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DSM-IV Religious and Spiritual Problems

LESSON 6.1 Therapeutic Interventions: Spiritual Crises

Overview of Treatment Therapeutic Interventions for Acute CrisesCase Example

Overview of Treatment

The Mystical, Near-Death, Meditation and Spiritual Practice, Visionary and Shamanic types of spiritual problems have been associated with crises ("spiritual emergencies") where a person has difficulty functioning. Each of these problems has a section on Therapy

Mystical experiences
Near-death experiences
Meditation and Spiritual Practice
Visionary experiences
Shamanic experiences

There are also a number of therapeutic strategies that apply to all spiritual crises. Stanislav Grof, MD, and Christina Grof, founders of the Spiritual Emergence Network, describe a spiritually-sensitive approach:

The most important task is to give people in crisis a positive context for their experiences and sufficient information about the process that they are going through. It is essential that they move away from the concept of disease and recognize the leading nature of their crisis...

Whether attitudes and interactions in the narrow circle of close relatives and friends are nourishing and supportive or fearful, judgmental, and manipulative makes a considerable difference in terms of the course and outcome of the episode...

[Therapy] should not be limited to talking and should allow full experience and direct release of emotion. It is absolutely essential to respect the healing wisdom of the transformative process, to support its natural course, and to honor and accept the entire spectrum of human experience
(Spiritual Emergency: When Personal Transformation Becomes a Crisis
, p. 195)

Interventions can range from support for a time-limited crisis, with possible involvement of relatives, friends, support groups, and medical persons, to intensive long-term psychotherapy. Choice of specific interventions depends on the intensity, duration, and type of spiritual problem, and also on the individual and their support network.

Therapeutic Interventions for Acute Crises
Therapy with spiritual emergency patients in crisis ("spiritual emergency") can include the following 9 interventions.

People in the midst of intense spiritual experiences need a framework of understanding that makes sense of them. Mental health theory has provided little guidance in this area, and has often pathologized religious and spiritual experiences. Often it is the lack of understanding, guidance and support that allows such experiences to go out of control. Jung described how providing a normalizing framework helped in the following case:

I vividly recall the case of a professor who had a sudden vision and thought he was insane. He came to see me in a state of complete panic. I simply took a 400-year-old book from the shelf and showed him an old woodcut depicting his very vision. "There's no reason for you to believe that you're insane," I said to him. "They knew about your vision 400 years ago." Whereupon he sat down entirely deflated, but once more normal (Man and His Symbols, p. 58).

In a similar way, Ram Dass, a spiritual teacher, originally trained as a clinical psychologist, helped a person in distress by framing his experience as a kundalini reaction. He recounted a telephone call from someone saying he thought he was going crazy. After the caller described uncontrollable tearfulness and so much energy he couldn't sleep, Ram Dass said,

Brant Cortright, PhD, describes the clinical value of educating the patient and significant others:

Education about spiritual emergency serves two primary functions. First, it gives the person a cognitive grasp of the situation, a map of the territory he or she is traversing. Having a sense of the terrain and knowing others have traveled these regions provides considerable relief in itself.

Second, it changes the person's relationship to the experience. When the person (and those around him or her) shifts into seeing what is occurring as positive and helpful rather than bad and sick, this changes the person's way of relating to the experience. To know that this process is healing and growthful permits the person to turn and face the inner flow of experiences, to welcome them rather than turning away or trying to suppress them (Psychotherapy and Spirit, p. 173)

The term spiritual emergency is one that describes and normalizes such crises. It provides a nonpathological understanding and is a gateway for patients, family and friends to the rapidly developing literature on these types of problems.

Ed Podvoll, MD, a psychiatrist who has used Buddhist approaches including compassion and mindfulness training with patients, points out that this is not an easy process:

    The difficult task becomes the need to shift one's view from seeing the experience as a totally destructive cataclysm to being able to see and appreciate the constructive attempt at self-transcendence, to see that its conscious goal is not a relinquishing of life but an attempt at renewal. The Seduction of Madness, p. 587).

Usually, the patient's family and friends play a critical role in implementing and maintaining the spiritual and grounding interventions described below. Therefore, they also need to be educated about the potential for positive transformation and how to support a person in spiritual crisis.

Create a therapeutic container
John Perry, MD, who founded Diabysis, a residential treatment center for working with people in visionary psychotic states, emphasized that when a person's psyche in energized and activated, what he or she needs is contact with a person who empathizes, who actively encourages the process, who provides a loving appreciation of the qualities emerging through the process, and who facilities the process rather than attempting to halt or interfere with it. Brant Cortright, PhD highlights the qualities required of the therapist:

In spiritual emergency, the personal presence of the therapist is key. Although some people are able to sail these waters successfully by themselves, for many people the presence of one or more wise compassionate guides on this journey can be of enormous help...Warmth and compassion combined with a degree of softness and gentleness are essential, for hardness, coldness, or insensitivity can be highly jarring to the delicate and refined perceptions of a person undergoing these consciousness changes. Additionally, a certain calmness and quiet confidence serves to energetically reassure and soothe the apprehension and alarm that are frequently present (Psychotherapy and Spirit, p. 174).

Help patient to reduce environmental and interpersonal stimulation
The person undergoing a spiritual emergency needs to be shielded from the psychic stimulation of the everyday world, which is usually experienced as painful and interfering with the inner process. The therapist needs to work with the patient to determine the specific people and situations that exacerbate the dysfunctional aspects of the spiritual emergency.

Have patient temporarily discontinue spiritual practices
Meditation has triggered many reported spiritual emergencies. Meditation teachers who hold intensive retreats are familiar with this form, and have developed strategies for managing such occurrences (case example). Yoga, Qi gong, and other spiritual practices can also be triggers. Usually teachers advise ceasing the practice temporarily. It can be reintroduced as the person becomes more stable.

Use the therapy session to help ground the patient
Therapy sessions can be used in various ways depending on the phase of spiritual emergency, and its specific features. In the case vignette below, Stuart Sovatsky, PhD, Clinical Director of the Kundalini Clinic, gives an example from his psychotherapy practice of grounding a patient in a spiritual emergency into the present during the therapy session:

Client: I'm, overwhelmed, (crying, sobbing) with this kundalini, I can't take it anymore, I don't know what to do.
Therapist: (Talking right over the client, simultaneously). You have an amazingly musical voice, I hear it as you are sobbing.
Client: I have been a singer, I want to be one."
Therapist: Then that will be a big part of our goal. That goal will channel a lot of this energy into a creative outlet, the vishuddha chakra, the throat wants to sing, you want to sing.
The client listened for half of what I said, then eyes went down and sobbing returned.
Therapist: Please, look back at me, you slipped back out of rapport with me and into your cycling thoughts of despair. Look. See, I am actually admiring you, which I do. I admire how courageous you are, coming to a stranger out of the hope that he could help. I admire your ability to trust, yes, yes, NOW you are growing in your trust of me, I see it in your eyes as you look (Client smiles).

This is our cooperative relationship....This "looking" is the beginning of open-eyed meditation that grounds the client in time/space, so she won't drift back into her mind-chatter of despair.

Suggest the patient eat a diet of "heavy" foods and avoid fasting
Grains (especially whole grains), beans, dairy products, and meat are considered grounding ("heavy") foods as opposed to fruit and fruit juices, salads. Sugar and stimulants like caffeine are also not advised.

Encourage the patient to become involved in simple, grounding, calming activities
Gardening is one such activity, or any simple tasks, such as knitting, housecleaning, shoveling, sorting. Encourage the patient to participate in regular exercises. Walks are probably the best way to help a person bring their consciousness back into their body. Walks in nature have the added benefit of enhancing tranquility and a calm mind. If the patient is a regular participant in other activities such as swimming or biking, they could engage in that. However, competitive sports would be too stimulating.

Encourage the patient to draw, paint, mold clay, make music, journal, write poetry, dance, both in the sessions and at home.
These creative arts can help a person express and work through their inner experience. The language of symbol and metaphor can help integrate what can never be fully verbalized.

Evaluate for medication
Some practitioners, such as John Perry, MD, have argued that medication only inhibits a person's ability to concentrate on the inner work and it mutes the psychic energy needed to sustain the effort to move the process forward. When medication is used to simply repress the inner process, it becomes frozen in an unfinished state. Suppression can impede the potential for a complete working through to a point of resolution.

Sometimes the process is so intense that the person is overwhelmed and becomes very anxious. That person could benefit from slowing down the process. Bruce Victor, MD, a psychiatrist and psychopharmacologist, uses low doses of tranquilizing or antipsychotic medication to alleviate some of the most distressing feelings and allow the person to better assimilate the experience.

The resolution of this seeming contradiction lies in the assessment of whether the presence of the debilitating state serves the function of psychological growth. Although the experience of pain, whether psychological or physical, can be a powerful motivator for personal change, its persistence beyond a certain point can retard it...

It becomes a challenge to determine whether the person can actively work with the pain therapeutically toward further psychological growth...One important role of pharmacotherapy is to titrate the level of symptoms, whether they be pain, depression, anxiety, or psychotic states, so that they can be integrated by the person in the service of growth. (Textbook of Transpersonal Psychiatry and Psychology, p. 332)

Some psychiatrists with a sensitivity to the spiritual emergency process have discussed their methods at conferences. Their approach is to prescribe dosages of medication that dampen down the inner process so the patient can continue work on an outpatient basis instead of an inpatient basis (e.g., Robert Turner, MD). Medication practices have already been influenced by new understandings of spiritual emergencies. For example, Bruce Greyson, MD reports that persons in intensive care units (ICU) who report out-of-body experiences and encounters with angels are no longer seen as having "ICU psychoses" requiring treatment with antipsychotic medication.

The major criterion I use in deciding whether to make a referral for medication evaluation is whether the person is in a situation which can support his/her involvement in intensive inner process. A person living in a communal setting, such as a spiritual retreat center, can go much deeper while being cared for physically and supported in working through the crisis. I observed this at The Ojai Foundation, a retreat center, when a person went into a spiritual emergency that required round-the-clock attention. The community provided full-time support for 2 weeks until she could maintain on her own.

However, people living in less supportive environments often do need to maintain themselves at a higher level of functioning. Otherwise, they risk hospitalization, loss of their livelihood, living situation, and other essentials. I have referred such individuals for medication if I assessed that they were a risk to themselves in this way. I would always refer for a medication evaluation if I thought a patient might be a risk to others, but this is rare in a spiritual emergency. However, spiritual emergency patients can engage in risky behaviors such as driving recklessly, which does endanger others. Therefore, a risk assessment is part of an assessment for medication and must take into account the spiritual emergency patient's support system. Of course, any use of medication should be with the full understanding and consent of the person, who should be an active participant in the decision-making.

Case Example
Emma Bragdon describes her personal crisis which involved questioning of spiritual values.

Separating From a Spiritual Teacher can lead to a loss of spiritual connection as the individual questions, and then severs, the social support for that belief system and set of practices.



Meditation is always a helpful intervention for spiritual crises.


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Medication is always contraindicated in spiritual crises.


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