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Guide XIII-308

Prostration

A 35 · L 52 · M 1312 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: prostration as a cross-traditional observance, described from institutional and teacher sources in five traditions: Tibetan Buddhism (Samdhong Rinpoche's published guidance talk; the YoWangdu Experience Tibet explainer), Eastern Orthodox Christianity ("On Bows and Prostrations", Archives of Orthodox America / ROCA, reprinted from The Shepherd, 1990), Roman Catholic ordination (USCCB priesthood FAQ; Hekima University College), Sunni Islam (Dar al-Ifta al-Misriyyah fatwa on prayer when sick) and Hindu/Vaishnava devotion (a Hare Krishna temple blog page, publisher not named [uncertain]). The psychotherapist's work alongside it follows the DSM-5-TR Cultural Formulation Interview (CFI) and the IOCDF guidance for faith leaders. Where traditions differ, the tradition is named.

What it is. Prostration is a bodily act of reverence in which the practitioner lowers the body to the ground before what the tradition holds sacred. It is not a therapy. Forms range from a full-length lying prostration, to a kneeling bow with palms, knees and forehead on the ground, to a slight bow or hand gesture. [source: Samdhong Rinpoche; YoWangdu; Episcopal Church glossary]

  • Tibetan Buddhism. Samdhong Rinpoche describes prostration as reverence expressed through the body, alongside praise in speech and faith in mind. He names a "stretched prostration" (full length, arms extended) and a "contracted prostration" (palms, knees and forehead on the ground), each begun by touching joined hands to the crown, forehead, throat and heart. The stated purpose is to gather merit and purify negativity. He calls the practice "easy to do and of great meanings". YoWangdu adds that practitioners often take up a regular prostration practice as part of the preliminary practices (ngöndro) before long retreat. It also notes that pilgrims have long prostrated their way towards holy sites such as the Jokhang in Lhasa. [source: Samdhong Rinpoche; YoWangdu]
  • Eastern Orthodox Christianity. Full prostrations express penitence or deep reverence. The service rubrics call for them especially in Great Lent, for example with the Prayer of St Ephraim, and at set points of the Liturgy. They are omitted on Sundays and from Pascha to Pentecost, on the authority of canon 20 of the First Ecumenical Council, and on great feasts. Where practice is unclear, the worshipper follows the celebrant or the senior person present, and local custom applies. [source: ROCA, On Bows and Prostrations]
  • Roman Catholic ordination. The ordinand lies prostrate. The USCCB says the posture "symbolizes his unworthiness for the office to be assumed" and ties it to dependence on God and on the community's prayer. Hekima University College links it to the Litany of the Saints and to submission. [source: USCCB FAQ; Hekima]
  • Islam. Prostration (sujud) is one of the positions of the ritual prayer (salat), with standing, bowing and sitting. [source: Doufesh et al. 2013] Dar al-Ifta (Egypt) rules that a sick person who cannot stand may pray seated on a chair. A person who can bow but cannot prostrate from a chair should sit on the ground in order to prostrate. A person who can do neither may perform both while seated on a chair. [source: Dar al-Ifta fatwa 7958]
  • Hindu/Vaishnava devotion. Dandavat pranam ("falling like a stick") is described as a sign of surrender and reverence to God, guru or a revered person. The page describes an eight-limbed form (ashtanga) for men and a five-limbed kneeling form (panchanga) for women. [source: Hare Krishna Mandir blog, publisher not named [uncertain]]

Core idea of change, as the traditions frame it. Each tradition holds that humbling the body before the sacred brings about an inner change. Tibetan teachers name purification and merit. Orthodox sources name repentance. The Catholic rite names unworthiness and reliance on grace. These are religious claims, attributed to the traditions and neither endorsed nor dismissed here. For the psychotherapist, change does not come from the prostration itself. It comes from understanding what the act means to the client, protecting the client's freedom to practise safely, and spotting when the practice has become fear-driven, injurious or coerced. [synthesis]

Health claims. Some popular and religious sources describe prostration as good for the body. Studies are small: one measured heart rate and blood pressure across the positions of Muslim prayer (Doufesh et al. 2013). Another cites a trial of prayer-based exercise for low back pain and a survey that found no link between prayer and knee or hip osteoarthritis. These findings do not establish prostration as a treatment for any physical condition, and this guide does not present it as one. [source: Doufesh et al. 2013; NCT06190769 protocol] Samdhong Rinpoche likewise warns against practising mainly for physical health or worldly gain. [source: Samdhong Rinpoche]

2. Framework

There is no manualised therapy protocol for prostration, and no source gives a session count. The religious authority lies with the tradition: lamas and Dharma teachers, Orthodox priests and confessors, Catholic bishops (at ordination), imams and muftis, gurus and temple authorities. The phases below describe the therapist's own work alongside the client's practice. They are a [synthesis] built on the CFI and the IOCDF guidance.

  • Phase A: Understand the practice and its meaning. Goal: learn what the client does, in which tradition and setting, under whose guidance, and what it means to them. Format: part of assessment, using the core CFI and, where religion is salient, the Supplementary Module on "Spirituality, Religion, and Moral Traditions". The APA notes that the module can be used at intake, later in care or more than once, since rapport may reveal more over time. Move on when you can state the practice's meaning in the client's own words and the client confirms it. [source: APA CFI and Supplementary Modules]
  • Phase B: Screen for health and safety. Goal: find any musculoskeletal, cardiac or other health concern linked to the practice and route it to the client's doctor. Format: a brief qualitative enquiry, not an exercise prescription. Move on when any concern has been raised with the doctor, or the client declines and that is documented. [synthesis]
  • Phase C: Accommodate. Goal: fit treatment around the client's observance (prayer times, Lent, retreat periods, feasts) and support the client in finding the tradition's own adapted forms. Move on when the plan is agreed and the client's religious authority has been consulted if the client wishes. [source: Dar al-Ifta; ROCA; Samdhong Rinpoche; synthesis]
  • Phase D: Address clinical problems connected to the practice (scrupulosity, moral injury, pressure in a group, grief), only where the client brings them or the assessment shows them. Format: ordinary evidence-based treatment for the problem, adapted with the client's consent and, for scrupulosity, coordinated with the faith leader. [source: IOCDF; synthesis]
  • Phase E: Review. Goal: check that the practice remains values-driven and physically safe, and that collaboration with the doctor and clergy is working. Repeat the CFI module questions at review if new material emerges. [source: APA CFI; synthesis]

Phases can overlap. A client with no difficulties may need only Phase A and a brief Phase B check.

3. Guiding principles

  • The tradition holds the authority on the practice. In practice: you never set, raise or lower how much or how often a client prostrates. Questions of form go to the client's teacher or clergy, and questions of health go to the doctor. [synthesis]
  • Meaning comes before mechanics. In practice: ask what the prostration expresses (penitence, refuge, surrender, gratitude) before you ask how it is done. [source: APA CFI module]
  • Attribute religious claims, neither endorse nor dismiss them. In practice: say "in your tradition, prostration purifies…" rather than "it purifies" or "there is no such thing". [synthesis]
  • Traditions provide adapted forms. In practice: when health limits the practice, help the client find the form their own tradition provides. Examples are the slight joined-thumb bow (Samdhong Rinpoche), symbolic or visualised prostration (YoWangdu), not judging those who only bow (ROCA), and praying seated (Dar al-Ifta). [source: those named]
  • Route health questions to the doctor. In practice: describe musculoskeletal and cardiac concerns qualitatively and refer. Give no exercise targets, counts or durations. [synthesis]
  • Motivation matters. In practice: tell faith-driven practice from fear-driven practice. The IOCDF contrasts praying for support from the Divine with praying out of fear. [source: IOCDF; Samdhong Rinpoche on motivation]
  • Do not accommodate OCD. In practice: do not give repeated reassurance about whether a prostration was "done correctly". Plan the gradual reduction of accommodation together with the client and their faith leader. [source: IOCDF]
  • Respect the client's role and freedom. In practice: you are not the client's teacher, confessor or spiritual director. Consider your own religious commitments before any self-disclosure, and avoid dual relationships. [synthesis; Vieten et al. 2013 competencies [uncertain: not verified]]
  • Watch for coercion. In practice: when prostration is demanded by a teacher or group as a punishment or proof of loyalty, or carried on despite injury under pressure, assess for coercive control. [synthesis]
  • Consent and assent for minors. In practice: where children are expected to prostrate in a harsh or punitive way, consider safeguarding duties under local law and the policies of safeguarding bodies. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions alongside the client's practice. The prostration itself is taught and authorised by the client's tradition. This guide gives no instructions for how to prostrate, and no number, frequency or duration, as a target.

4.1 Exploring what prostration means in the client's life

  • Purpose / when: at intake whenever the client mentions bowing or prostrating, in prayer, at a shrine, in Lent, in a preliminary-practice commitment, at ordination or vows, or on pilgrimage. Also whenever the practice is linked to the presenting problem. [synthesis]
  • Steps: (1) Ask which tradition and community the client belongs to and who guides their practice. (2) Ask the client to describe the practice in their own words and record the tradition's own terms (sujud, metania or great prostration, dandavat, stretched or contracted prostration). (3) Ask what it expresses for them: repentance, refuge, surrender, gratitude, devotion, belonging. (4) Ask how it relates to the presenting problem, whether as a support, a strain or both. (5) Reflect back your understanding and ask the client to correct it. [source: APA CFI module (domains); synthesis]
  • Example language (illustrative): "You mentioned your prostrations each morning. Could you tell me what they mean to you, in your own words?" / "When you bow down, what are you hoping for, or offering?"
  • Watch for: the client checking whether you will judge or mock the practice. Notice shifts between warmth ("it steadies me") and dread ("I have to, or else"). Working: the client volunteers more detail over time and uses their tradition's language freely with you.

4.2 The Cultural Formulation Interview and its spirituality module

  • Purpose / when: a structured way to place the practice in the client's cultural and religious context. Use the core CFI at assessment, and add Supplementary Module 5, "Spirituality, Religion, and Moral Traditions", when religion is salient. [source: APA CFI; Supplementary Modules]
  • Steps: (1) Use the core CFI domains: the cultural definition of the problem, its perceived causes and context, stressors and supports, cultural identity, self-coping and past help-seeking, and current help-seeking. (2) Add the module and, as APA instructs, put the client's own name for their tradition in place of the generic placeholders. (3) Cover the module's areas: affiliation and community ties; the role of the tradition in daily life and decisions, including practices like prostration; how the tradition has helped with coping (leaders, texts, rituals); and any stress, conflict or discrimination linked to practice. (4) Skip items already answered and rephrase as needed to keep it conversational. (5) Repeat later in care if new material emerges. Do not reproduce the instrument; use the official APA forms. [source: APA CFI; Supplementary Modules]
  • Example language (illustrative): "Some people find their religious practices help with problems like this, and some find they add pressure. How has it been for you?"
  • Watch for: the CFI is an aid to understanding, not the sole basis for diagnosis (APA). Note conflicts, for example with family over the level of observance, or a recent change in community standing. Working: you can write a short formulation that the client agrees reflects them. [source: APA CFI]

4.3 Accommodation in scheduling and treatment

  • Purpose / when: to keep therapy compatible with observance. Examples are daily prayer times, Lenten services with prescribed prostrations, preliminary-practice periods before retreat, ordination or vow ceremonies, and feasts on which Orthodox prostrations are omitted. [source: ROCA; YoWangdu; synthesis]
  • Steps: (1) Ask about fixed times and seasons and mark them in the treatment plan. (2) Offer session times that avoid prayer times or major services. (3) If the client needs to pray during a long appointment or a day programme, discuss a quiet, clean space and a short break. (4) Expect changes in energy, sleep or mood around intensive seasons and plan homework accordingly. (5) Do not use the practice itself as homework unless the client wishes it and the teacher agrees. [synthesis]
  • Example language (illustrative): "Are there times in the day or seasons in the year when your practice takes priority? Let's plan our sessions around them."
  • Watch for: clients who feel they must apologise for their observance. Working: fewer missed sessions, and the client says therapy and practice feel compatible.

4.4 Musculoskeletal health check and routing to the doctor

  • Purpose / when: prostration involves repeatedly lowering the body to the floor and rising again, kneeling, and bending the spine, so it places demands on the knees, hips, lower back, wrists and neck. Use this check when the client practises intensively (for example a preliminary-practice commitment, Lenten services, pilgrimage), is older, or reports pain, injury, arthritis, or pregnancy. [source: NCT06190769 protocol rationale; synthesis]
  • What the sources say, qualitatively: a Cairo University protocol sets out to survey musculoskeletal disorders in Coptic monks and nuns. Its rationale is that frequent prostration, prolonged standing in services and manual work may contribute to back pain and other soft-tissue problems; this is a hypothesis, not a finding. The protocol also reports, as cited there [uncertain: not verified]: a study of Muslim prayer that found no link with knee or hip osteoarthritis; a survey of Thai Buddhist monks that found no significant link between lifetime kneeling and symptomatic knee osteoarthritis; and a trial of prayer-based exercise for non-chronic low back pain. The evidence is limited and mixed. It does not say that prostration is either harmful or therapeutic for a given person. [source: NCT06190769; cited studies [uncertain: not verified]]
  • Steps: (1) Ask neutrally whether the practice causes pain, stiffness or injury, or whether a health problem makes it hard. (2) If so, encourage the client to discuss it with their doctor or a physiotherapist the doctor recommends, and offer to write a brief note if they wish. (3) Do not suggest a number, pace or technique; that belongs to the doctor (for safety) and the teacher (for form). (4) If the doctor advises limits, help the client bring the question to their teacher or clergy, who can say which adapted form the tradition accepts (4.6). [synthesis]
  • Example language (illustrative): "You've said your knees ache after the evening prostrations. That sounds worth checking with your doctor. Would you be willing to mention it at your next appointment?"
  • Watch for: the client pressing on through pain because stopping feels like spiritual failure; that may point to scrupulosity (4.7) or group pressure (4.11). Working: the client has seen the doctor and either continues with medical clearance or uses an adapted form without guilt.

4.5 Cardiac and other medical concerns: routing to the doctor

  • Purpose / when: repeated rising from the floor is physical exertion and involves changes of head and body position. Use this check when a client has a known heart condition, high or low blood pressure, diabetes, a history of fainting, eye or neurological conditions, or is pregnant, and also when the client reports symptoms during practice. [synthesis]
  • What the sources say, qualitatively: in a small study of thirty Muslim adults, heart rate was highest when standing and lowest in prostration, and blood pressure fell after the prayer. The authors propose that future studies examine patients with cardiovascular disease. The study is not clinical guidance for any individual. [source: Doufesh et al. 2013]
  • Steps: (1) Ask whether the client has noticed dizziness or light-headedness on rising, chest pain or tightness, unusual breathlessness, palpitations, or fainting during or after practice. (2) Any of these: advise prompt medical review, and urgent help for chest pain or collapse, following ordinary first-aid and emergency guidance. (3) For known conditions, encourage the client to tell their doctor about the practice, including how intense it is, so the doctor can advise. (4) Do not comment on medicines; refer all medication questions to the prescriber. (5) Record the advice given. [synthesis]
  • Example language (illustrative): "When you feel light-headed coming up from the prostration, that's something your doctor should hear about. It isn't my place to say what's safe for your heart, but I'd like you to have a proper answer."
  • Watch for: minimising ("it's nothing, it passes"), and practising alone after symptoms have occurred. Working: the client has a doctor's view and knows their tradition's options if limits are needed.

4.6 Supporting the tradition's own adapted forms

  • Purpose / when: when health, age, pregnancy, disability or space limits full prostration, the client may feel they are failing. Many traditions publish lighter or adapted forms. [source: as below]
  • What the traditions publish: Samdhong Rinpoche says that the sick, the elderly or those unable to prostrate may make a slight bow with joined thumbs, which still counts, and that the requirement to rise straight does not apply to someone who is unwell. YoWangdu describes partial and symbolic forms and, for someone with a spinal injury, recommends consulting a teacher and mentions visualising prostrations. The ROCA article asks that the elderly or infirm who only bow should not be judged. Dar al-Ifta permits a sick person to pray seated and to indicate bowing and prostration as they are able. [source: Samdhong Rinpoche; YoWangdu; ROCA; Dar al-Ifta]
  • Steps: (1) Ask whether the client knows of an adapted form in their tradition. (2) Invite them to ask their teacher, priest, imam or guru, and do not rule on it yourself. (3) Explore any feelings of loss or inferiority about the adapted form. (4) Revisit after they have spoken with their teacher or clergy. [synthesis]
  • Example language (illustrative): "Some teachers in your tradition say that a smaller bow made with a sincere mind is still a full offering. Would it help to ask your lama how that applies to you?"
  • Watch for: the client rejecting every adapted form as "not enough", which may point to scrupulosity. Working: relief, and practice continues within medical advice.

4.7 Scrupulosity: assessment and ERP coordinated with the faith leader

  • Purpose / when: prostration can become a compulsion. Examples include repeating a prostration until it "felt right", fearing that a hurried or distracted prostration is invalid or sinful, keeping exhaustive tallies, or being unable to stop despite pain. The IOCDF describes scrupulosity as OCD centred on religious or moral fears. Its features are a demand for certainty, over-focus on minor points of practice, or avoidance of practice altogether. [source: IOCDF]
  • Steps: (1) Separate values-driven from fear-driven practice. The IOCDF contrasts faith rooted in meaning, peace, hope or gratitude with faith driven by fear, obligation, guilt or shame. (2) Assess for OCD with standard clinical methods. (3) With the client's consent, contact their faith leader. The IOCDF asks faith leaders to avoid accommodation such as repeatedly answering "correct practice" questions, to limit reassurance, to validate the struggle without agreeing that intrusive thoughts are sinful, and to reduce accommodation gradually under a plan agreed with the client and treatment team. (4) Plan exposure and response prevention in your own words with the client, for example making a prostration once and resisting the urge to redo it, or tolerating uncertainty about whether it was "valid". Confirm with the faith leader that each step is within normal religious practice. ERP is standard clinical practice; this pairing with the faith leader is [synthesis] from the IOCDF guidance, which does not name ERP. (5) Help the client re-engage with practice as a value and grieve what OCD took from them, as the IOCDF suggests. [source: IOCDF; synthesis]
  • Example language (illustrative): "Let's look at whether this prostration is something you offer, or something OCD demands. How does it feel when you finish one?" / "Your priest has said one sincere prostration is complete. What would it be like to let that be enough tonight, even with the doubt?"
  • Watch for: reassurance-seeking directed at you ("was that enough?"); answering it is accommodation. Watch for exposures that would ask the client to break a genuine religious obligation; check with the faith leader. Note that people often hide scrupulosity for years out of shame. Working: less time and distress around practice, and fewer repeats and checks, while the client's faith remains intact or deepens.

4.8 Moral injury, guilt and penitential prostration

  • Purpose / when: in traditions where prostration expresses repentance (for example Orthodox penitential prostrations, Tibetan purification practice), a client may use it to carry heavy guilt or shame, or may feel that no amount is enough. [source: ROCA; Samdhong Rinpoche; synthesis]
  • Steps: (1) Explore what the client is seeking forgiveness or purification for. (2) Distinguish proportionate remorse from guilt that cannot be satisfied (which may be OCD, depression or moral injury). (3) Treat depression or trauma with standard evidence-based methods. (4) With consent, involve the confessor or teacher, who can speak to the tradition's teaching on forgiveness and completion. Do not take the confessor's role. [synthesis]
  • Example language (illustrative): "It sounds like the prostrations are carrying something very heavy. Can we talk about what it is, here, alongside what your tradition offers?"
  • Watch for: self-punishment framed as devotion; suicidal thinking (assess following current standards). Working: the client feels the practice now expresses repentance rather than self-punishment.

4.9 Grief, ritual and community

  • Purpose / when: prostration is often communal (temples, liturgies, ordinations). Losing access to it through illness, injury, migration, leaving a community or bereavement can be a real loss, and practising it can support mourning. [synthesis]
  • Steps: (1) Ask about the community setting and who the client practises with. (2) Acknowledge loss when the client can no longer prostrate as before. (3) Explore adapted or communal ways to stay connected (4.6, 4.10). [synthesis]
  • Example language (illustrative): "Not being able to kneel with everyone at the Liturgy seems to have hit you hard. What does it mean to you to be part of that?"
  • Watch for: isolation following injury or conflict with the community. Working: the client feels connected whatever form their practice now takes.

4.10 Collaboration with clergy, chaplains and teachers

  • Purpose / when: whenever the question is one of religious form (whether an adapted form is acceptable, how much is required, what counts as complete) or the client wants spiritual support alongside therapy. [source: IOCDF (faith leaders); ROCA (follow the celebrant); synthesis]
  • Steps: (1) Ask whether the client wants you to collaborate, with whom, and on what. (2) Get written consent and agree what will be shared. (3) Keep roles clear: the faith leader advises on practice, you on mental health, the doctor on physical health. (4) Feed back to the client after any contact. [synthesis]
  • Example language (illustrative): "Would it help if I spoke with your imam about praying seated while your back recovers, so you hear the same message from both of us?"
  • Watch for: the client feeling exposed, or conflicting messages from different helpers. Working: a coherent plan that the client trusts.

4.11 Teacher power, coercion and leaving a group

  • Purpose / when: prostration to a teacher (for example YoWangdu describes prostrating when a teacher enters or leaves a teaching, and dandavat may be offered to a guru) is a normal sign of respect in many traditions. It can also be used to enforce submission in high-control settings. [source: YoWangdu; Hare Krishna Mandir blog; synthesis]
  • Steps: (1) Explore the client's relationship with the teacher or group neutrally. (2) Ask about pressure: punishment by prostration, practice demanded despite injury, threats of spiritual harm or expulsion, isolation from outsiders. (3) If coercion is present, support autonomy and safety planning, and help the client find independent advice within or outside the tradition. (4) For clients who have left, treat religious trauma and loss without disparaging the tradition. [synthesis]
  • Example language (illustrative): "Bowing to a teacher is part of many traditions. I'm curious how it feels for you, and whether you've ever felt you couldn't say no."
  • Watch for: labelling a group without evidence. Use only what reliable reports document. Working: the client can name their own wishes about the practice and the relationship.

4.12 Children and minors

  • Purpose / when: children are often taught prostration at home (YoWangdu notes this for Tibetan families), which is ordinary religious upbringing. Safeguarding concerns arise only where prostration is used as harsh punishment, causes injury, or is part of wider abuse. [source: YoWangdu; synthesis]
  • Steps: (1) Ask about the child's experience and assent at their developmental level. (2) Distinguish ordinary practice from punitive or injurious practice. (3) Follow local safeguarding law and your service's procedures when you suspect harm. [synthesis]
  • Example language (illustrative, to a parent): "Many families pray this way together. I'd like to hear how your son feels about it."
  • Watch for: physical injury, fear, or punishment framed as devotion. Working: the child's voice is heard and the family's practice is respected.

5. Handling problems

Most of the guidance below is [synthesis]; sources are named where they apply.

  • The client asks you how many prostrations are safe or "enough". Do not give a figure. Safety is for the doctor and sufficiency is for the teacher or clergy. Explore what the question means to the client: it may be reassurance-seeking (4.7). (illustrative) "That's a question for two people, your doctor and your teacher. I can help you prepare to ask them."
  • The client keeps going despite pain or symptoms. Name the concern, recommend medical review (4.4, 4.5), and explore what stopping would mean spiritually. Point to the tradition's own permissions for the sick and elderly (Samdhong Rinpoche; ROCA; Dar al-Ifta), and suggest the client confirm them with their own teacher or clergy. [source: those named; synthesis]
  • The client declines to see a doctor. Respect their autonomy. Document your advice, revisit it, and say clearly when to seek urgent help (chest pain, fainting). Ask what makes the doctor feel unsafe; for example, a fear of being told to stop may be the real barrier.
  • The teacher or community insists on full practice despite medical advice. Help the client consider getting a second view from another recognised authority in the same tradition. Assess for coercion (4.11). Do not advise the client to defy their tradition or bypass legitimate teachers.
  • Resistance to ERP ("if I don't redo it, I'll have sinned"). Go back to the faith leader collaboration (4.7). Build a graded plan the client chooses, and use the IOCDF's distinction between values-driven and fear-driven practice. Expect setbacks during holy seasons.
  • Rupture: the client feels you look down on the practice. Acknowledge it, repair, and return to curiosity (4.1). Check your own reactions: unfamiliarity, a different faith, or none. Keep self-disclosure purposeful and brief. [synthesis; Vieten et al. 2013 spiritual and religious competencies [uncertain: not verified]]
  • The client wants to prostrate or pray during a session, or invites you to join. Allow prayer if the space and service policy permit. Decline to participate yourself unless that is clearly in the client's interest; explain that your role differs from that of a teacher or fellow worshipper.
  • Intensive periods (preliminary practices before retreat, pilgrimage, Lent) bring up strong emotion, exhaustion or unusual experiences. Ask about sleep, eating and rest. Screen for depression, mania, psychosis and dissociation without pathologising religious experience. Encourage the client to talk with the teacher about pacing; the tradition, not the therapist, decides the practice. Published research on meditation-related adverse experiences may be relevant when prostration is part of a wider retreat practice (Lindahl et al. 2017, PLOS ONE; Farias et al. 2020, Acta Psychiatrica Scandinavica) [uncertain: not verified]. DSM-5-TR lists a religious or spiritual problem as a focus of clinical attention, code Z65.8.
  • Overwhelm or flashbacks linked to bowing, kneeling or lying face down (for example in survivors of assault or abuse, including abuse within a religious setting). Treat it as a trauma reaction: slow down, give the client choice and control, and use grounding. Support the client in finding a form of reverence that does not trigger them, and in discussing this with their teacher if they wish. [synthesis]
  • Conflict in the family over how much to observe (for example a parent requiring a teenager to prostrate). Use the CFI to understand the different positions. Mediate without siding on doctrine, and consider safeguarding if the practice is punitive (4.12). [source: APA CFI; synthesis]
  • Non-attendance in holy seasons. Plan ahead (4.3). Offer flexible times or a planned break rather than treating absence as disengagement.
  • The client's prostration is to a teacher later named in misconduct reports. Name a teacher as a wrongdoer only where independent investigations, courts, regulators or major news organisations have done so. Documented misconduct by the teachers and institutions cited in this guide: none found in the sources consulted. Help the client process betrayal and decide for themselves about continuing the practice.

Sources

Web sources

Also cited

  • Yilmaz et al. 2008; Tangtrakulwanich et al. 2006; Jokarborzabad et al. 2021 (as cited in the NCT06190769 protocol).
  • Vieten et al. 2013, spiritual and religious competencies for psychologists [uncertain: not verified].
  • Lindahl et al. 2017, "The varieties of contemplative experience", PLOS ONE; Farias M et al. 2020, Acta Psychiatrica Scandinavica [uncertain: not verified].
  • 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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