in works in psychiatry as early as the late 1990s. In 1997, ‘Religious or Spiritual Problem’ was cited in the habilitation thesis on mental disorders among religious ministers, by Francisco Lotufo Neto (1997), a Full Professor of Psychiatry at the University of São Paulo. In this case, the mobilization of the category occurs in an introductory section dedicated to theoretical discussion, to justify the attention given to spirituality by psychiatric research. That is because the ‘need for a more culturally sensitive psychiatric practice has been extensively debated’, and while psychiatry has tended to ignore or pathologize religious and spiritual experiences, ‘[t]he DSM-IV seeks to repair the previous lack of attention to the spiritual dimension of problems by including the category ‘Psychoreligious or psychospiritual problems’ (Lotufo Neto, 1997: 28). ⁵

The way that ‘Religious or Spiritual Problem’ was mobilized by Lotufo Neto can be understood as a prototype of how it would be articulated in the Brazilian psychiatric literature from the 2000s onward: in the introductions of scientific theses and articles, to justify the research; and accompanied by important elements of its previous appearances, that is, the issue of spirituality and, to a lesser extent, culture. During the research, I noticed how several works in psychiatry and psychology tended to replicate, with some variations, this modality of referencing. However, the themes addressed by these works became narrower: they began to investigate the mediumistic experiences of religious practitioners. Thus, works on Kardecist Spiritism mediums (Moreira-Almeida, 2004) and practitioners (Menezes Júnior, 2012), and Santo Daime and Umbanda practitioners (Mizumoto, 2012) were some of the first scientific theses that mobilized the category to justify their research. In common, these works tended to have as research objects mediumistic practices associated with more or less established religious communities in Brazil, but articulating the notion of spirituality to emphasize subjective aspects of the personal experience of its practitioners. In addition, some of these works also mobilize a certain notion of cultural sensibility, following the proposal of the Diagnosis and Culture Group of the DSM-IV.

Besides being present in scientific theses and articles in the field, ‘Religious or Spiritual Problem’ even inspired the creation of a pioneer research group on religion and spirituality in psychiatry. It is the Center for the Study of Spiritual and Religious Problems (Núcleo de Estudos de Problemas Espirituais e Religiosos – NEPER). NEPER was founded in 2000 at the Psychiatry Institute of the University of São Paulo. Among its founders were Lotufo Neto and Alexander Moreira-Almeida (2004), author of one of the first psychiatric theses that mentioned the DSM-IV category. The Center’s objective was to promote the ‘study, research, and assistance of religious and spiritual issues according to the scientific approach of modern psychiatry, not linked to any philosophical or religious current’ (Moreira-Almeida et al., 2000: 114).

With a hiatus in 2006, the group resumed its activities with a new name in 2008, calling itself the Program on Health, Spirituality, and Religiosity (ProSER), at the University of São Paulo. Moreira-Almeida then became a professor at the Federal University of Juiz de Fora and created in 2006 the Center for Research in Spirituality and Health (NUPES). One can say that these are the two main psychiatric research groups on spirituality in Brazil today. Both were also involved in different ways in the two events I attended. The establishment of these two groups also represents the consolidation of these researchers’ interest in spirituality, making the category central to their research. More than that, as Toniol (2022: 94) argues, they also indicate a shift from previous research focused on religious leaders and the possibility of the existence of mental disorders, to an emphasis on research on the positive effects of spirituality on ordinary people.

Thus, ‘Religious or Spiritual Problem’ was critical to legitimize a research agenda in mainstream psychiatry around the theme of spirituality in Brazil, especially on the mediumship of religious practitioners. This is not to say that the DSM category introduced in Brazil is an innovative (non-pathological) way of conceiving the relationship between psychiatry and religious or spiritual experiences. Since the second half of the twentieth century, there have already been huge efforts conducted by Kardecian Spiritist physicians to legitimize and introduce its practices and health models in mainstream psychiatric institutions (Aureliano and Cardoso, 2015). However, given that this was a topic already addressed by important Brazilian psychiatrists at the beginning of the twentieth century from a pathological viewpoint (Giumbelli, 1997), the Kardecian Spiritist physicians could not achieve their goals regarding the main scientific institutions. To be able to persuade their academic peers and raise funds for their research on spirituality, contemporary psychiatrists felt the need to legitimize their scientific endeavor through other connections: by referring to a category in the main diagnostics manual of North American psychiatry. ⁶ After all, if the American Psychiatric Association recognized the importance of investigating spiritual and religious experiences without assuming they were mental disorders, the door was open for research on the subject to be done in leading universities in Brazil.

Conclusion

The analysis of the history of the category ‘Religious or Spiritual Problem’ shows us a trajectory that goes from transpersonal psychology, through its institutionalization via the cultural debate, and ends in Brazilian psychiatrists’ research on spirituality. In a certain sense, it is a trajectory that mirrors the debate itself around spirituality in the social sciences.

As stated in the introduction to this article, studies on spirituality in the social sciences have transformed in recent years. A classic example of the first studies on the topic is the work of Paul Heelas (1996), in which he studied the New Age movement and used the concept of spirituality to describe the anti-institutional aspect of the relationship with the sacred held by the people he was interested in. In a way, we could also use this theoretical framework to analyze the transpersonal psychology and, in this specific case, Lukoff’s work. He lived some aspects of the New Age, such as the interest in ‘Eastern’ and indigenous practices and traditions, as well as the emphasis on spirituality as a kind of desired attribute that allows personal development. However, as the history of ‘Religious or Spiritual Problem’ and its relation to transpersonal psychology shows us, over time, people and groups connected to the New Age movement have also sought recognition from certain mainstream institutions. That is especially the case in the healthcare field (Toniol, 2022).

From the New Age to its institutionalized forms, what is most important in this article concerns the particularities of this process in psychiatry. If we pay attention to the mediations performed in each appearance of the category, we see how it transforms itself during its path, producing effects through where it has passed. More than that, we need to think of ‘Religious or Spiritual Problem’ as this aggregate of concatenations and mediations throughout time. Following Latour (1987: 104), if a statement becomes a fact from its reference and collective acceptance, it also transforms itself during the process: This is because the statement ‘is not only collectively transmitted from one actor to the next, it is collectively composed by actors’. Every time it is mobilized with some success as an ally, it will also become composed of these new mediations. In the case analyzed here, it is about thinking of its ‘lives’ as composing its mobilization: the transpersonal and praising spirituality ‘past’ and its ‘appearance’ in the DSM-IV through the cultural debate.

We have seen that the ‘prehistory’ of the category is marked by the influence of the transpersonal field and, in particular, on how it addresses spirituality. More than a subject of psychological and psychiatric research or care, spirituality is conceived positively despite religion, as the essential dimension for one’s personal growth. If this kind of understanding persists when people related to the transpersonal field mobilized ‘Religious or Spiritual Problem’, there was a negotiation carried out by the proponents during the process of creating the category. Although they had proposed a rather ‘neutral’ category for common transpersonal standards, two modifications had to be made. First, the inclusion of ‘religion’ as an issue. Second, and more importantly, the claim that ‘Religious or Spiritual Problem’ would bring greater ‘cultural sensitivity’ to the DSM. In doing so, the issue previously conceived in a New Age environment and its prioritization of spirituality, came to be enunciated from the cultural discourse of psychiatrists and anthropologists who had been proposing changes to the DSM. As an effect, ‘spirituality’ became one among other dimensions encompassed by culture, thus losing its foundational priority.

However, upon arriving in Brazil, psychiatrists interested in studying spirituality mobilized ‘Religious or Spiritual Problem’ to legitimize their own work. The constant mentions of the category in scientific theses, articles, and events indicate the importance it assumes in the Brazilian field. The mobilization of ‘Religious or Spiritual Problem’ encompasses a kind of ‘package’, adding, in different intensities, its transpersonal background and its prestige from the North American psychiatric mainstream, marked by cultural discourse and an interest in religious practices. Such a package leads to three effects: (1) its inclusion in the DSM-IV gives new credibility to the theme, affirming that the American Psychiatric Association recognizes the importance of addressing spirituality; (2) the ‘cultural’ dimension allows religious practices previously pathologized in Brazilian mainstream psychiatry to be reframed as non-pathological; and (3) finally, the Brazilian medical field that researches spirituality replicates the praiseworthy emphasis on the topic of transpersonal psychology, but without including the New Age arsenal, such as the main interest in esoteric and oriental practices.

This is how this article sought to contribute to the social sciences debate on the institutionalization of spirituality. By focusing on how the topic enters mainstream research and discussions in psychiatry, we see how an international network of mobilizations and circulation of people, categories, and theories is formed. If medical studies on spirituality have grown substantially in recent years, we need to understand how and by which allies these research and theories are supported in the mainstream medical field. In a sense, it is about following the associations of these academic and institutional networks to find the unexpected alliances between people, things, and categories that make up the phenomenon of spirituality today.