Ignatian Exercises, Examen and discernment

1. Introduction

Version followed: Ignatius of Loyola, The Spiritual Exercises, in the English translation from the Spanish autograph by Elder Mullan SJ (preface dated 1909; public-domain text as published by EWTN and IntraText), for the Annotations, Examens, method of prayer, Additions, Rules for Eating and Notes concerning Scruples; the modern five-step Daily Examen as published by the Jesuits USA East Province; the Rules for Discernment as introduced by Loyola Press's IgnatianSpirituality.com; the IOCDF information packet for faith leaders for scrupulosity and ERP; and one Jesuit retreat house's published 30-day application for retreat screening. [source: Mullan tr., EWTN; Jesuits East; IgnatianSpirituality.com; IOCDF Clergy Packet; Ignatius House]

The Spiritual Exercises is a manual written by Ignatius of Loyola (approved by Pope Paul III in 1548, as the printed text records) for a person who gives the Exercises to another. It is not a book to be read straight through. Ignatius defines "spiritual exercises" broadly as any way of examining conscience, meditating, contemplating or praying, and compares them to walking or running as bodily exercise (Annotation 1). The full Exercises are arranged in four "Weeks" and take about thirty days in seclusion (Annotations 4, 20). They can also be given in daily life to people who cannot withdraw (Annotation 19), or in lighter forms (Annotation 18). Two parts of the Exercises are widely practised on their own: the Examen (examination of conscience, today often taught as a daily prayer of reviewing the day) and the discernment of spirits (rules for noticing and responding to "consolation" and "desolation"). [source: Mullan tr., EWTN; Jesuits East]

How change happens, as the tradition states it. In the tradition's own terms, the person is helped to order their life towards God by freeing themselves from "inordinate" attachments, to come to know Christ more intimately through imaginative prayer on the Gospels, and to notice how the good spirit and "the enemy of our human nature" move them, so that they can choose well. The giver gives the material briefly, then steps back so that God can deal directly with the person (Annotations 2, 15). These are theological claims of the Catholic tradition, attributed here, neither endorsed nor dismissed. [source: Mullan tr., EWTN; IgnatianSpirituality.com]

The psychotherapist's place. The psychotherapist does not give the Exercises and is not the client's spiritual director or confessor. The therapist's work is: client-led integration of the client's own Ignatian practice within spiritually integrated psychotherapy (cross-refer Domain VII); using published or derived secular reflective reviews only with consent (cross-refer Domains II and VII); screening and support around intensive retreats, including the 30-day retreat; recognising and treating scrupulosity (religious OCD), for which the Examen and the Notes on Scruples are directly relevant; and collaborating with the client's spiritual director or priest when the client wishes. [synthesis]

2. Framework

2a. The Exercises as Ignatius structures them

Four Weeks (Annotation 4): First Week, on sin; Second Week, the life of Christ up to and including Palm Sunday; Third Week, the Passion; Fourth Week, the Resurrection and Ascension, with three methods of prayer added. A "Week" is a stage, not seven days: the giver may shorten or lengthen each according to how the person is progressing, and the whole takes about thirty days, "a little more or less". [source: Mullan tr., Annotation 4, EWTN]
Daily rhythm in the full retreat: Ignatius's text describes several prayer periods a day, including at night and at dawn, and asks the person not to cut a period short, especially in desolation (Annotations 12–13). Retreat houses today set their own timetables and adapt them to the person. This is a description of the tradition, not a target. [source: Mullan tr., EWTN]
Formats (Annotations 18–20):
- Annotation 20, the full or "closed" retreat: all the Exercises in order, in seclusion, for a person free to withdraw from ordinary life. Today this is usually called the 30-day retreat; some centres divide it into stages (Epiphany House in the UK lists three residential stages). [source: Mullan tr., EWTN; Epiphany House]
- Annotation 19, the retreat in daily life: for a person occupied with public affairs, a daily period of prayer, with the material spread over a longer period while life continues. Directors usually meet the person weekly [source: Peloso, The Way]; total length varies by programme [uncertain: not verified].
- Annotation 18, lighter forms: for people with less education, capacity or time, Ignatius recommends the Particular and General Examens, a morning method of prayer on the Commandments and the capital sins, and frequent confession and Communion, without proceeding into the Weeks. [source: Mullan tr., EWTN]
Moving between stages: the giver adapts the pace to the person. If the person reports no consolation or desolation, the giver asks closely how they are doing the exercises and Additions (Annotation 6). The Second Week rules for discernment are not explained to someone still facing gross, open temptation, but are given when the person is tempted "under the appearance of good" (Annotations 9–10). The detailed criteria for moving from one Week to the next are set by the director's judgment of the grace being sought [uncertain: not verified].
Prerequisites for the 30-day retreat, as one Jesuit retreat house publishes them (Ignatius House, Atlanta): at least two prior 8-day Ignatian retreats; current spiritual direction; regular prayer and comfort with Scripture prayer; ability to keep the silence; a supporting letter from the applicant's spiritual director about the timing (and a superior's or bishop's endorsement for priests and religious); a written autobiographical sketch and answers to set questions; a question on special health needs and on any past counselling or therapy, with explanation; and an interview before acceptance. Other houses use their own application as a discernment of readiness (Epiphany House). [source: Ignatius House 30-Day Application; Epiphany House]

2b. The psychotherapist's framework alongside the practice [synthesis]

No published clinical protocol for integrating the Exercises was found in the sources consulted, so the phases below are synthesis, built on the sources' content.

Assessment and consent. Spiritual history, including what Ignatian practice the client already does and with whom; screening for scrupulosity, depression, trauma, psychosis or mania history, eating difficulties. Use the DSM-5-TR Cultural Formulation Interview, including its spirituality, religion and moral traditions supplementary module [uncertain: not verified]. Agree explicitly whether, and how, the client's practice will be referred to in sessions.
Collaboration set-up (when the client wishes): written consent to talk with the spiritual director, retreat director or priest; agree roles (therapist: mental health; director: prayer and discernment).
Integration or treatment. Either (a) client-led use of the Examen or discernment language as a reflective resource, or (b) where scrupulosity is present, ERP in which the Examen, confession and the Notes on Scruples are handled within an agreed plan.
Retreat cycle, if an intensive retreat is planned: readiness review before; a contingency plan for during; re-entry and integration sessions after.
Review and ending: check that religious practice is chosen freely and that symptoms are not driving it.

Session counts are not given in the sources consulted; set them by clinical need. [synthesis]

3. Guiding principles

Principles drawn from the Exercises concern the director, but several translate directly into the therapist's stance; others are clinical. Each is tagged.

The giver stands "in the centre like a balance". The giver must not push the person towards a choice of life, vow or austerity, but let God deal directly with them (Annotation 15). Practical meaning: never steer a client's religious decisions; reflect, do not recommend. [source: Mullan tr., EWTN]
Let the person discover meaning. A brief, faithful account is better than lengthy explanation, since what the person grasps for themselves satisfies more (Annotation 2). Practical meaning: ask about the client's experience of prayer; do not teach spirituality. [source: Mullan tr., EWTN]
Be gentle with a person in desolation. The giver should be kind and encouraging, not harsh (Annotation 7). Practical meaning: a client in spiritual distress needs warmth before analysis. [source: Mullan tr., EWTN]
Adapt to the person. Ignatius adjusts the Exercises to age, education, ability and circumstance, and gives some people only the lighter forms (Annotation 18). Practical meaning: "not now" or "a lighter form" is part of the tradition, not a failure. [source: Mullan tr., EWTN]
No rash vows in consolation. Ignatius warns against hasty promises, especially by people of unsteady character (Annotation 14). Practical meaning: slow down major decisions made in emotional highs, including hypomania. [source: Mullan tr., EWTN]
Make no change in desolation. Decisions made in consolation are not to be reversed during desolation (First Week rules). Practical meaning: a shared, faith-congruent reason to delay big decisions during low mood. [source: rules summary, Prodigal Catholic; IgnatianSpirituality.com]
The giver does not need the person's sins, but does need the movements. The giver need not ask about personal sins, but should know the consolations, desolations and thoughts (Annotation 17). Practical meaning: the therapist likewise does not hear confessions, and focuses on experience and functioning. [source: Mullan tr., EWTN]
Seek the mean in scruples. For the delicate conscience, Ignatius advises settling in the middle way (Notes on Scruples, fifth note). Practical meaning: the tradition itself supports reducing excessive moral checking. [source: IntraText, Notes on Scruples]
Client-led, in the client's own language and tradition. Practical meaning: use Ignatian terms only if the client uses them; spiritual practice is not homework unless the client asks for it. [synthesis]
Role clarity. The therapist is not a spiritual director, retreat giver, confessor or theologian. Avoid dual relationships, such as directing a client's retreat. Practical meaning: refer religious questions back to the client's director or priest. Professional ethics codes on competence, multiple relationships and respect for religion apply; the APA Ethics Code is cited in principle only [synthesis]. Published spiritual and religious competencies for psychologists (Vieten et al. 2013) are relevant [uncertain: not verified].
Self-disclosure of the therapist's own faith is used only when it serves the client, and never to align with or argue against the client's tradition. [synthesis]
Do no harm with intensity. Silent, intensive contemplative retreats can bring challenging experiences, including in people without a prior mental health history. Practical meaning: screen, plan and follow up. [source: Farias et al. 2020; Lindahl et al. 2017 via Brown University]
Separate symptom from practice without dismissing either. Desolation, "dark night" experiences and depression or OCD can look alike; take the religious meaning seriously and still assess for illness. [synthesis]
Austerities belong to the tradition and the doctor, not to therapy. Ignatius's Additions include fasting, reduced sleep and bodily penance, which he says must not cause illness. Practical meaning: never prescribe or endorse them; raise health concerns with the client's doctor and director. [source: Mullan tr., Tenth Addition; synthesis]

4. Intervention inventory

Part A gives the practices as the tradition teaches them, in plain words, so that the therapist understands what the client is doing. They are taught by spiritual directors, retreat directors and priests, not by the therapist. Part B gives the therapist's own interventions. Example language is illustrative throughout.

Part A. The practices as taught

A1. The Daily Examen (modern five-step form)

Purpose and when used: a short daily prayer reviewing the day to notice God's presence and one's response. Jesuit sources describe it as the heart of daily Ignatian prayer and report that Ignatius urged early Jesuits to keep it even if they dropped other exercises. In therapy it comes up when a religious client already prays it, or asks how it fits with treatment. [source: Jesuits East]
Steps as publicly taught (Jesuits USA East): (1) become aware of God's presence and give thanks; (2) ask for the grace to understand how God is acting in one's life; (3) review the day from rising to bedtime, recalling specific moments and the feelings at the time (described as the heart of the prayer); (4) reflect on what one did, said or thought, and whether it drew one closer to God or further away; (5) look ahead to tomorrow, with a concrete way to cooperate with God, and close with the Our Father. The page gives no fixed time or frequency beyond the daily review. [source: Jesuits East]
Example language (illustrative): "You mentioned you pray the Examen most evenings. Would it help to talk about what you notice in it, or would you rather keep it separate from our work?"
Watch for: the Examen turning into a nightly hunt for sin with mounting guilt, long rumination or a need to "get it right" (possible scrupulosity, see B4); a depressed client noticing only failures and none of the gratitude step; using step 5 to make punishing resolutions. Signs it is working, in the client's own terms: shorter, gentler reviews, more noticing of gratitude, ordinary sleep.

A2. The General Examen (Ignatius's text)

Purpose and when used: in the Exercises, a daily examination "to purify oneself and to make a better confession". [source: Mullan tr., EWTN]
Steps as written (paraphrase): Ignatius first explains three kinds of thoughts (one's own, and those coming from a good and from a bad spirit) and how thoughts, words and deeds can be sinful or meritorious. Then five points: give thanks; ask grace to know one's sins; go over the day hour by hour for thoughts, words and deeds; ask pardon; resolve to amend with grace; end with the Our Father. Ignatius also recommends a general confession after the First Week. [source: Mullan tr., EWTN]
Example language (illustrative): "When you go through the day hour by hour, what happens in your body? Does it end in peace, or do you find you need to go back over it again?"
Watch for: the hour-by-hour review is the point where checking compulsions most easily attach. If the client repeats the review, cannot finish it, or keeps re-confessing, assess for OCD (B4). Signs of healthy use: the client finishes in a set time and moves on.

A3. The Particular Examen

Purpose and when used: focused work on one fault or habit. Taught in the First Week and in the lighter forms (Annotation 18). [source: Mullan tr., EWTN]
Steps as written (paraphrase): on rising, resolve to guard against one particular fault; at midday and again in the evening, review the period since the last check and mark each lapse on a simple daily chart, then renew the resolution. Ignatius adds four refinements: a small gesture of sorrow at each lapse, and comparing the marks between the two checks, between days and between weeks to see improvement. [source: Mullan tr., EWTN]
Example language (illustrative): "This sounds like a habit-tracking method from long before CBT. What's it like for you to count?"
Watch for: for most people a self-monitoring tool; for a scrupulous client, the counting and charting can become a checking ritual and fuel intrusive doubt about whether a lapse happened. Do not borrow it as therapy homework for a scrupulous client without the director's and client's agreement on limits. [synthesis]

A4. Ignatian meditation (method of prayer)

Purpose and when used: the basic shape of each hour of prayer in the Exercises. [source: Mullan tr., EWTN]
Steps as written (paraphrase): a preparatory prayer that all one's intentions be directed to God's service; a first prelude, the composition of place (imagining the scene, or for an invisible subject such as sin, an image of the soul's condition); a second prelude, asking for what one desires, suited to the subject (for example shame for sin, sorrow in the Passion, joy in the Resurrection); then points worked through with memory, understanding and will; and a closing colloquy, speaking to Christ, Mary or the Father "as one friend speaks to another", ending with an Our Father or Hail Mary. [source: Mullan tr., EWTN]
Example language (illustrative): "What did you ask for at the start of that prayer, and how did that feel to ask for?"
Watch for: First Week subjects (sin, hell, death) can trigger intrusive fears in scrupulous or depressed clients; the "grace asked for" (shame, confusion, sorrow) may be heard as a demand to feel worse. [synthesis]

A5. Imaginative contemplation and application of the senses

Purpose and when used: in the Second to Fourth Weeks, the person enters a Gospel scene in imagination, as if present, and later repeats the contemplation and "applies the senses", imagining seeing, hearing, smelling, tasting and touching within the scene. [source: Mullan tr., EWTN]
Steps as written (paraphrase): the same preparatory prayer and preludes; contemplation of persons, words and actions in the scene; repetitions that return to points where the person felt consolation or desolation; and the application of the senses as the last prayer of the day. [source: Mullan tr., EWTN]
Example language (illustrative): "When you placed yourself in that scene, where were you standing? Did you feel free to step back if it got too much?"
Watch for: vivid sensory imagery, especially in the Third Week Passion contemplations (arrest, beating, crucifixion), can trigger trauma memories, dissociation or intrusive images. A client with violence or abuse history may need the director to adapt the material. [synthesis]

A6. The review after prayer (Fifth Addition) and the other Additions

Purpose and when used: the Additions are practical conditions Ignatius adds to help the prayer. [source: Mullan tr., EWTN]
Content (paraphrase): thinking briefly before sleep about the next exercise; turning the mind to it on waking; a moment of reverence before beginning; choosing a posture (kneeling, lying, seated, standing) and staying with what helps; and, after each exercise, a short review of how it went, with resolve to do better. For the First Week Ignatius also suggests avoiding cheerful thoughts, darkening the room, not laughing and restraining the eyes. He changes several of these for the Fourth Week. [source: Mullan tr., EWTN]
Penance (Tenth Addition), qualitatively: Ignatius distinguishes interior penance (sorrow for sin with a resolve not to repeat it) from exterior penance: going without in food and sleep, and bodily mortification. He says it must not cause illness, and in the Fourth Week replaces it with temperance and moderation, apart from Church-commanded fasts. This guide gives no quantities or methods. [source: Mullan tr., EWTN]
Rules for eating, qualitatively: Ignatius's Rules for Eating urge moderation and self-restraint in food. They are described here, not given as rules for anyone to follow. [source: Mullan tr., EWTN]
Example language (illustrative): "Has your director talked with you about how the retreat handles food and sleep? Given what we've worked on, would it help to bring that up with them before you go?"
Watch for: darkened rooms and an instruction to avoid cheerful thoughts in a person already depressed; reduced sleep in someone with bipolar history; restriction framed as virtue in someone with an eating disorder history; bodily penance in someone who self-harms. Route medical questions to the doctor and practice questions to the director. [synthesis]

A7. Discernment of spirits: First Week rules

Purpose and when used: fourteen rules (Exercises 313–327) for recognising and responding to spiritual consolation and desolation. Loyola Press describes them as aimed especially at desolation and at people beginning a serious spiritual life, used with an experienced director. [source: IgnatianSpirituality.com]
Content (paraphrase): for a person moving away from God, the enemy offers apparent pleasures and the good spirit stings the conscience; for a person moving towards God, the enemy saddens, raises obstacles and false reasons, while the good spirit encourages and consoles. Consolation is described as an increase of faith, hope and love, interior peace and drawing to God; desolation as the opposite: darkness, disturbance, attraction to low things, feeling far from God. In desolation, make no change to earlier decisions; act against the desolation with more prayer, meditation and self-examination and some suitable penance; remember that grace remains; be patient, since consolation will return. Desolation may come from one's own negligence, as a trial, or to teach that consolation is a gift. In consolation, prepare for desolation and stay humble. Three images describe the enemy: one who grows weak when firmly resisted, a false lover who wants secrecy (so tell a confessor or spiritual person), and a commander attacking the weakest point. [source: rules summary, Prodigal Catholic (a modern adaptation; its translation is not named); IgnatianSpirituality.com; Mullan tr. Annotations 7, 13–14]
Example language (illustrative): "In your own words, it sounds like you're in desolation. Your tradition says not to change direction in desolation. How does that sit with the decision you're thinking of making this week?"
Watch for: the frame "desolation comes from the enemy" can, in some clients, feed fear of demonic influence or self-blame ("it's my negligence"). Explore what the client actually believes; do not teach or correct the theology; involve the director. Desolation lasting weeks with loss of sleep, appetite, function or hope warrants a depression assessment. [synthesis]

A8. Discernment for the Second Week and the Election

Purpose and when used: eight rules (Exercises 328–336) for people well established in spiritual life, focused on testing consolation itself, since the enemy can tempt "under the appearance of good" (Annotation 10). The Second Week also contains the Election, a structured way of making a major life choice. [source: IgnatianSpirituality.com; Mullan tr., EWTN]
Public outline only: the detailed content of these rules and of the Election methods is not summarised here [uncertain: not verified]. Ignatius himself held these rules back from someone still facing open temptation (Annotation 9).
Example language (illustrative): "You're weighing a big decision on retreat. How are you sleeping and eating, and how fast are your thoughts moving?"
Watch for: life decisions (vocation, marriage, leaving a job) made during an intensive retreat in a state of elation, sleeplessness or agitation; Annotation 14 already cautions against rash vows. [synthesis]

A9. The Notes concerning Scruples (Exercises 345–351)

Purpose and when used: six notes in which Ignatius, who suffered severe scruples himself, distinguishes kinds of scruple and how to respond. Directly relevant when treating a Catholic client with scrupulosity. [source: IntraText, Notes on Scruples; biographical point: uncertain: not verified]
Content (paraphrase): (1) A mistaken conclusion one reaches by one's own judgment, such as deciding one sinned by accidentally stepping on a cross made of straws, is not properly a scruple but an erroneous judgment. (2) A true scruple is when, after a thought, word or deed, a thought "from without" says one has sinned while one's own judgment says one has not, leaving one doubting and not doubting at once. (3) The erroneous judgment should be rejected outright; the second kind can help for a time a person doing the Exercises, by making them careful of sin, and Ignatius quotes Gregory that good souls see fault where there is none. (4) The enemy studies whether a conscience is lax or delicate: the delicate one he pushes to extreme fineness, seeing sin where there is none; the lax one he makes more lax. (5) So the person must act in the opposite direction: a delicate conscience should seek "the mean" to be at peace. (6) When a good intention is met by a temptation, for example to vainglory, the person should act against the temptation, quoting Bernard's reply that he did not begin for the tempter and will not stop for him. [source: IntraText, Notes on Scruples]
Example language (illustrative): "Ignatius described a thought that comes 'from outside' and says you sinned when your own judgment says you didn't. Does that match your experience? Your treatment and your tradition both seem to say: don't obey that thought."
Watch for: the third note (that a scruple can be useful for a while) may be grabbed as a reason to keep checking; the fourth and fifth notes, which tell the delicate conscience to seek the middle way and act against the scruple, are the clinically relevant ones. Leave the theology to the priest or director. [synthesis]

A10. The Contemplation to Attain Love

Purpose and when used: the closing contemplation of the Exercises. Ignatius notes that love shows itself more in deeds than in words, and consists in mutual giving. [source: Mullan tr., EWTN]
Content (paraphrase): the person recalls benefits received, God's presence and work in all creatures, and all gifts as coming from above, and responds with a prayer of self-offering beginning "Take, Lord, and receive all my liberty" (the Suscipe). [source: Mullan tr., EWTN]
Example language (illustrative): "You said the last days of the retreat left you grateful. How would that look in an ordinary Tuesday?"
Watch for: a client who hears total self-offering as a demand to give up all needs and boundaries; explore with care and refer the theology to the director. [synthesis]

A11. The 30-day retreat (Annotation 20) and the retreat in daily life (Annotation 19)

Purpose and when used: the full Exercises, given by a trained director, either in seclusion or in daily life. [source: Mullan tr., EWTN]
Outline: in the closed retreat Ignatius foresees several prayer periods a day, seclusion and daily Mass; today the retreatant typically meets a director regularly and keeps silence [uncertain: daily meeting and rest days not verified]. In daily life, a daily period of prayer with regular meetings with a director; Peloso describes weekly meetings and problems such as loss of momentum, unresolved past hurt surfacing, and family resentment of the time commitment. Admission to a 30-day retreat is by application, director's letter and interview at least at one Jesuit house. [source: Mullan tr.; Peloso, The Way; Ignatius House]
Example language (illustrative): "The retreat house asks about past counselling. Would you like us to think together about what's useful for them to know?"
Watch for: see B5–B7 for screening, adverse effects and re-entry.

Part B. The psychotherapist's interventions

B1. Spiritual assessment and consent to integrate

Purpose and when used: at intake, or when a client mentions the Examen, a director or a planned retreat. [synthesis]
Steps: (1) Ask open questions about faith and practice, in the client's words. (2) Map the Ignatian elements: daily Examen, regular spiritual direction, confession, past directed retreats, plans for a 30-day or daily-life retreat. (3) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions where helpful [uncertain: not verified]. (4) Screen for scrupulosity, depression, trauma, psychosis or mania history, eating difficulties and self-harm. (5) Agree whether the practice is in or out of the therapy, and record consent. (6) Ask whether the client wants you to speak with their director or priest. [synthesis]
Example language (illustrative): "Some people want their prayer life to be part of therapy, some prefer to keep it separate. Both are fine. What would you like?"
Watch for: pressure in either direction, including your own; a client who seeks the therapist's approval for religious choices. Working well: the client says clearly what is in and out of scope.

B2. Client-led use of the Examen as a reflective resource

Purpose and when used: when a client who already prays the Examen wants to bring its noticing into therapy, for example to track moods, gratitude or moments of connection. Cross-refer Domain VII (spiritually integrated psychotherapy). [synthesis]
Steps: (1) Ask the client to describe their Examen as they pray it; do not teach a version. (2) Invite them, if they wish, to note one moment of consolation and one of desolation (in their terms) to bring to session. (3) In session, explore the situation, feelings and needs behind each moment. (4) Keep the prayer the client's own: do not grade it or set targets. (5) Review after two to four weeks whether this is helping. [synthesis]
Secular adaptation: a non-religious end-of-day review (a moment of gratitude, a moment of difficulty, one intention for tomorrow) is a reflective exercise in its own right, with no claim to be the Examen; no published clinical protocol for it was found in the sources consulted. Cross-refer Domains II and VII. [synthesis; uncertain: published secular adaptations not verified]
Example language (illustrative): "When you bring a moment of desolation from your Examen, we can look at it from the angle of mood and thinking, and leave the spiritual meaning to you and your director. Does that division work?"
Watch for: the review becoming a list of failures (depression) or a checking ritual (OCD, see B4). Working: brief entries, more variety of emotion, links made between events and mood.

B3. Desolation, depression and the "dark night": differential assessment

Purpose and when used: when a client reports prolonged desolation, spiritual dryness or a sense of God's absence, especially during or after a retreat. [synthesis]
Steps: (1) Hear the experience in the client's spiritual language first. (2) Ask separately about sleep, appetite, energy, concentration, hopelessness, suicidal thoughts, psychotic experiences, elevated mood and dissociation. (3) Ask how long it has lasted, how much it affects work and relationships, and whether it lifts at times. (4) Do a standard suicide risk assessment if indicated. (5) If criteria for a disorder are met, offer treatment alongside the spiritual frame, not instead of it. (6) If no disorder is present, the DSM-5-TR offers a code for a religious or spiritual problem as a focus of clinical attention (Z65.8). (7) With consent, talk with the director. [synthesis]
Example language (illustrative): "Your tradition has words for this: desolation, dryness. I'm also wondering about your sleep and appetite, because sometimes depression travels alongside. Could we look at both?"
Watch for: pathologising normal spiritual dryness; equally, missing depression, mania or psychosis because the client frames it as spiritual. The First Week rules themselves note that bodily vulnerabilities make desolation harder, so physical care is congruent with the tradition. [source for the last point: rules summary, Prodigal Catholic; rest synthesis]

B4. ERP for scrupulosity, adapted with the client's priest or spiritual director

Purpose and when used: when the client's Examen, confession, prayer or discernment has become driven by obsessional doubt and compulsive checking. [source: IOCDF Clergy Packet]
How scrupulosity presents (IOCDF): obsessions such as whether all sins were confessed, whether prayers were sincere or perfect enough, whether one has committed an unforgivable sin, blasphemous intrusive thoughts, and doubt about understanding doctrine or following every rule exactly; compulsions such as repeated confession, avoiding Communion, repeating prayers until they feel "right", reassurance seeking, excessive religious research and rumination. The packet distinguishes a "tender" conscience, which competent explanation can settle, from a scrupulous one, which it cannot, and notes that scrupulosity often goes beyond what the religion actually requires. [source: IOCDF Clergy Packet]
How it may attach to Ignatian practice [synthesis]: the General Examen's hour-by-hour review, the Particular Examen's tallies, the recommended general confession, First Week meditations on sin and hell, "no change in desolation" turned into fear of any decision, and repeated questions to the director about whether a movement was from the good or the bad spirit.
Steps: (1) Assess and give a clear OCD formulation. (2) With consent, contact the client's priest or director early. The IOCDF asks clergy to work with the treatment team on one shared plan and to keep it consistent. (3) Agree with the religious authority which practices the faith actually requires and which are OCD; let the priest, not the therapist, rule on religious questions. (4) Build an exposure hierarchy. The IOCDF describes working on a few exercises at a time with daily practice, recording rituals, and "spoiling" a ritual that slips through. Its religious examples include writing the word "devil" on paper and reading scripture about Hell; Catholic examples might include an Examen held to a set short time, or receiving Communion while doubt is present [synthesis, to be agreed with the priest]. (5) Response prevention: one regular confessor and a confession schedule that is gradually spaced out, as the IOCDF suggests (for example weekly, then every two weeks, then monthly); no repeated confessions of the same sin; no checking of the day beyond the agreed review. (6) Ask the priest or director to reduce reassurance: the IOCDF suggests replies such as "What do you think?", "Maybe, maybe not" or "I don't have an answer for that", validating feelings instead, and asking what an answer would do for the anxiety. (7) Use the tradition's own resources where the client and priest agree: Ignatius's fifth note (the delicate conscience should seek the mean), Alphonsus Liguori's guidance quoted in the IOCDF packet ("assume grace, not sin"), and Liguori Publications' Ten Commandments for the Scrupulous (Santa, adapted in the packet), which include not repeating confessions and confessing only clear and certain sins. [source: IOCDF Clergy Packet; IntraText, Notes on Scruples]
Exposure safety and consent: explain ERP in full and get informed consent; agree hierarchy steps the client chooses; never design exposures that require acts the client believes are actually sinful — check them with the priest; stop or slow if the client shows suicidal thinking or severe depression; plan medication review with the prescriber if relevant (no drug advice here). [synthesis]
Example language (illustrative): "Father has agreed that, for now, one confession a fortnight is enough, and that the doubt afterwards is the OCD talking. Our job is to let that doubt be there without answering it."
Watch for: the director or priest accidentally reassuring, or the client finding a new priest to confess to; the Examen becoming the new compulsion; avoidance of Mass or Communion. Working: fewer confessions and reviews, shorter rumination, more participation in religious life, and the client describing practice as freer.

B5. Screening before a 30-day or other intensive retreat

Purpose and when used: when a client in therapy plans a 30-day, 8-day or daily-life retreat. Retreat houses screen too (Ignatius House asks for prior retreats, current direction, a director's letter, an account of health needs and past counselling, and an interview), but they do not do a clinical assessment. [source: Ignatius House; synthesis]
Steps [synthesis, informed by Farias et al. 2020 and Lindahl et al. 2017]: (1) Review current symptoms and history: psychosis, bipolar disorder, severe depression, suicidal thinking, recent self-harm, active PTSD, dissociation, eating disorders, OCD/scrupulosity, substance use, recent bereavement or major crisis. (2) Ask about prior retreat experiences, good and difficult. (3) Discuss the retreat's conditions as the house describes them: silence, solitude, long daily prayer, emotionally heavy First and Third Week material, and Ignatius's provisions on food, sleep and penance. (4) Discuss whether to tell the retreat house about therapy and health needs, since the application asks. (5) Make a plan: whom to contact if distress rises, what the client will do (tell the director, use grounding, contact the therapist or a doctor), and agreement that pausing or leaving is permitted. (6) If timing is poor, explore a lighter form (a shorter directed retreat, the daily-life form, or Annotation 18 practices) — a decision for the client and director, which the therapist can inform. (7) Check medication continuity and sleep with the client's doctor where relevant.
Example language (illustrative): "Thirty days of silence can be wonderful, and it can also stir up a lot. Let's plan for both, so that if something hard comes up you already know what you'll do."
Watch for: a client minimising history to be accepted; a retreat chosen as an escape from crisis; a client who feels the therapist is gatekeeping their faith. Working: the client goes with a written plan and their director knows what they chose to share.

B6. Adverse effects: recognising and responding during and after a retreat

Purpose and when used: when a client describes distress during or after intensive prayer. Research on meditation, mostly from Buddhist and secular settings, applies here only by analogy, since no study of Ignatian retreats was found in the sources consulted. [synthesis]
What the research reports: Lindahl et al. (2017, PLOS ONE) interviewed nearly 100 Western Buddhist meditators and teachers and catalogued 59 kinds of challenging experience in seven domains (cognitive, perceptual, affective, somatic, conative, sense of self, social), including fear, anxiety, panic, loss of emotion, hypersensitivity to light and sound, insomnia and involuntary movements; effects lasted from days to over a decade; practice intensity, trauma or psychiatric history and quality of supervision mattered for some but not all. The systematic review by Farias et al. (2020, Acta Psychiatrica Scandinavica; 83 studies) found a pooled adverse-event prevalence of 8.3%, mainly anxiety, depression and cognitive anomalies, sometimes in people with no previous mental health problems. Britton's Cheetah House offers resources and support for meditators in difficulty [uncertain: not verified]. [source: Brown University news on Lindahl et al.; PubMed record of Farias et al.]
Steps [synthesis]: (1) Listen without dismissing the religious meaning. (2) Assess safety, sleep, reality testing, mood elevation and dissociation. (3) Reduce intensity: fewer or shorter prayer periods, less imaginative material, more ordinary activity, walking, meals and sleep — to be agreed with the director, since it changes the retreat. (4) Grounding: orienting to the room, naming objects, feet on the floor, cool water, talking to someone. (5) Medical review urgently for psychosis, mania, suicidal risk or several nights without sleep. (6) After the retreat, schedule re-entry sessions: integrate what was meaningful, process what was hard, and watch for delayed effects. (7) With consent, coordinate with the director.
Example language (illustrative): "It makes sense this is frightening. Let's first get you steadier, feet on the floor, look around the room, then we can think together and with your director about how much prayer is right just now."
Watch for: sleeplessness with racing thoughts or grandiosity, voices or visions experienced as commands, persistent derealisation, suicidal thinking, and First Week guilt that becomes despair. Working: sleep returns, the client can tell experience from interpretation, and spiritual life resumes at a pace they choose.

B7. Trauma-sensitive adaptation

Purpose and when used: for clients with trauma histories who pray imaginatively, especially with Passion material or images of God as harsh. Peloso describes a retreatant whose image of God was "a ruthless dictator". Trauma-sensitive mindfulness (Treleaven 2018) is a published model for meditation; its application to Ignatian prayer is by analogy [uncertain: not verified]. Cross-refer Domain IV. [source: Peloso, The Way; synthesis]
Steps [synthesis]: (1) Choice: the client may pause, open their eyes, stand at the edge of a scene or leave it. (2) Window of tolerance: shorter periods, and a familiar or comforting scene to start and end. (3) Suggest the client tell the director which scenes are triggering; the director, not the therapist, adapts the material (Annotation 18 permits adaptation). (4) Distinguish a trauma flashback from a spiritual experience by asking what is happening in the body and whether the client is "here" or "back then". (5) Process intrusive memories in trauma therapy, not in the retreat.
Example language (illustrative): "Ignatius asks you to imagine yourself in the scene. You're also allowed to watch from a distance. Which feels safer?"
Watch for: freezing, numbness or losing time during prayer; the client blaming themselves for not managing; the Passion scenes stirring abuse memories. Working: the client chooses how close to come, and recovers quickly from activation.

B8. Collaboration with the spiritual director or priest

Purpose and when used: whenever the client wishes, and especially for scrupulosity (B4), retreat planning (B5) and adverse effects (B6). Ignatius himself advises bringing temptations into the open to a confessor or spiritual person (First Week rules, the false-lover image). [source: rules summary, Prodigal Catholic; IOCDF Clergy Packet]
Steps [synthesis]: (1) Written consent stating what may be shared. (2) Agree roles: the director accompanies prayer and discernment; the priest rules on sin and sacraments; the therapist treats mental health conditions. (3) For scrupulosity, agree a written plan (confession schedule, reassurance policy) as the IOCDF suggests. (4) Agree how to reach each other in a crisis during a retreat. (5) Review regularly; do not use the director as a co-therapist or the therapist as a theologian.
Example language (illustrative), to a director: "With [client]'s permission: we're treating OCD, and the main problem is reassurance seeking. When they ask whether a movement was from the bad spirit, it helps if you don't settle the doubt for them. Would that fit with how you direct?"
Watch for: splitting (the client telling each a different version), boundary drift, a director who views therapy as opposed to faith, or a therapist overriding religious judgment. Working: consistent messages, fewer crises.

5. Handling problems

Most of the guidance below is synthesis; source-based points are tagged.

The Examen has become a nightly trial. The client reviews for an hour, cannot stop, and goes to bed in dread. Response: formulate as possible scrupulosity (B4); with consent, ask the director or priest to agree a time limit and a gratitude-first form; use Ignatius's note that the delicate conscience should seek the mean. (illustrative) "Your tradition itself warns that the enemy pushes a tender conscience to extremes. What would the middle way look like tonight?" [source: IntraText, Notes on Scruples; IOCDF Clergy Packet; synthesis]
The client fears ERP is sinful (for example, not confessing a doubtful sin). Response: do not argue theology. Ask the client's priest to say which practices are required; the IOCDF packet's adapted Liguori guidance says to confess only clear and certain sins. Choose exposures that the priest confirms are not sinful. [source: IOCDF Clergy Packet; synthesis]
Reassurance seeking moves to the director, or to many confessors. Response: agree one confessor and a shared reassurance policy, as the IOCDF suggests; name doctor-shopping for absolution as a compulsion. (illustrative) "Finding a new priest to ask again is the same loop in a new place." [source: IOCDF Clergy Packet]
Prolonged desolation or "dark night" versus depression. Response: do both assessments (B3); treat depression if present without denying the spiritual meaning; in the tradition, no major changes during desolation, which supports holding off big decisions. [source: rules summary, Prodigal Catholic; synthesis]
A major decision made during a retreat (vows, leaving a marriage or job). Response: explore timing, sleep and mood; Ignatius warns against rash vows in consolation (Annotation 14), and the Exercises leave the decision free (Annotation 15). Invite the client to test it with the director over time. [source: Mullan tr., EWTN; synthesis]
Signs of mania or psychosis on retreat (sleeplessness, racing thoughts, commands from visions). Response: urgent medical assessment; contact plan with the retreat director; resume prayer later, at lower intensity, as the client and director choose. Do not interpret the content theologically. [synthesis]
Trauma memories in imaginative prayer. Response: grounding; choice about closeness to the scene; suggest the client tell the director which scenes to adapt; process memories in trauma therapy afterwards (B7). [synthesis]
Austerities and eating. A client with an eating disorder, bipolar disorder or self-harm history plans fasting, reduced sleep or bodily penance as part of the Exercises. Response: note that Ignatius himself says penance must not cause illness, and later replaces it with temperance; involve the client's doctor and director; give no quantities. [source: Mullan tr., Tenth Addition and Fourth Week; synthesis]
Loss of momentum in a daily-life retreat. Peloso describes retreatants losing commitment because of life changes, fading enthusiasm or avoidance, sometimes of painful past material, and options such as a short break, a week away from the material, or stopping. Response: explore avoidance and resource needs without pushing the client to continue; stopping is a legitimate choice. [source: Peloso, The Way]
Family resents the time the retreat takes. Peloso notes that daily-life retreatants need honest support from spouse and family, and that some may need to wait or seek counselling first. Response: couple or family conversation if wanted; timing is the client's and director's decision. [source: Peloso, The Way]
A harsh image of God surfaces. Response: explore its origins (family, religious trauma) at the client's pace; leave the theology to the director; do not replace the client's image of God with yours. [source: Peloso, The Way; synthesis]
Rupture: the client feels the therapist doubts their faith, or is gatekeeping a retreat. Response: name it, repair, restate that the choice is theirs and that your concern is their health. (illustrative) "I'm not trying to keep you from the retreat. I want you to go well-supported." [synthesis]
The therapist and director disagree. Response: return to roles: religious requirements belong to the priest, prayer to the director, symptoms to the therapist; meet together with the client if possible. [synthesis]
The client asks the therapist to direct their Exercises or pray with them. Response: decline the dual role kindly and help find a trained director through a Jesuit province, retreat house or spiritual direction network. [synthesis]
The therapist's own beliefs (devout Catholic, other faith, or none) pull them to agree, correct or avoid. Response: supervision; disclose only when it helps the client. [synthesis]
Fear of the demonic. The client takes "the enemy" in the rules as direct evidence of demonic attack. Response: explore what this means within their faith; assess for OCD (fear of having sold one's soul is among the IOCDF's examples) and psychosis; involve the priest. [source: IOCDF Clergy Packet; synthesis]

Sources

Web sources:

Works cited:

Ignatius of Loyola. The Spiritual Exercises of St. Ignatius of Loyola, translated from the Spanish autograph by Elder Mullan SJ (preface dated 1909).
Lindahl JR, et al. (2017). The varieties of contemplative experience: a mixed-methods study of meditation-related challenges in Western Buddhists. PLOS ONE.
Farias M, et al. (2020). Adverse events in meditation practices and meditation-based therapies: a systematic review. Acta Psychiatrica Scandinavica 142(5):374–393. doi:10.1111/acps.13225.
Santa TM. Ten Commandments for the Scrupulous, as adapted in the IOCDF packet.

Also referred to [uncertain: not verified]: American Psychiatric Association, DSM-5-TR (Cultural Formulation Interview); Treleaven D (2018), Trauma-Sensitive Mindfulness; Vieten C, et al. (2013) on spiritual and religious competencies for psychologists; Cheetah House resources; the APA Ethics Code (https://www.apa.org/ethics/code); the Second Week rules and Election methods in the primary text.

ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances

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