GUIDELINES FOR EVALUATING

SPIRITUAL/PSYCHOLOGICAL EMERGENCIES

ON A RETREAT

Three Sections

1. A General Outline of Conern

2. Meditation and the Mind

3. Shifts in Behaviour

 

A GENERAL OUTLINE OF CONCERN

The Dharma is a powerful vehicle. Retreats ranging from a daylong non-residential gathering to an intensive three-month retreat or long personal retreat at a centre can have a major impact on the inner life.

Very occasionally, teachers, managers and students find themselves facing what has come to be called a spiritual/psychological emergency affecting heart, mind, body and consciousness of a retreatant.

Certain meditation practices call on meditators to practice meditation hour after hour, day after day. Some teachers expect meditators to make strong resolutions to sit still for 45 or 60 minutes. These approaches generate an atmosphere of pressure and intensity. The majority of participants can handle such pressure.

 

A minority find themselves experiencing emotional, mental and physical difficulties. Symptons may show as anxiety, agitation and a shaking in the body.

 

Sometimes there are early outer signals that indicate the potential for overwhelming or problematic issues arising and staying without appearing to dissolve. For others, there is an abrupt and painful change in the inner life, utterly unexpected for one and all.

The range, depths and varieties of these experiences are too many to attempt to list here. There are inner processes that can unfold on retreats and in all manner of other environments that requires both skilful attention and the necessary appropriate action.

 

The questionnaire and brief meetings with vulnerable students before a retreat can help recognise those who may need extra support on a daily basis. Although some retreatants feel reluctant to fill out honestly the confidential questionnaire at the beginning of a retreat in case they are barred from the retreat.

There is no single medicine that cures all the types of anguish of the inner life. At times, the forms and practices of insight meditation (vipassana) serve the deepest need of the individual and sometimes the same form and practices work against the welfare of the person. Wisdom matters. Method, technique and form or their absence have the function of serving wisdom.


In more than four decades of teaching hundreds of retreats, I have witnessed and responded to a wide range of problematic and sometime indefinable experiences of meditators in centres, monasteries, various locations in India,Thailand and elsewhere. Some teachers blame old karma, old samkharas and behaviour in past lives for all the painful states of mind and body arising for meditations in retreats. 

Some teachers and managers refuse to accept that painful experiences may well have a connection with the medods, techniques and pressure imposed on students. Some teachers lack the skills to handle a crisis. The placing of all pain on past conditioning often reveals denial rather than wisdom.

 

Trauma can arise for a participant even with all the skill of application of the practice. Teachers need to recognise the wise steps rather than telling such a person to keep on doing the same practice on the meditation cushion. The retreatant might need a different kind of practice including communication, the outdoors and much support.

In the late 1990’s, we had a number of discussions in Bodh Gaya about such emergencies. Outside the sangha in Bodh Gaya, there is little in the way of real support in the area for comprehensive treatment for a major emergency. The nearest hospital is more than three hours drive away. Appropriate medication may not be available in the village or in Gaya, 12 kilometers away.

 

We rely on years of experience, our health manager, certain retreatants in the health professions and a local doctor for wise counsel. For a tiny number of travellers in India, various kinds of erratic or fixated perceptions and experiences can arise on a retreat, during a train journey, under pressure or through the loss of medication. Our sangha in India has regularly looked after lost souls in various parts of the sub-continent.


Various meetings from Tel Aviv to Totnes and San Francisco have been held on issues around attending to the spiritual emergency and knowing the difference between an emergency and a spiritual breakthrough. It is a view too far to say that meditation can cause abnormal psychological behaviour.

 

The function of meditation, as the Buddha points out, is to act like a mirror to reveal what is.

MEDITATION AND THE MIND

 

Apart from conditions dormant in a person’s history, some retreatants:

 

  • put immense pressure upon themselves

  • push the mind far too hard

  • try to suppress thought

  • try to exercise complete control over unwanted states of mind

  • force stillness of posture

  • engage in intense slowing down

  • fasting

  • try to push through unacceptable levels of pain

  • detach themselves from their feelings, emotions or contact with others

  • fast, reactive speech

  • enforce sleep deprivation

 

Such attitudes or through clinging to certain methods or meaningful experiences can set up undue pressure for the individual. The road to hell is often lined with good intentions. It is too simplistic to put all the responsibility for any chaos or pain in the inner life on the past, on old samkharas (mental formations), or old karma.

 

Our relationship to the present moment and other causes and conditions also affects the stare of consciousness, and the mind/body process. Even when the practice is approached with calm and insight, causes and conditions can allow unresolved or repressed material to flow into consciousness.

 

There is a powerful healing component to Dharma practice that often dissolves the conditions for such a personal crisis. Often, we hardly realise the huge benefits of calm and insight meditation for our life in the short and long term.

 

I have very occasionally witnessed people go through very traumatic experiences on retreats requiring the necessity for round the clock support, the use of strong drugs, injections and hospitalisation. One person on a retreat may require more wise attention and metta (loving-kindness) that 99 other retreatants together.

 

Others may experience a short lived terror of the mind utterly out of control, a temporary fear of going mad or overrun with papanca, that is projections and tendencies to proliferate problems or undergo a kind of multiple hindrance storm.

 

We can also experience a storm in a teacup. Or we can go through a depth of terror or alienation from conventional reality that makes it difficult for consciousness to recover without active intervention. Retreatants can engage in forms of transference upon a teacher or others that seems absolutely real and true at the time. Or long after!

 

A single word or an innocent gesture from a person of authority can make an extraordinary impact upon a student stimulating infatuation, aversion, tortuous self-doubt or doubt in the Dharma. The wisdom of the sangha, the retreat atmosphere of respect and support, the power of goodwill and skilful teaching carry most through these temporary spells of reactivity.

 

It is important that managers and staff on a retreat have wherever possible emergency information quickly available such as the telephone numbers of emergency services, doctors, psychiatrists, health officials and to know whether there are professionals in the mind/body field who are participating in the retreat. Access to this information is necessary day or night.

 

What follows this brief introduction is the backbone of these guidelines for the benefit of teachers, managers and retreatants. Please feel free to copy and send onto others. The information is regarded as part of a process of learning to approach and address various kinds of spiritual/psychological emergency. We will expand on these points as time goes by.

 

The Buddha said:

 

‘I state that there suffering in this world and there is the cessation of suffering.” Fortunately, there are very few spiritual/psychological emergencies compared to the thousands who attend Buddhist retreats. A human being is extraordinarily resilient. There is a capacity to go through the darkness and chaos of hell or periods of immense disorientation or confusion lasting weeks, months or much longer and emerge out of the tunnel into a bright, grounded and spacious existence.

May all beings live in peace and harmony

SHIFTS IN BEHAVIOUR

 

You have some idea what this person’s baseline is because they have been on retreat. You are looking for a shift in behavior in the following areas to determine the severity of their situation.

 

Please consider each of these categories as part of a whole. A shift in behavior in just one area would not necessarily mean there is a crisis. However if many areas are compromised combined with a decrease in ability to cope, it will become more likely that outside support may need to be engaged.

 

STEP 1: Medical problems need to be ruled out.

 

If someone presents with behavior or thought patterns that appear out of their norm, first consider if medical problems may be the cause of their symptoms. Ask someone to get the application form to see if the yogi has any pre-existing medical or psychological problems.

Does the person appear ill?

 

  • unusual respiration

  • unusual skin tone (jaundice, red, flushed, pale?)

  • irregular heart beat?

  • fever? (can cause delirium)

  • Pupils equal and not reactive to light? (or are they dilated, constricted, or unequal?)

 

Questions that can be asked

 

  • Any history of diabetes, heart condition, substance withdrawal, thyroid problems, seizures?

  • Are there shifts in consciousness (not mood---orientation to person, place, & time)? Do they know where they are, who they are, morning or night/know month/year? (Major orientation problems may be caused by medical conditions/poisoning.)

  • Are they taking medications that could be causing the problem OR have they forgotten to take meds that may be causing these symptoms?

 

YES??? CALL the Emergency Number in the respective Western country, such as 999 in the UK, or 911 in the USA. Make sure other important phone numbers are quickly at hand in an emergency.

Risk factors to definitely call Emergency (when in doubt can always call for assessment)

 

  • Anyone over 50 years old with severe chest pains or numbness or any radiating through either arm or neck (especially left arm.)

  • Any asymmetrical numbness or weakness.

  • Crushing head pain.

  • Pregnant women with heavy vaginal bleeding.

  • Loss of consciousness (can’t wake them up.)

  • Severe shortness of breath. (if not sure it is an anxiety attack should go to hospital to be checked it.)

  • Fractures, especially severe or older individuals.

  • Any severe distress without an explanation.

 

STEP 2: Assess safety to self and others.

 

If you have concern about this person being at risk of hurting themselves or others then you need to assess further for self-harm thoughts or /behaviors or thoughts/actions of hurting others.

 

Evaluate for suicidal ideation.

 

  1. Ask the individual directly whether he/she has thoughts about hurting herself.

  2. Are there current life circumstances that are precipitating these thoughts? (relationship difficulties, experiences of loss or death, and serious physical illness increase the risk of an individual attempting suicide)

  3. Has he/she thought of HOW he would hurt himself?

  4. Do these plans appear imminent and are the means available?

  5. History of attempts? Or hospitalizations for this problem?

  6. Ask if thinking about suicide for this person is an unusual event. It is possible that some people (especially those experiencing a long term depression) think about suicide often, but don’t have a strong intention of acting on those thoughts or feelings. On the other hand, if someone habitually thinks about suicide AND has a history of attempts or has experienced a recent crisis, the risk of an possible attempt is higher.

  7. Assess capacity to cope. Can the person commit to not taking any action during retreat? Can they contract with you to talk to you if depression or suicidal ideation worsens? You could ask, “Is there a reason why you wouldn’t commit suicide?” If the person does have past suicidal ideation, how did they work through it.

  8. Does he have support system when he goes home? If you’re not sure he is fully disclosing the seriousness of the situation, is he willing to have you call family/friends to discuss your concerns?

  9. Does this person abuse alcohol or drugs? Intoxication decreases inhibitions and often can lead to a suicide attempt even in someone that is ambivalent about taking her life. This would be a factor to consider when attempting to ensure there would be an adequate support system for this person when going home.

 

Evaluate for potential harm to others.

 

  1. Vague ideation or is there someone specific? Is he making direct threats about hurting another person?

  2. Exhibiting any behavior that seems threatening or endangering to others on retreat site?

  3. Able to gain perspective and calm through conversation? Directable and follows suggestions?

  4. Does he/she have a specific plan and immediate means to implement this plan?

  5. Can they contract with you to not act on their ideation and continue to talk to you about how they are doing?

 

STEP 3: Assess yogi’s current coping capacity

 

As you are assessing the yogi’s current coping capacity, take into account all aspects of the mental status exam with emphasis on the following possible questions.

 

  • capacity to witness the experience?

  • a curiosity about the experience?

  • what was the pre-episode functioning? How much of a change is this?

  • pre-retreat functioning? (pre-existing problems—how long have they been experiencing these issues?)

  • emotional or cognitive availability?

  • capacity to move between consensual reality and internal experience?

  • can the person respond to and follow direction/suggestions? (Like start eating, less meditating, more walking?)

  • can the person identify ways he/she can shift out of present state?

  • can they respond to normalizing? (for example, look for exceptions---times he/she is not experiencing current state of mind. What is different about those periods? What is he/she doing differently, thinking about, etc? Eliciting recent times when the person has not been in emotional crisis can be empowering and help the person access their coping abilities.) Has there been a time in the past day you have not felt this way?

  • Scaling question: On a scale of 0 to 10, with 10 being when you are at your best and really coping, and 0 that you are overwhelmed and not able to cope at all, what would you rate your present ability to cope with this situation?

  • Can give you an idea of how overwhelmed, fearful the person is.

  • Can also help you gauge whether person feels they are decompensating or improving as time goes on.

  • Have they experienced this state before?

  • What helped them at that time? Can they do those things now?

 

STEP 4:  Teacher’s awareness of their own personal reaction to this person and situation.

 

The Teacher should also consider the following to determine whether the yogi can continue to stay on the land.

  • honest assessment of your personal skill level to continue to work with this person (may consider consultation OR refer for outside intervention)

  • teacher feels they have confidence and resources to protect the safety of the yogi?

  • teacher able to maintain safety/container of the retreat?

  • how safe do you feel with this person?

 

STEP 5: Evaluate the needs of the yogi and determine if these resources are available.

 

  • If you have decided this yogi could continue retreat if he/she had more support or modification of practice---can all of these resources be put in place?

  • If you have decided you want this person to stay on retreat are there any additional resources or support that you feel you need to continue working with the yogi? (Will you need more help from staff and can they provide this help? This would require determining whether there are staff available.)

  •  

Appendix: CONSIDERATIONS WHEN DETERMINING FUNCTIONING (a mental status exam)

APPEARANCE

 

  • change in dress

  • change in hygiene

  • change in mannerisms

  • change in facial expression/ability to engage/ eye gaze (soft vs grasping vs intense vs. disengaged?)

 

BEHAVIOR

 

  • isolating?

  • intrusive?

  • odd, out of the norm behavior?

  • pacing?

  • immovable?

  • paranoid?

  • stopped eating?

  • sleep patterns----not sleeping or sleeping excessively?

  • non-stop meditating?

 

VERBAL

 

  • pressured speech?

  • slowed speech?

  • slurred speech?

  • hyperverbal?

 

THOUGHT CONTENT

 

  • able to track and comprehend in conversation?

  • tangential (shifts from subject to subject somewhat nonsensically?

  • fight of ideas (grandiosity in evidence)?

  • any fixed delusional process evident (unable to see other perspectives)?

  • out of the ordinary perseveration?

 

HALLUCINATIONS

 

  • auditory, olfactory, visual?

  • can occur in meditation process. (What is wise method for differentiating this from a possible psychotic process?)

 

MOOD/AFFECT

 

  • flat (no emotion)?

  • elated/giddy?

  • depressed?

  • overwhelmed?

  • frightened?

 

The teacher(s) and the wisdom of the Sangha co-operate together to give skilful support to a person experiencing significant mental/physical issues.

Originally written in the late 1990s, this essay evaluating spiritual emergency was updated in 2015.

 

Special thanks to Subhana, the Dharma teacher and psychotherapist, who contributed some practical notes in the 1990s. Mark Coleman, a Dharma teacher, added more invaluable information at that time.

 

 

  May all beings live with insight and wisdom 

 Christopher Titmuss's

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