Religious, Spiritual and Moral Problems: A Proposed Expanded Diagnostic Category in the DSM-5-TR
John Peteet, MD, Harvard Medical School, Boston, MA, and Seth Mattson, Baylor College of Medicine, Houston, TX
The DSM has made significant advances in helping clinicians address the cultural factors that impact mental health care. One of these has been acknowledging but not pathologizing the religious and spiritual dimension of a patient’s life with the addition of “Religious or Spiritual Problem” in the DSM-IV (1994) as an “Other Condition That May Be a Focus of Clinical Attention”. In connection with religious and spiritual (R/S) problems, research demonstrates that moral problems are under-recognized in clinical care and have various negative clinical consequences in multiple patient populations.
Moral problems include moral injury, moral distress, and moral dilemmas. Moral injury was initially studied in military populations, later in healthcare workers, and literature has now expanded to demonstrate moral injury as a prevalent phenomenon in many other populations who experience potentially morally injurious events (sexual abuse victims and perpetrators, prisoners, etc.). Moral distress, as historically defined, occurs when individuals are externally constrained from acting on their moral judgements. Although the concept has been studied almost exclusively in healthcare workers, it applies to other individuals and contexts as well. Moral dilemmas have been empirically studied in multiple populations but are of a lower intensity relative to moral distress and moral injury. Moral injury, moral distress, and moral dilemmas all overlap in that the individual’s moral intuitions of what is right and wrong are challenged, transgressed, or outright contradicted by a moral event, leading to varying degrees of severity of psychological and emotional distress. Manifestations of distress include guilt, shame, blame towards self and others, loss of trust, loss of meaning, self-condemnation, difficulty forgiving self and others, anger, and existential/spiritual distress. Moral events can be one-time events of varying degree, such as a potentially morally injurious event, or multiple events, such as exposure to repeated morally transgressing experiences.
Research has demonstrated that the nature of distress caused by moral problems can often be spiritual in nature in that these problems lead to disillusionment over deeply held values. These values are also often developed in the context of cultural, religious and spiritual norms informing what individuals hold as sacred. The existential or spiritual distress associated with moral problems connects these problems to the Z-code Religious or Spiritual problem as outlined in the DSM-5-TR and aligns with the Cultural Formulation Interview supplementary module on Religion, Spirituality, and Moral traditions.
Moral problems have various negative clinical consequences. Moral injury has been found to be a unique type of experience that contributes to worse outcomes in various domains of mental health, exacerbating depression, substance use disorders, and increasing suicide risk. Moral distress has been associated with adverse emotional and behavioral consequences in healthcare workers, namely burnout, emotional exhaustion, increased medical errors, and increased attrition from the workforce. Moral dilemmas can lead to varying degrees of emotional distress, depending on the context.
Expansion of the current Z-code Religious or Spiritual problem to Religious, Spiritual, or Moral Problems will equip clinicians with the language necessary for identifying and treating these problems in the clinical context. The Z-code will also provide language for public health initiatives to consistently and uniformly address environmental factors that lead to moral problems, mitigating distress before it occurs and following up with individuals after moral events occur. Overall, this Z-code expansion will allow for the more wholistic care of patients from diverse religious and cultural backgrounds.
Moral problems include moral injury, moral distress, and moral dilemmas. Moral injury was initially studied in military populations, later in healthcare workers, and literature has now expanded to demonstrate moral injury as a prevalent phenomenon in many other populations who experience potentially morally injurious events (sexual abuse victims and perpetrators, prisoners, etc.). Moral distress, as historically defined, occurs when individuals are externally constrained from acting on their moral judgements. Although the concept has been studied almost exclusively in healthcare workers, it applies to other individuals and contexts as well. Moral dilemmas have been empirically studied in multiple populations but are of a lower intensity relative to moral distress and moral injury. Moral injury, moral distress, and moral dilemmas all overlap in that the individual’s moral intuitions of what is right and wrong are challenged, transgressed, or outright contradicted by a moral event, leading to varying degrees of severity of psychological and emotional distress. Manifestations of distress include guilt, shame, blame towards self and others, loss of trust, loss of meaning, self-condemnation, difficulty forgiving self and others, anger, and existential/spiritual distress. Moral events can be one-time events of varying degree, such as a potentially morally injurious event, or multiple events, such as exposure to repeated morally transgressing experiences.
Research has demonstrated that the nature of distress caused by moral problems can often be spiritual in nature in that these problems lead to disillusionment over deeply held values. These values are also often developed in the context of cultural, religious and spiritual norms informing what individuals hold as sacred. The existential or spiritual distress associated with moral problems connects these problems to the Z-code Religious or Spiritual problem as outlined in the DSM-5-TR and aligns with the Cultural Formulation Interview supplementary module on Religion, Spirituality, and Moral traditions.
Moral problems have various negative clinical consequences. Moral injury has been found to be a unique type of experience that contributes to worse outcomes in various domains of mental health, exacerbating depression, substance use disorders, and increasing suicide risk. Moral distress has been associated with adverse emotional and behavioral consequences in healthcare workers, namely burnout, emotional exhaustion, increased medical errors, and increased attrition from the workforce. Moral dilemmas can lead to varying degrees of emotional distress, depending on the context.
Expansion of the current Z-code Religious or Spiritual problem to Religious, Spiritual, or Moral Problems will equip clinicians with the language necessary for identifying and treating these problems in the clinical context. The Z-code will also provide language for public health initiatives to consistently and uniformly address environmental factors that lead to moral problems, mitigating distress before it occurs and following up with individuals after moral events occur. Overall, this Z-code expansion will allow for the more wholistic care of patients from diverse religious and cultural backgrounds.