J Relig Health

DOI 10.1007/s10943-016-0279-7

ORIGINAL PAPER

Psychospiritual Resiliency: Enhancing Mental Health

and Ecclesiastical Collaboration in Caring for Those
Experiencing Dissociative Phenomena

Christopher J. Howard1

Ó Springer Science+Business Media New York 2016

Abstract Trauma can oftentimes be a catalyst for changes in an individual’s religious and
spiritual beliefs. Beliefs about the cause of the trauma, for instance, may include attribu-
tions of possessing spirits, and are to be found in an increasingly pluralistic and multi-
cultural society. Such preternatural explanations may be referred to as dissociative identity
disorder, possession form. Unwittingly, an overreliance on neurobiological explanations
and relegation of cultural idioms of distress may diminish effective collaboration with
ecclesiastical authorities. Concomitantly, ecclesiastical experts are confronted with
bewildering posttrauma dissociative symptomatology, and may not be prepared as diag-
nosticians to rule out psychobiological explanations. In both instances, client care may be
compromised. Noteworthy, the current investigation integrates the author’s participant
observation research at the Vatican’s school of Exorcism in Rome, Italy.

Keywords Trauma
Dissociative identity disorder
Religious or spiritual problem

Psychospiritual resiliency

Introduction

Since the early 1990s, the Catholic Church worldwide has been actively recruiting mental
health professionals to serve as members of interdisciplinary evaluation teams. These
teams evaluate claims of possession and at times, requests for Exorcism. In the Diagnostic
and Statistical Manual of Mental Disorders, fifth edition (DSM-V; APA 2013), the
aforementioned clinical presentation is known as dissociative identity disorder (DID),
possession-form. ‘‘Possession form-identities in dissociative identity disorder typically
manifest as behaviors that appear as if a spirit, supernatural being, or outside person, has

& Christopher J. Howard

choward@antioch.edu
1
Antioch University, 602 Anacapa Street, Santa Barbara, CA 93101, USA

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taken control, such that the individual begins speaking or acting in a distinctly different
manner’’ (APA 2013, p. 293). The experience is not considered a normal part of religious
or cultural practice.
As of 2004, per papal decree and Canon Law every Diocese in the world is to have
appointed and trained an Exorcist who spearheads a Healing and Deliverance team. The
team is interdisciplinary in nature, comprised of psychologists, psychiatrists, neurologists,
and laity. Functions of the team are to provide recommendations for psychospiritual
assistance. Psychological, neurological, and exhaustive medical screenings are typically
utilized prior to providing services.
It should be noted that oftentimes individuals present to such teams after an arduous and
demoralizing journey. In no instances are individuals asked to relinquish their ongoing
receipt of psychological or medical care. However, such care may be isolated from their
religious and spiritual care. Paradigmatic differences may at times preclude integrated
intervention.
What follows is an overview of the inextricable link between dissociation and trauma,
neurobiological conceptualizations, and consideration of psychospiritual practices. Thus,
this paper has two primary objectives: to alert clinicians to the need for their services,
including robust psychobiological and culturally competent assessment, and to discuss the
need for an integration of assessment strategies and interventions from psychobiological
and psychospiritual paradigms.

Dissociation and Traumatic Stress

Dissociative experiences in the context of traumatic stress have been discussed in the
literature for over a century and fall into one of three domains: (1) loss of continuity in
subjective experience accompanied by involuntary and unwanted intrusions into awareness
or behavior; (2) an inability to access information or control mental functions that are
normally amenable to such access or control; or (3) a sense of experiential disconnect-
edness (Cardena and Carlson 2011; Carlson et al. 2012; van der Hart and Dorahy 2009).
Examples include intrusions of sensorimotor aspects of traumatic life experiences,
including pain and tics, sensory distortions and pseudoseizures (i.e., positive dissociative);
loss of function-analgesia, sensory anesthesia, and motor inhibition (i.e., negative disso-
ciative); cognitive phenomena, including flashback symptoms, internal voices keeping a
running commentary, and thought insertion (i.e., psychoform); and finally, somatoform
expressions, such as paralysis and pain insensitivity (Reyes et al. 2009; Nijenhuis 2004;
van der Hart et al. 2000).
Dissociative symptomatology is variegated and can be understood as a lack of psy-
chobiological integration in response to trauma and life threat. At times, said trauma and
threat may be understood from an individual, familial, cultural, professional, or evaluation
team perspective as natural (e.g., psychobiological) or preternatural (e.g., a demon). Thus,
it is paramount to understand a client’s conceptual frame (i.e., cultural, religious or spir-
itual), and unique neurobiological expression.

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Neurobiological Theories

Neurobiological theories posit that emotional competencies and neurobiological self-reg-

ulatory capacities develop as a result of secure attachment (Bowlby 1958; Thompson
2008). Trauma (e.g., abuse and neglect) has been consistently linked with both affective
and neurobiological dysregulation, including dissociation via alteration of developing
autonomic and central nervous systems (Ford 2005; van Dijke et al. 2013). In both Western
and non-Western cultures, rates of reported childhood trauma ranging between 85 and
97 % are observed in individuals with DID. 80–100 % of DID patients also meet diag-
nostic criteria for posttraumatic stress disorder (PTSD) in clinical settings (Reyes et al.
2009). Neurobiological sequelae are multi-faceted as will now be discussed.

Neuroendocrine System

Post et al. (1997) were among the first to draw attention to the concept of sensitization and
desensitization in limbic structures, such as the amygdala, and the hypothalamic–pituitary–
adrenal-cortical axis (HPA-axis). Prefrontal cortical disinhibition of amygdala hyperre-
sponsiveness and hyperarousal has been associated with positive psychoform dissociative
symptoms (i.e., pain tics, sensory distortions, and pseudoseizures). Amygdala hyperre-
sponsiveness has also been associated with a decrease in prefrontal and parahippocampal
function (Arnsten 2007). The prefrontal cortex and hippocampus interact to govern
functions, such as autobiographical memory, emotional regulation, and personality inte-
gration. Excessive prefrontal inhibition of the amygdala and hypoarousal has been asso-
ciated with negative somatoform dissociative symptoms, such as depersonalization,
derealization, numbing, and analgesia (Etkin and Wager 2007).
Regarding HPA-Axis activity, research has largely revealed increased salivary cortisol,
and positive associations with dissociation (Dalenberg and Carlson 2012). However, there
are important distinctions in cortisol/stress reactivity and dissociative phenomenology. For
example, when hyperaroused, dissociative symptomatology may manifest in increased
release of cortisol and enhanced amygdala activity, while when experiencing dissociative
avoidance, decreased amygdala activity and increased activity in emotional regulation
centers such as the prefrontal cortex, and anterior cingulate gyrus. Interestingly, the effects
of spirituality (e.g., feelings of closeness to God or self-transcendence) on health have been
found to be primarily mediated via the effect of emotion regulation on physiological
processes, including the HPA and sympathetic adrenal medullary (SAM) axes, and their
influence on inflammatory processes (Aldwin et al. 2014; Levenson and Aldwin 2013).

Neurochemicals

Norepinephrine has been linked with positive dissociative symptoms, including intrusions
and sensory alterations, altered body states, and more specifically, with DID (Shin et al.
2006; Reinders et al. 2006). The self-injurious behaviors characteristic of individuals with
dissociative symptoms have been hypothesized to serve the function of dampening the
arousal associated with increased levels of norepinephrine, via activation of endogenous
opioids.

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The endogenous opioid system is responsible for analgesia, and has also been linked
with negative somatoform dissociative symptoms and ‘‘possession’’ (Reyes et al. 2009;
Kawai et al. 2001). In an exemplary cross-cultural study by Kawai et al. (2001), it was
discovered that the ‘‘possessed’’ group, experiencing a religious trance, exhibited signifi-
cant increases in plasma concentrations of norepinephrine, dopamine and b-endorphin as
compared with controls. Further support for the role of dopamine and ecstatic and
pathological religious states was also found by Previc (2006) pointing to a ventral cortical
axis for religious behavior, involving primarily the ventromedial temporal and frontal
regions, and dopaminergic system.

Neuroimaging

Structural studies have revealed smaller than normal hippocampal, parahippocampal and
amygdalar volumes, which in certain dissociative disorders, including DID, have been
linked with both psychoform, and somatoform dissociation (Chalavi et al. 2015; Ehling
et al. 2007; Vermetten et al. 2006; Reyes et al. 2009). For example, Chalavi et al. (2015)
found that subjects with DID–PTSD and PTSD exhibited similarly smaller cortical gray
matter (GM) volumes of the whole brain and of frontal, temporal, and insular cortices.
DID–PTSD patients additionally showed smaller hippocampal and larger pallidum vol-
umes relative to healthy controls, and larger putamen and pallidum volumes relative to
PTSD only. Severity of lifetime traumatizing events and volume of the hippocampus were
negatively correlated. Severity of dissociative and depersonalization/derealization symp-
toms correlated positively with volume of the putamen and pallidum, and negatively with
volume of the inferior parietal cortex.
Functional research by Vuilleumier (2005) has presented evidence of decreases in
frontal and subcortical brain activity in dissociative paralysis, decreases in somatosensory
cortical metabolism in dissociative anesthesia, and decreases in metabolism in the visual
cortex with dissociative blindness. ‘‘Healthy’’ parts of the personality were found to have
demonstrable increases in blood flow in prefrontal, frontal, parietal, and occipital cortices,
while ‘‘emotional parts’’ displayed decreases in prefrontal, and parahippocampal blood
flow, with increases in blood flow in the insular cortex, sensory cortex, and amygdala
(Reinders et al. 2003, 2006). Functional network analyses reveal several altered connec-
tivity strengths among dissociative patients as well as lower cognitive performance and
increased contribution of the orbitofrontal, insular, and subcallosal cortex in the fronto-
parietal network; the cingulate and insular cortex in the executive control network; the
cingulate gyrus, superior parietal lobe, pre- and postcentral gyri and supplemental motor
cortex in the sensorimotor network; and the precuneus and (para-) cingulate gyri in the
default-mode network (van der Kruijs et al. 2014).
Findings from EEG and qEEG include excessive theta and alpha power, deficient beta
power, and decreases in frontal and parietal functional connectivity (van der Kruijs et al.
2012; Oohashi et al. 2002; Goodman 1986; Putnam et al. 1984). Lest the reader not be
aware quantitative EEG or qEEG is distinguished from visual examination of EEG traces
based on high standards of reliability and validity and enhanced temporal and spatial
resolution allowing for assessment of connectivity and network dynamics (e.g., coherence
and phase metrics), especially when combined with source localization techniques such as
low resolution electromagnetic tomography or LORETA (for reviews, see Thatcher
2010, 2012). For instance, preliminary research combining qEEG LORETA has been used

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to cross validate the six fundamental modules of axonal connections of the human cortex as
found in previous diffusion tensor imaging investigations (Thatcher et al. 2012; Hagman
et al. 2008).
Combined qEEG and functional magnetic resonance imaging (fMRI) has revealed
connectivity dysregulation in subcortical, limbic, and prefrontal regions that subserve
emotion regulation and motor behavior. These regions or networks have been linked with
various dissociative symptoms and disorders (van der Kruijs et al. 2012, 2014). Dysreg-
ulated activation and connectivity within the default mode network (DMN) in particular,
due to its role in autobiographical memory, self-monitoring, social cognitive functions, and
dissociative states, is emerging as a consistent neurobiological marker (Daniels et al. 2013;
van der Kruijs et al. 2014).
Although elucidating these vital linkages has been instrumental in conceptualizing
dissociative symptomatology on the psychobiological level, this can and should be bol-
stered by an equally rigorous investigation of an individual’s cultural identity and religious
or spiritual heritage, particularly as it informs symptom expression, explanation, help-
seeking behavior and ultimately resiliency.

Psychospiritual Resiliency

Resiliency has been understood as positive adaptation in the face of adversity or risk
(Masten and Reed 2002). Posttraumatic growth and positive religious coping (Kuhl and
Ehring 2014; Calhoun et al. 2000; Decker 1993; Joseph and Linley 2006; Zoellner and
Maercker 2006) are included within the current conceptual frame of resiliency. Attribu-
tions for trauma, meaning-making, and perception of social support posttrauma can
enhance or diminish effective coping.
Trauma disrupts what has been referred to as the assumptive world, and at times,
preternatural explanations are advanced. In the context of religious or spiritual beliefs, both
increases and decreases (e.g., negative religious coping, demonic attributions) have been
noted. An increase in religious and spiritual beliefs and practices has largely salutary
benefits on both mental and physical health (Koenig 2008; Aldwin et al. 2014; Masters and
Hooker 2013; Park and Slattery 2013). For instance, Aldwin et al. (2014) recently reported
on religiousness (e.g., religious affiliation or service attendance), and its strong associations
with improved behavioral control, such as less smoking, alcohol consumption, and more
frequent medical screenings, while spirituality (e.g., feelings of closeness to God, self-
transcendence, meditation) was found to be more strongly associated with improved
emotional self-regulation, and various physiological markers, including blood pressure,
cardiac reactivity, immune factors, and disease progression. However, decreases in reli-
gious and spiritual beliefs and practices and negative religious coping have been consis-
tently linked to poorer mental and physical health (Ai et al. 2009; Exline and Rose 2013;
Pargament et al. 2001).
Within the United States for example, there is widespread and increasing usage of
complementary and alternative care to address religious, spiritual and emotional problems
(Barnes and Bloom 2008; Kessler et al. 2001; Unutzer et al. 2000). Results reveal that
between 15 and 57 % of individuals in large national surveys have sought complementary
care, or religious services for psychological distress. The most prevalent forms of service
are mind–body treatments, including biofeedback, exercise, movement therapy, imagery
techniques, relaxation and meditation techniques, spiritual healing by others, energy

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healing, prayer and hypnosis. Complementary and alternative health care use is highly
prevalent among individuals with posttraumatic stress disorder (PTSD), with rates ranging
from 12.6 to 38.9 % in nationwide epidemiological studies (Wang et al. 2005; Libby et al.
2013).

Implications for Assessment, Treatment, and Research

In the area of religious/spiritual assessment, caution should be exercised, as religiosity and

spirituality, may or may not overlap and in fact mediate different styles of coping and
health outcomes. In addition to assessment of religious affiliation or service attendance
(religiosity), and self-transcendence or meditation (spirituality), instruments that specifi-
cally assess both positive and negative religious coping are important, particularly in light
of possible preternatural attribution for traumatic experiences. One exemplary instrument
is the brief RCOPE (Pargament et al. 2011) due to its inclusion of negative religious
coping.
In relationship to DID, and DID possession-form, the DSM-V specifically requires that
the clinician rule out the possibility that the ‘‘disturbance is not a normal part of a broadly
accepted cultural or religious practice’’ (APA 2013, p. 292). The Cultural Formulation
Interview (APA 2013) may be particularly useful in this regard. In sum, understanding
cultural and religious/spiritual milieus that sanctify or label as pathological dissociative
states and possession experiences is important.
Neurobiological assessment can be easily integrated with psychospiritual assessment.
The qEEG appears to deserve special merit, given its portability (i.e., Bluetooth technol-
ogy), ability to assess ambulatory subjects, economic feasibility, non-invasiveness, long
history of validation and reliability, superior temporal resolution, and enhanced cortical
spatial resolution with LORETA (i.e., 1–3 cm). Importantly, clinicians employing this
technique in private practice settings or in the field can amass data for laboratory studies,
paving the way for a combination of effectiveness and efficacy research. In addition, the
DSM-V (APA 2013) specifically admonishes clinicians assessing DID for instance, to rule
out competing neurological and neurocognitive disorders (e.g., complex partial seizures,
amnesia, and head injury) to which qEEG is particularly well suited. As stated by the
DSM-V: ‘‘normal electroencephalographic findings differentiate non-epileptic seizures
from the seizure like symptoms of dissociative identity disorder’’ (APA 2013, p. 297).
Within the psychological domain explicit measurement of dissociation versus more
classically defined PTSD symptomatology is important, given the 90 %? prevalence rate
of childhood abuse and neglect among those with DID, and need to differentiate DID only,
or DID comorbid with PTSD (APA 2013; Loewenstein and Putnam 2004). Chu et al.
(2005) has summarized extant instruments specific to the assessment of dissociative states,
such as the widely used Dissociative Experiences Scale (DES; Burnstein and Putnam
1986). As echoed by Dalenberg and Carlson (2012), classification of dissociative symp-
toms is imperative as some belong under the avoidance cluster of PTSD (e.g., derealiza-
tion, depersonalization, amnesia related to a traumatic event), and others are unique to DID
(e.g., amnesia, flashbacks, intrusions, identity disturbance not related to traumatic events)
with important treatment implications.
Guided by the theory of autonomic regulation (Aldwin et al. 2014; Moore et al. 2011;
Chambers et al. 2009; Koole 2009; Nilsson 2014), interventions assist clients in the reg-
ulation of negative affect, and physiological and psychological arousal. It should be noted

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that treatments specific to DID and other dissociative disorders are distinct from those of
PTSD. For instance, DID treatments are often multimodal combining psychodynamic and
cognitive-behavioral techniques with adjunctive pharmacotherapy and hypnotherapy,
which may or may not overlap with treatments specific to PTSD.
PTSD is traditionally viewed as an issue of hyperarousal and underregulation of affect
in response to traumatic related sensory experiences. The dissociative subtype of PTSD
and other dissociative disorders (Lanius et al. 2010) include overregulation of affect, which
can be a response to non-traumatic material. As summarized by van Dijke et al. (2013),
treatments that address underregulation of affect, such as dialectical behavior therapy,
transference-focused psychotherapy and mentalization-based therapies, should be consid-
ered distinct from therapies that address overregulation of affect, such as sensorimotor
psychotherapy, accelerated experiential-dynamic psychotherapy, and emotion-focused
therapy for trauma.
Clinicians working with individuals who have experienced trauma, dissociative phe-
nomena, and advance preternatural explanations might also consider the integration of
psychospiritual interventions. Examples include mindfulness, prayer, meditation, com-
munity service, service attendance, insights gained from reading religious and/or spiritual
texts, and forgiveness. As summarized by Aldwin et al. (2014), there are various religious
and/or spiritual dimensions (e.g., commitment, identity, involvement, prayer, worldviews,
faith, mystical experiences, obedience) that operate via distinct pathways (e.g., health
related behavior, heredity, social support, psychodynamics of ritual, belief and faith,
superempirical, and supernatural effects), with distinct mediating factors (health behavior
habits, phenotype, social support, positive emotions, positive cognitions, religious trance,
divine blessing) that have distinguishable salutogenic mechanisms (e.g., morbidity, mor-
tality, hereditary transmission, stress-buffering, psychoneuroimmunology, placebo effect,
supernatural intercession). A complete description of this integrative model is beyond the
scope of this paper, but the reader is encouraged to review this exemplary work, as well as
additional research by Koenig (2008), Cotton et al. (2006), Masters (2008), Levin (1996),
Park (2012), and Krause (2011).
Interestingly, the effects of religiousness have been found on behavioral regulation of
health habits (e.g., smoking and drinking alcohol), while spirituality operates via the
effects of emotion regulation on inflammatory processes, with stronger linkages to
biomarkers (e.g., blood pressure, cardiac reactivity, immune factors, and disease pro-
gression). Perhaps, most pertinent is the finding that religious alienation has adverse effects
on both health behavior and biomarker pathways. Such alienation might inadvertently
occur as a result of dichotomizing an individual’s suffering as purely psychological or
spiritual, and decreased collaboration between mental health and a client’s religious or
spiritual support system.
Regarding research implications, multidisciplinary teams who evaluate cases of disso-
ciative phenomena such as DID possession-form who utilize formal assessment instru-
ments can consider discussing the merits and limitations of this approach from both
Daubert and Frye standards (Daubert v. Merrell Dow Pharms., Inc. 1993; Frye v. United
States 1923). Absolute certainty does not exist with either traditional psychological or
ecclesiastical approaches to DID, possession-form, and in a broader sense to what has been
previously referred to as a Religious or Spiritual Problem in various renditions of the
Diagnostic and Statistical Manual of Mental Disorders (APA 1994, 2000). Clinical
members of multidisciplinary research teams working with individuals who voice not only
psychobiological concerns, but also spiritual concerns, such as threat from a supernatural
entity, can assist in ruling out more plausible (e.g., neurological, psychological)

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explanations, while remaining open to the idea that psychological problems can have
spiritual dimensions and vice versa.

Summary and Conclusions

A resiliency-based approach to the assessment and treatment of psychological and reli-

gious/spiritual problems that are oft intertwined invites a comprehensive and integrative
approach. It has been argued that biopsychosocial factors (interpersonal, intrapersonal,
gender, cultural, spiritual, and socioeconomic variables) play an important role in the
etiology of and response to trauma induced dissociative symptoms. However, although
there are consistent neurobiological sequelae based on correlational neuroimaging
research, the cultural and religious/spiritual elements embedded within an individual’s
suffering and explanatory model beckons further understanding, as some clinical presen-
tations cannot be easily explained from an either or perspective (i.e., psychological or
spiritual).
In accordance with the worldview of the client, psychologists and other health care
providers can effectively collaborate with ecclesiastical authorities in the interests of
promoting psychospiritual resiliency. Such a paragon may be a beacon of hope, as an
integration of nomothetic and idiographic approaches offers to ameliorate the profound
spiritual and psychological suffering that certain individuals endure.
Compliance with Ethical Standards

Conflict of interest There has been no conflict of interest.

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