These guidelines were written in 2000 following retreats in India. The guidelines were updated in 2012. They were originally published on one of my websites. A few minor edits were made this year.
Here are the guidelines:
Christopher Titmuss, Subhana
and Mark Coleman
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 copy and send onto others. The information supports a process of learning to approach and address a spiritual/psychological emergency.
The guidelines can support workshops, courses and zoom meetings.
Background to the Guidelines
During the 1970s–1990s, spiritual/mental health issues might arise with a meditator in India every couple of years on the international retreats with some 100-130 participants for two consecutive 10-day retreats, back-to-back. Many internationals travelled to India with a variety of needs – seekers, those fleeing from the West, dealing with issues around drugs, family violence, ex-military with others yearning to change their behaviour.
Others arrived on a retreat with a wide variety of spiritual/religious changes in consciousness—visions, yoga, kundalini, angels, God and a sense of the sacred. For some these experiences were life-changing and for others found themselves in a crisis.
Some meditators took intensive vipassana or Zen retreats which disturbed the natural balance of their mind. Others stayed in monasteries and ashrams. A spiritual environment, religious services, various practices and guru devotion could unsettle emotions for a few generating a spiritual/religious/psychological crisis.
Vulnerable meditators have reduced considerably in the past 20 years. There is more support for such people although generally physicians and psychiatry has little knowledge or understanding of a spiritual crisis or the various states of religious/existential turmoil.
Facing a Spiritual Emergency
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.
Occasionally, teachers, managers and students face a spiritual/psychological emergency affecting heart, mind, body and consciousness of a retreatant. Sometimes there are early outer signals that show 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 list here. There are inner processes that can unfold on retreats and in many other environments that require both skilful attention and the appropriate action.
The questionnaire and brief meetings with vulnerable students before a retreat can help recognise those who may need extra support daily. Although some retreatants feel reluctant to fill out honestly the confidential questionnaire at the beginning of a retreat in case the teacher or manager bars the person from the retreat.
There is no single medicine that cures all the anguish of the inner life. 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 the past 35 years of daily connection with the Sangha, I have witnessed and attended–like others—to a wide range of severely problematic and sometime indefinable experiences in monasteries in the East, in various locations in India, and retreat centres in the West.
In the late 1990’s, we had several 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 kilometres away.
Support of Resources
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.
Sanghas in San Francisco and Tel Aviv held public meetings on issues around spiritual emergency. Teachers need to understand 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. Apart from conditions dormant in a person’s history, some retreatants:
Signs of Pressure of an Individual upon themselves:
- detach themselves from their feelings, emotions or contact with others
- enforce sleep deprivation
- engage in intense slowing down
- fast, reactive speech
- push the mind far too hard
- try to exercise complete control over unwanted states of mind force stillness of posture
- try to push through unacceptable levels of pain
- try to suppress thought
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. Approaching the practice with calm and insight 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.
Traumatic and Short Lived Experiences
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 proliferation of thoughts/projections and undergo a storm of multiple hindrances.
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. 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.
The Buddha said:
The Buddha said: ‘I state that there is 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.
DETERMNG THE SEVERITY
OF A SITUATION
You have some idea what this person’s baseline is because they have been on retreat. You are looking for a shift in behaviour 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 behaviour in just one area would not mean there is a crisis. If compromised in a number of areas, this could combine for a decrease in the ability of the meditator to cope with the intensity of their experience.
This means it will become more likely that this is a spiritual/psychological emergency which requires wise and skilful attention. It is unwise to leave a meditator to try and meditate their way through inner turmoil and distorted perceptions.
STEP 1: Medical problems need ruling out.
If someone presents with behaviour or thought patterns that appear out of their norm, first consider if medical problems cause 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 heartbeat
- Fever (can cause delirium)
- Pupils equal and not reactive to light? (or are they dilated, constricted, or unequal?)
Questions to Ask
- 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? (Disorientation problems may arise due to medication, absence of it or prevalence of a state of mind.
- Are they taking medications that could be causing the problem OR have they forgotten to take their tablets which triggers symptoms?
If YES to all or any of the above, then ask if there is a doctor, psychiatrist or psychologist on the retreat or the teacher/manager ensures contact with medical support.
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. Or find the local doctor in a rural environment in the East.
Be ready to act by making a Emergency call. When in doubt call for an 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 for an examination
- 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 /behaviours or thoughts/actions of hurting others.
Evaluate for Suicidal Thoughts
- Ask the individual directly whether he/she has thoughts about hurting herself.
- 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)
- Has he/she thought of HOW he would hurt himself?
- Do these plans appear imminent and are the means available?
- History of attempts? Or hospitalizations for this problem?
- 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. If someone habitually thinks about suicide AND has a history of attempts or has experienced a recent crisis, the risk of an attempt is higher.
- 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?” Has the person experienced suicidal ideation? Did they work through it? How did they work through it.
- Does he have a 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?
- 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
Vague ideation or is there someone specific? Is he making direct threats about hurting another person?
- Exhibiting any behaviour that seems threatening or endangering to others on retreat site?
- Able to gain perspective and calm through conversation? Directable and follows suggestions?
- Does he/she have a specific plan and immediate means to implement this plan?
- 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 the meditator’s current coping capacity
As you are assessing the meditator’s current coping capacity, consider 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? You can remind the person when they have working through a challenge and come out the other side. This can support empowerment for the person to access their ability to handle their experience. Check with the person for items he or she can see or hear or touch. This contributes to grounding and normalising perception.
- 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 feel overwhelmed and unable 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? 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 meditator and determine if these resources are available.
- If you have decided this meditator could continue retreat if he/she had more support or modification of practice—can you put the necessary resources in place?
- If you have decided you want this person to stay on the 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)
- Notice change in appearance.
- Facial expression/ability to engage/ eye gaze (soft vs grasping)
Intense vs. disengaged.
- Odd, out of the norm behaviour?
- Stopped eating?
- Sleep patterns—-not sleeping or sleeping excessively?
- Non-stop meditating?
- Pressured speech?
- Slowed speech?
- Slurred speech?
- 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?
- Other senses
- Images in the mind
- Flat (no emotion)?
MAY ALL BEINGS LIVE
IN PEACE AND HARMONY
Subhana, a Dharma teacher and psychotherapist from Australia, and I wrote practical notes at the end of one of our retreats together in Bodh Gaya, India on symptoms on a retreat indicating a spiritual/psychological emergency for a meditator.
Mark Coleman, a Dharma teacher, originally from the UK, who has also taught with us in the Royal Thai Monastery, Bodh Gaya, added more invaluable information. Long-term practitioners in California, who ran a crisis unit, also contributed information for these guidelines.