Ayahuasca and Spiritual Crisis: Liminality as Space for Personal Growth
This anthropological analysis of phenomenological case reports examines how ayahuasca ceremonies occasion liminal spaces, wherein participants undergo a period of transformation characterized by the process of stripping away one's prior beliefs, identity, and social status, which can also lead to the emergence of spiritual crises. On the basis of a case study within the context of ayahuasca tourism, the authors highlight the need for clinical support to integrate challenging experiences through the exploration of their spiritual and psychological meaning.
Abstract
There is an increased controversy surrounding Westerners' use of ayahuasca. One issue of importance is psychological resiliency of users and lack of screening by ayahuasca tourism groups in the Amazon. Given the powerful effects of ayahuasca coupled with lack of cultural support, Western users are at increased risk for psychological distress. Many Westerners who experience psychological distress following ayahuasca ceremonies report concurrently profound spiritual experiences. Because of this, it may be helpful to consider these episodes “spiritual emergencies,” or crises resulting from intense and transformative spiritual experiences. Although the author warns readers to avoid romantic comparisons of Western ayahuasca users to shamans, ethnographic data on indigenous shamanic initiates along with theory on liminality may be of some use to understand difficult experiences that accompany ayahuasca use. Given that psychotherapy is culturally sanctioned, therapists trained in treating spiritual crises can help Western ayahuasca users make meaning of their distress. Three case studies are offered as examples of individuals working through various sorts of crises following ayahuasca ceremonies.
Research Summary of 'Ayahuasca and Spiritual Crisis: Liminality as Space for Personal Growth'
Introduction
Abramson frames the paper within a rising Western interest in non-Western healing and spiritual practices, using ayahuasca — a traditional Amazonian botanical brew combining Banisteriopsis caapi and Psychotria viridis (and sometimes other potent plants such as brugmansia) — as the focal example. The introduction summarises that ayahuasca commonly produces powerful, often spiritual experiences (visions, perceived spirit contact, death-rebirth imagery) that may sit uneasily with Western worldviews and social norms. Because many Western users undertake ceremonies without embedded cultural supports, the author highlights an increased risk of acute psychological distress following ceremonies; yet these same distressing episodes are often appraised by participants as having deep spiritual significance. The study sets out to explore these difficult post-ceremony episodes through ethnographic, phenomenological case material and clinician interviews, and to interpret the material through the anthropological concept of liminality. Abramson aims to show how what clinicians and lay Westerners may label as psychopathology can also be understood as a ‘‘spiritual emergency’’ or liminal phase that, if worked through with meaning-centred therapeutic support, can lead to personal growth and identity transformation. The paper uses three American case studies and interviews with US clinicians to illustrate experiential trajectories and clinical implications.
Methods
The investigation is qualitative and ethnographic. Abramson conducted in-depth interviews with three US individuals who experienced significant psychological distress after participating in ayahuasca ceremonies; each informant was recruited via personal contacts, participated voluntarily, and was assigned a pseudonym (Emma, Sophie, Will). The author also interviewed a number of US clinicians for professional perspectives; named clinicians in the text include Carol Kats (LCSW), Dawna Gutzmann (MD), and Thomas Kramer (psychiatrist and clinical director). The extracted text does not clearly report the total number of clinician interviews or formal ethical approvals. Analysis proceeds as phenomenological case description combined with theoretical interpretation. Abramson situates participants' narratives against anthropological theory of rites of passage and liminality (notably Victor Turner’s threefold scheme of separation, liminality, and reaggregation), and draws on literature on ‘‘spiritual emergencies’’ (Grof, Lukoff) and shamanic initiation. The methods therefore emphasise rich narrative accounts, clinician commentaries, and theoretical synthesis rather than formal coding procedures or systematic qualitative analytic techniques; the extraction does not detail specific analytic steps such as thematic coding or triangulation.
Results
Abramson presents three detailed case narratives and synthesises recurrent themes from participant accounts and clinician interviews. Emma: A woman in her mid-twenties with prior ayahuasca experience (eight ceremonies over three years) reported a single ceremony in which she sequentially experienced states she described as analogous to a wide array of mental disorders — severe panic, paranoid delusions, auditory and visual hallucinations, profound depression, catatonia, obsessive-compulsive states, mania, and dissociation — across an approximately eight-hour episode. In the subsequent weeks she believed she was experiencing other people’s mental illnesses and described a severe erosion of personal boundaries (for example, feeling ‘‘flooded’’ by others’ emotions while walking in public). This period progressed into severe depression with suicidal ideation; she sought help from a clinical psychologist who diagnosed an induced major depressive disorder with psychotic features. Emma rejected a strictly pathological reading and, over time, reported gaining insight and a sense of being ‘‘called’’ to become a healer, interpreting the crisis as catalytic for a vocational reorientation. Sophie: A woman in her late forties and an apprentice to a Peruvian curandero, Sophie had undertaken a three-month dieta and numerous ayahuasca ceremonies (30–40 over six years). After a ‘‘closing’’ ceremony with a reportedly large dose, she described being profoundly incapacitated during the session and ‘‘crashing’’ the next day into severe hopelessness and disconnection from family, work and apprenticeship; she believed she might have required hospitalisation or medication had the state persisted. Sophie questioned whether the episode was part of a shamanic initiation, whether it signalled failure to be chosen, or whether a neurochemical imbalance had been precipitated by the ceremony and dieta. Will: A man in his early thirties with a significant history of depression who self-administered ayahuasca (and used psilocybin) outside formal ceremony reported increasing isolation, marital breakdown, worsening depression and suicidality, eventually leading to psychiatric hospitalisation and antidepressant treatment. Will described a lack of social understanding for his experiences and an unsatisfactory encounter with conventional psychotherapy. Cross-cutting findings: Abramson identifies recurrent motifs across cases: intense spiritual or ‘‘call’’ experiences concurrent with severe psychological symptoms; participants’ ambivalence between pathological and transformative interpretations; the exacerbating role of minimal cultural support in Western contexts; and the potential for crisis to function as a liminal, knowledge‑producing period leading to identity change. Clinician perspectives varied: some (e.g. Gutzmann) framed symptoms as opportunities for growth, whereas others (e.g. Kramer) invoked a stress‑diathesis model, seeing ayahuasca as a stressor that may reveal latent vulnerability. The paper also notes systemic gaps in clinical training on religious/spiritual issues and references the DSM code V62.89 (Religious or Spiritual Problem) as recognition of the phenomenon.
Discussion
Abramson interprets the case material through liminality: spiritual crises following ayahuasca ceremonies are conceptualised as transitional, ‘‘betwixt and between’’ phases in which former identities and explanatory frameworks are dissolved, creating both acute vulnerability and a capacity for deep knowledge acquisition or ‘‘gnosis.’’ The author argues that the three-stage rite-of-passage model (separation, liminality, reaggregation) helps explain how distressing experiences can nonetheless produce lasting personal transformation when integrated. The paper contrasts Western users with traditional shamanic initiates: while ethnographic literature shows that shamanic callings often involve illness-like episodes that are culturally framed, supported and integrated by elders and ritual specialists, Western users typically lack such scaffolding. This absence of culturally sanctioned meaning can magnify distress and the risk of misdiagnosis. Abramson emphasises that spiritual emergencies are not synonymous with psychiatric disorder and that clinicians should focus on meaning-making and integration rather than immediately pathologising experiences. Interviews with clinicians illustrated divergent responses in practice: some clinicians pursue additional training in spiritual and transpersonal approaches and view crises as therapeutic opportunities, whereas mainstream psychiatry commonly relies on diagnostic and medical models (and insurance coding) that may default to conventional pathology-based care. Key limitations and uncertainties are acknowledged in the extracted text indirectly: the narratives are drawn from a small, purposive sample recruited via personal contacts and the analysis relies on theoretical interpretation rather than systematic qualitative methods; the extraction does not provide comprehensive details on the clinician sample or formal analytic procedures. Abramson stresses that not all ayahuasca use leads to harm and that there is emerging clinical interest in therapeutic applications (for example, addiction), but cautions that ayahuasca is not risk‑free and may be inappropriate for some individuals. The author recommends that psychotherapists develop sensitivity to religious and spiritual issues and that treatment for spiritual crises emphasise exploration of meaning, cultural context, and careful support for integration.
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I N T R O D U C T I O N
There is currently a trend in the West to explore non-Western forms of healing and spirituality. The use of ayahuasca, a botanical hallucinogenic brew used in South America, is one example that has been of considerable interest to both academic scholars and members of the general public. Ayahuasca is drunk by curanderos (shamans) who enter nonordinary states of consciousness to cure illness, combat (or perform) sorcery, prophesize, or engage in other spiritual activities. Westerners who drink ayahuasca may have powerful experiences (communicating with spirits, experiencing one's own death, clairvoyant experiences, and so forth), which are often experienced as spiritual in nature and may be incongruent with their worldview and normative cultural value system. In this article, I discuss how these experiences can lead to acute psychological distress, and yet how the crisis itself can be a source of insight, personal growth, and overall positive transformation. I will give the phenomenological accounts of three people I interviewed, all of whom suffered from psychological distress following an ayahuasca ceremony. All of these informants stressed the religious or spiritual significance of this distress. Their experiences suggest that distress was a necessary catalyst for a transformation leading to personal growth. I also interviewed a series of U.S. clinicians to gain perspective on religious and spiritual issues in psychotherapy. The clinicians themselves argue that much more training on religious and spiritual issues is necessary. To articulate the transformation process, and conceptualize my data, I draw upon classic anthropological theory involving liminal states. Liminality accurately reflects the crisis period experienced by my informants and helps to explain how even radical shifts in identity and worldview are possible. Liminality is discussed generally in regard to small-scale, traditional or indigenous groups. I argue that this theoretical model is also applicable to transitional states in contemporary Western society. Victorsuggests three phases of ritual experience (separation, liminal phase, reaggregation) that articulates clearly the transformation some people experience as a result of crisis following ayahuasca ceremonies. Although there are loose similarities between indigenous shamanic initiates and crisis experiences of Western ayahuasca users, it is essential to avoid a romantic comparison of the two groups as some have done (see, e.g.,. Quite unlike shamanic initiates, Western ayahuasca users have little cultural support and guidance within which to contextualize their powerful experiences. All of my Western informants feared they had become seriously mentally ill as a result of the acute and debilitating distress they struggled to understand. Indigenous shamanic initiates, on the other hand, have the support of the master curandero (as well as their family, community, and culture at large), who helps the initiate to integrate and understand the distress that invariably results from ayahuasca. I argue that for Westerners who use ayahuasca in any number of various forums available, psychotherapy (a culturally sanctioned institution) has the potential to help individuals make meaning of their experiences and integrate them into culturally relevant methods of learning. The use of ayahuasca outside traditional South American context takes many forms. Researchers in disciplines such as psychology, psychiatry, neuroscience, and ethnobotany have become interested in the therapeutic potential of the brew. Much of the Western research on using ayahuasca in psychotherapy focuses on treating addiction 1, although many psychotherapeutic areas are considered. Laypeople around the globe have also developed an interest in ayahuasca. While some wish to simply experiment recreationally, most state that their intention is a serious desire to have a spiritual experience of some kind. Travel groups have sprung up around the Amazon at extraordinary rates where tourists can participate in ayahuasca ceremonies. Most of these travel packages advertise ''native shamans'' and an authentic indigenous healing ceremony. These tours are extremely controversial, with indigenous Amazonians and Western anthropologists as the strongest critics (Dobkin de Rios 1994. Although ayahuasca is an extremely powerful hallucinogen (seefor pharmacological description), its danger is not physical. It has been used for millennia and is not considered a toxic substance 2; rather, potential danger is psychological in nature. Curanderos state they use the substance to leave their bodies, travel to spiritual realms, and engage with spirits. In a similar vein, many people (regardless of culture or religion) seem to have profound spiritual experiences when they drink ayahuasca. Although the ceremonies can be difficult to endure, people emerge feeling cleansed, revived, and empowered. It is also important to note that not all ayahuasca brews are the same. Ayahuasca is an admixture of two plants, banisteriopsis caapi and psychotria viridis, which combines monoamine oxidase-inhibiting b-carboline alkaloids with N,N-dimethyltryptamine (DMT), a psychedelic agent showing 5-HT2A agonist activity. Other psychoactive plants are sometimes mixed in to increase potency. Most notably, brugmanisa, a flowering tree plant belonging to the Solanaceous genus (similar to the Datura genus) is added, making the brew significantly stronger. Brugmanisa is known to produce piercingly strong and clear visions and is known among curanderos as an extremely powerful plant. If ingested in toxic doses, brugmanisa causes. Ayahuasca brews containing brugmansia and other powerful plants increase the risk of psychological distress, particularly among naı ¨ve users. The psychological distress reported by Westerners who use ayahuasca is complex and should not be reduced to theories about ''bad trips.'' While the idea of ''trauma'' is almost always linked to a negative stressor, a person can be traumatized as a result of a powerful positive experience as well. Religious and spiritual experiences are sometimes so profound that one is unable to cope and might develop distressing psychological symptoms as a result. A new diagnostic category, Religious or Spiritual Problem (Code V62.89), has been included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) to address psychological symptoms concurrent with religious or spiritual issues (American Psychiatric Association 2000). David Lukoff, a psychologist specializing in the treatment of religious and spiritual crises in a therapeutic context, describes religious problems as those involving ''conflicts over the beliefs, practices, rituals and experiences related to a religious institution'' and spiritual problems as those involving ''distress associated with a person's relationship to a higher power or a transcendent force that is not related to a religious organization'. This category was added to the DSM-IV based on extensive literature documenting the frequent occurrence of religious and spiritual problems in clinical practice. It was also developed at the urging of more transpersonal and humanistic psychologists who have been discussing ''spiritual emergencies'' for decades. Stanislov and Christina Grof who coined the term ''spiritual emergencies'' define them as: Crises when the process of growth and change becomes chaotic and overwhelming. Individuals experiencing such episodes may feel that their sense of identity is breaking down, that their old values no longer hold true, and that the very ground beneath their personal realities is radically shifting. In many cases, new realms of mystical and spiritual experience enter their lives suddenly and dramatically, resulting in fear and confusion. They may feel tremendous anxiety, have difficulty coping with their daily lives, jobs, and relationships, and may even fear for their own sanity.Individuals dealing with spiritual emergencies often seek clinical treatment for their anxiety and other distressing symptoms that happen as result of this tumultuous period. Because of this, it is necessary that these issues be addressed by clinicians and coded in the DSM. Lukoff argues that someone working through a spiritual emergency may ''appear to have a mental disorder if viewed out of context, but are actually undergoing a 'normal reaction' which warrants a non-pathological diagnoses (i.e., a V Code for a condition not attributable to a mental disorder)''. In other words, distress is a normal response to a stressful event and should be treated as such. Spiritual emergencies differentiate transformational crises from psychiatric disorders. These reactions are often quite severe, ranging from depression, to dissociative problems, to florid psychosis. While symptoms should be treated appropriately and taken seriously, it is important to bear in mind that a religious or spiritual experience is the etiology of the distress. In the West, psychological symptoms are treated as ''attacks'' on the healthy mind, and things to rid oneself of as quickly as possible. The psychological distress associated with spiritual emergencies, however, may be an opportunity for deep healing and transformation.articulates a particular type of spiritual emergency he calls a ''shamanistic 3 initiatory crisis.'' This is characterized by a nonshaman who has various spiritual experiences analogous with shamanic activities, such as the ability to diagnosis illness (psychically), awareness and communication with spirits, or the experience of leaving one's body and ''traveling'' to other realms. Ayahuasca can often be a catalyst for a shamanistic initiatory crisis. I argue that non-Amazonian people who experience shamanistic activities during an ayahuasca ceremony are at risk for spiritual emergencies due to lack of cultural support. In places throughout the Amazon where ayahuasca is used ritually and/or medicinally, the worldviews of these cultures support and validate experiences one has in the ceremony; it is considered possible to leave one's body, communicate with spirits, and ''see'' illness in oneself and others. If one has experiences that are not culturally sanctioned, one is more likely to experience some kind of distress and feelings of isolation. Concepts of normalcy and pathology are at least, in part, defined by cultural context. A Westerner having shamanistic experiences violates cultural concepts of normalcy. This can produce anxiety in and of itself. Many people believe they are going crazy if they have religious or spiritual experiences that are inconsistent with cultural norms. Furthermore, if one is involved in treatment by a clinician who does not take the spiritual aspects of the situation seriously, it follows that the patient becomes even more likely to view himself as mentally ill and disordered. Stanislov and Christina Grof argue ''[i]t is essential that [people dealing with spiritual emergencies] move away from the concept of disease and recognize the healing nature of their crisis'. Many Western clinicians are not accustomed to treating their patients outside of a disease model and are thus not trained properly to work with patients coping with spiritual emergencies. In a survey of Association of Psychology Internship Centers training directors, ''83reported that discussions of religious and spiritual issues in training occurred rarely or never. One hundred percent indicated that they had received no education or training in religious or spiritual issues in clinical training'' (cited in. Although patients present with familiar symptoms ranging from depression to paranoid delusions, the etiology of the symptoms is unfamiliar territory. This marks a slew of moral and ethical clinical issues. If the clinician's own religious beliefs prevent him or her from believing that the patient had a near-death experience or communicated with a dead relative, for example, the question remains if the clinician will provide optimal therapy. Among the clinicians I interviewed, there seems to be agreement that more training and sensitivity is needed in the profession. In some ways, psychiatry and psychology, as disciplines, have always struggled with religion. Freud saw religion as ''a universal obsessional neurosis,'' and indicative of infantile narcissism. I argue that treating the spiritual experience as unreal is not an effective way to help patients manage, analyze, and integrate their transformative experiences. On the other hand, one must be wary not to romanticize spiritual experiences, or even mental illness, itself, as some have done. As Tanya Luhrmann has expressed in the introduction of her book, Of Two Minds: The Growing Disorder in American Psychiatry, it is considered fashionable in some intellectual circles to say that mental illness does not really exist at all (2000:10). Romantic sentiments are felt, and these people declare it is our oppressive society that stifles the creative and mystical visions of the mentally ill by labeling them as such. In this paper, I argue that individuals suffering a spiritual crisis are not shamans and are in real distress. Some people remain in so-called mystical or visionary states for days, weeks, or even longer, following an ayahuasca experience. Although this may sound like an enlightening experience, it can be extremely frightening and debilitating. On a purely theoretical level, I do not completely disagree with,,, and others who argue that there are no behaviors inherently pathological (or normal). On a more pragmatic level, however, those individuals coping with a spiritual crisis usually experience phenomena that is considered abnormal (if not pathological) by Western cultural standards. While this is not necessarily indicative of mental illness, it does suggest that these individuals might experience high levels of distress and could benefit from clinical treatment. It is important to note that many Western ayahuasca users do not experience psychological distress and indeed there is tremendous clinical potential in ayahuasca use. There is extremely promising research under way exploring its therapeutic effects on drug addicts, for example (see. I do believe, and argue in this paper, that ayahuasca opens the doors to many spiritual experiences that are extraordinarily valuable. It is imperative to consider, however, that individuals who have these experiences might experience difficulty if their worldview and normative cultural values do not support these powerful experiences. While some suffer psychologically, my data suggests that transient distress associated with ayahuasca can lead ultimately to personal growth and positive transformation. & a c c o u n t s o f s p i r i t u a l c r i s e s f o l l o w i n g a y a h u a s c a c e r e m o n i e s I offer the accounts of three Americans who claim to have suffered spiritual crises following ayahuasca ceremonies in order to cultivate a sense of what these kinds of experiences are like, phenomenologically. I will describe briefly each informant, including a summary of the spiritual crisis. These participants were recruited through personal contacts, and their participation was purely voluntary; each person has been given a pseudonym to protect his or her anonymity.
EMMA
Emma is a woman in her midtwenties. She had participated in eight ayahuasca ceremonies with Peruvian curanderos over a period of 3 years before the particular ceremony leading to her spiritual crisis. Emma reports that she never experienced any psychological symptoms that worried her or caused her to seek treatment in the past. During the ayahuasca ceremony that caused the subsequent distress, Emma reports that she systematically experienced a wide variety of mental disorders and symptoms including severe panic, paranoid delusions, auditory and visual hallucinations, 4 profound depression, catatonia, obsessive compulsions, mania, and dissociative symptoms. The various states continued, one by one, for a period of approximately 8 hours. Emma states she was shattered by this experience but that she had the sense all the while that it was ''meant'' to happen. For several weeks following the ceremony, Emma suffered from what a Western clinician might term ''delusions.'' She believed that she was experiencing other people's mental illnesses. Her sense of personal boundaries had become so fluid that she felt she could not keep from feeling others' experiences. For example, she had a difficult time walking down the street as she felt ''flooded'' by others' depression or anxiety as she walked past them. During this time period she was on an airplane and claims to have felt the anxiety attack of a woman located three rows behind her; she could identify the actual woman. Emma says that this anxiety was not ''hers,'' but rather, someone else's. After existing in this state for 3 weeks, Emma fell into a severe depression. She found it difficult to leave her apartment. Although Emma had never been in therapy, she felt she needed professional help. The depression became so severe that she had suicidal ideation and fantasized about cutting herself and stabbing herself with knives. The desire to cut and stab herself came from severe bouts of depersonalization. Emma reports that she saw a clinical psychologist who felt she induced a major depressive disorder with psychotic features as a result of taking the hallucinogen. She rejected this diagnosis believing there was something important she needed to learn. As Emma worked through the crisis, she had tremendous amounts of insight on healing and realized that she had a ''calling'' to be healer. In particular, she felt she needed to make a career change and become a clinician, herself, to work with the mentally ill.
SOPHIE
Sophie is a woman in her late forties. She does work on ayahuasca as part of her professional career and is also an apprentice to a Peruvian curandero. Like Emma, Sophie states that she has no history of mental illness. As part of formal apprenticeship, she started a 3-month traditional diet where she ingested a ''teacher'' plant (nonhallucinogenic) every day and abstained from sugar, salt, pork, shellfish, particular fruits and vegetables, alcohol, and sexual activity. ''Closing'' a diet is a special type of ayahuasca ceremony where the curandero transmits knowledge directly into the apprentice. Sophie had drunk ayahuasca approximately 30-40 times in ceremonies over 6 years before the closing of the diet triggered a spiritual emergency. Although she attributes this particular ceremony with her crisis, she says that some issues might have begun earlier and been rooted in fears and doubts she had about her apprenticeship. Sophie reports that she was given a very large dose of ayahuasca and was so ''far out there'' that she could not move, speak, or even think. She was able to observe the situation, however, and remembers ''thinking'' that this must be what dying is like: the lights are going out, your body won't respond, and you lose the ability to think. The next morning she reports she ''crashed.'' The world felt empty and hopeless; she did not care about her family, her job, her apprenticeship, or herself. Sophie says if this had persisted she knows she would have had to been medicated, and most likely hospitalized. She reports that she had an understanding for the first time how someone would prefer suicide to life.
WILL
Will is a man in his early thirties. Unlike Emma and Sophie, Will states that he has a significant history of depression and, indeed, seeks out hallucinogens as an attempt to cure his mental suffering. He purchased the ingredients to make ayahuasca off the Internet and did not use it in a formal ceremony with a curandero. He uses ayahuasca and psilocybin (hallucinogenic mushrooms) a few times a year. Although Will felt he was acquiring spiritual knowledge from the use of these substances, he states that he became isolated and could not incorporate this knowledge into his current life in a Western context. Will's wife eventually divorced him because she could no longer relate to him. She found his spiritual beliefs odd and considered his ''drug use'' problematic. Upon his wife leaving him, Will's depression, anxiety, and suicidality increased, motivating him to check into a psychiatric hospital and begin a course of antidepressant medication. Will describes a negative experience with a clinical psychologist, with whom he was unable to process this distress. I use these phenomenological accounts as case studies to articulate my argument that spiritual crises following ayahuasca ceremonies often lead to profound transformation and personal growth, but that there are serious psychological risks involved. It is important to note that not everyone who drinks ayahuasca has spiritual emergencies. Far from it, it has been widely documented the extent to which Westerners have placed high positive value on their experiences (see, e.g.,. Because there is risk associated with ayahuasca, however, it is important to document its problematic aspects as well. I will begin my analysis with a theoretical discussion of liminality and transition. At the end of the article, I address personal and spiritual transformation in psychotherapy, specifically describing how clinicians can help their patients manage and make meaning of spiritual crises.
& L I M I N A L I T Y A N D T R A N S I T I O N
Theory on liminal states stem from Arnold van Gennep's work on rites de passage. This work has been expanded on by anthropologists, beginning in the 1960s, focusing mostly on initiation rituals, and other highly symbolic activities. Victor Turner, a major figure in anthropology, employed theory on liminality to analyze ritual practices and rites of passage among Ndembu in his seminal work, The Forest of Symbols: Aspects of Ndembu. According to Turner, rites of passage mark transitions between states. Examples of these states include changes in legal status, professional calling, and culturally recognized states of maturation such as states of infancy or adulthood. The transition is ''a process, a becoming, and in the case of the rites de passage even a transformation''. This transformation moves a person from one particular and distinct category to another particular and distinct category. Rites of passage are marked by three phases: separation, liminality, and reaggregation. The separation phase is necessary to detach one from his or her previous state, which was marked by a fixed point in social structure or set of cultural conditions. When suddenly detached, the individual or group has an ambiguous identity. This ambiguous stateFwhere one exists betwixt and be-tweenFis known as the ''liminal phase.'' In the liminal state, one ''passes though a realm that has few or none of the attributes of the past or coming state''. Finally, in the third phase, reaggregation, one's identity and role in society is reshaped, and he or she is reintroduced to society as a ''new'' self. This three-stage process moves a person (or group) from one distinct category to another. Many theorists interested in rites of passage focus on the liminal phase. Here, too, I will pay special attention to ideas about liminality. There is a particular vulnerability ascribed to those existing in liminal states. While vulnerability is most often associated with negative or traumatic phenomena, its true meaning is simply a state of existence where something can happen. Turner describes the period of marginality or liminality as an interstructural situation (1967:93), where one is ''no longer classified and not yet classified'. Only in a state of vulnerability can one's actual structure or selfhood be threatened and ultimately changed. This change is usually a move into a higher or more prestigious status, such as a position in a secret society or political office. Although one can move from a ''lower'' status to a higher one as a result of ritual experience, this period is marked by anxiety, discomfort, pain, or altered states of consciousness. The neophyte is stripped of his or her ''familiar structural position, and consequently from the values, norms and sentiments, and techniques associated with these positions. They are also divested of their previous habits of thought, feeling, and action''. Emma states that her way of looking at the world, and also at herself, have been permanently altered as result of the ayahuasca ceremony: Things I thought were impossible were suddenly possible, only I didn't know what to make of it all. It was as if I was suddenly infused with a power I just didn't have before. I took certain norms for granted, you know, like everyone else. Cultural norms, I guess, and things proven by science. I suddenly had all these new ideas and feelings about the universe, and about myself. These ideas just became available, like I had access to a body of knowledge that I didn't have access to before. It was hard to take it in and know what to do with it. I literally felt like my mind had been blown, this knowledge was so immense. Even while dreaming I felt I was constantly analyzing and coming to understand things about the universe, in fact, my consciousness while dreaming seemed more analogous to what it feels like drinking ayahuasca, than ''normal'' dreams. Turner, as well, considers the liminal state a ''stage of reflection''. Emma makes it clear that she has not yet fully processed her new ideas and feelings but is nonetheless acknowledging and reflecting upon them. This liminal period, as mentioned above, has historically been associated with distress. In particular for Emma, her distress was psychological. She describes being profoundly depressed and dissociative. Her mental state was not only experienced as abnormal, subjectively, but when she visited a clinical psychologist, she was diagnosed as having induced a major depressive event. The psychologist felt she needed mood-stabilizing drugs to restore her health. In Will's situation, as well, he was prescribed psychiatric medication. Although he did not believe he had a mental illness, he had become so isolated and unhappy, he explains, that he felt medication might save him from suicide. Emma was resistant to psychiatric medication and to the conventional clinical treatment she received in general. Although she was in distress, Emma reports that she had the sense she had been ''called'' by a divine force. During the powerful ayahuasca ceremony where she systematically experienced a wide range of mental illnesses, she believes she could have made it stop but chose to let it happen because of the overwhelming feeling of being ''called'' to continue. In the following weeks, this sense of ''calling'' became stronger as she realized she had been called as a healer. Experiencing mental illness, both during the ceremony and for a period afterwards, was necessary to develop a profound and deep sense of empathy that is necessary in healing work. Emma's narrative treads perilously close to a long-standing debate in anthropology over shamanic initiation and illness. In many shamanic cultures, there is a strong suggestion that the period of ''calling'' or initiation of shamans often involves overcoming a debilitating physical or mental illness. s h a m a n i c i n i t i a t i o n a n d i l l n e s s Shamanism, and in particular, the initiation of shamans, has been linked with mental illness in some Western interpretations. Philip Bock states that ''some anthropologists feel that the irrational beliefs and bizarre behaviors of shamans indicate a severe psychological instability that has been channeled by their cultures into an acceptable role'. Although this position is considered outdated and ethnocentric, anthropologists have historically considered shamans inherently neurotic or psychotic. I argue, however, that strange behavior with mystical characteristics does not make one a practicing shaman. Shamans enter into altered states at will and with particular purposes. According to Holger Kalweit, ''shamanic cultures make a clear distinction between people who are shamans and those who are sick or crazy'. It is the case, however, that some shamans seem to discover their ''callings'' upon falling ill. More particularly, there is usually an illness or crisis situation where ''successfully overcome and completed, it results in personal healing, superior social functioning, and the development of shamanic abilities''. It is therefore a mistake to assume that those persons who are shamans are inherently ''mentally deranged,'' as Devereux and others have argued. The process of illness followed by healing is often a source of learning and transformation in shamanic initiation. In many shamanic cultures, people do not willingly decide to become shamans as if it were just another vocation. They are often ''called'' by a divine source. For example, Vilmos Dioszegi, a Hungarian explorer, has collected accounts of Siberian shamanic vocations experienced as a result of sickness. One shaman Dioszegi interviewed says, ''the man chosen for shamandom is first recognized by the black spirits. The spirits of the dead shamans are called black spirits. They make the chosen one ill and then they force him to become a shaman'. The act of becoming a shaman is discussed in such a way that it seems like more of a birthright than an occupation one may choose. Many groups stress the painfulness of the budding shaman's psychic experiences during initiationand also in practice. There are many ethnographic examples illustrating the degree to which shamanic callings are taken seriously by the community. Becoming a shaman can be a freighting and dangerous path. One becomes subject to spirit attacks and warfare with other shamans who might be jealous of one's power and status in the community. In some cases, people called to be shamans even try to reverse their calling, for example, ''[a]mong the Sedang Moi, a person who receives the 'call' may even drink his own urine in the hope that this act will so deprecate him in the sight of his divine sponsors that they will take back the power they had given him''. While some may resist their calling, it is known in shamanic communities that there can be grave consequences to do so. The Mohave, for example, believe that if a potential shaman refuses his calling, he will become insane. Mental illness in relation to ''callings'' is compelling in that (1) a shaman may discover his or her calling as a result of overcoming severe psychological symptoms, (2) a person who refuses a call to become a shaman may become mentally ill as a result, and (3) a person acting ''like'' a shaman, who is not one, may be described as mentally ill. It is not surprising, therefore, that shamanic callings are often discussed, inextricably, with mental illness. In looking at phenomenological accounts of people who describe themselves as healers, it seems that the ''call'' or path for healing is sometimes discovered as a result of illness or suffering, even in Western culture. Emma felt that her experience of mental illnesses during the ayahuasca ceremony and her subsequent depression and ''delusions'' brought her to the realization that she wanted to be a healer and to specifically treat people with mental illness: I had no desire, previously, to have a career in clinical work. It just became apparent that I was meant to be a healer. It was almost as if I had known it all along, only I didn't realize it. I see this as a calling that I can't refuse. Not that I want to refuse, but even if I did, it doesn't feel like I have that option. When I described this phenomenon to Carol Kats, a licensed clinical social worker I interviewed, she confided in me that she, herself, found her ''calling'' as a healer as a result of an illness. Kats realized she wanted to be a psychotherapist as she recovered from third-stage melanoma. It has become her philosophy that sometimes illness is necessary to bring one to an ultimate place of healing: For a whole month I didn't know if it [cancer] spread all over my body, if I was going to die. It was the opportunity to move me towards healers . . . it also opened doors for me because it was the opportunity for me think, ''okay, now say my life was going to be over. What did I not do? What was missing?'' So this is all free time now, because I overcame. [I say to myself,] do whatever you want! Well, this was my heart's desire. I wanted to work with the intuitive and heal. But I had to go through that [surviving cancer] to be healedFto get in touch with my healerFself. I consider myself a healer. Like the ethnographic accounts of indigenous shamanic callings, Kats not only had to overcome a potentially life-threatening illness, but also considers her ''realization'' of herself as a healer as a type of rebirth into her proper place in the world. In many ways this is consistent with ethnographic data on shamanism, and in particular with the idea that death-rebirth scenarios are common among initiates. The old ''self '' must die so that this more true (shamanic) ''self '' may emerge. According to Kalweit, many budding shamans have, ''visionary experiences of descent into the underworld, attacks from demons, and inhuman tortures and ordeals followed by a sequence of dying and being reborn and subsequent ascent into celestial realms'. Returning to the function of liminal states, the initiate ''dies'' symbolically, in order to be reborn into a higher status. Franz Boas, who worked with the Kwakiutl Indians, recounts the experience told to him by a shaman who says he had ''always doubted and been critical of shamans.'' Nonetheless, this individual was ''called'' to be a healer. Part of ritual ''death'' in initiation involves the destruction of previous identity and worldview. While hunting one day, this man helped an injured wolf. The wolf then visited him in a dream and gave him magical power to be a successful hunter, in return for his help. Later, the hunter and his associates fell ill with smallpox. The hunter was the only one who survived; he had a vision that: Two wolves came trotting along and began to lick him. They vomited foam all over his body, which they licked off again, only to vomit more foam over him. They continued to do this until he felt stronger. Then he recognized the wolf he had once saved.Some time after his restoration the hunter was visited again by the wolf in another vision. During this visit, the wolf vomited all his magical forces and power into the hunter, instilling the power to heal, power to project energy that makes people ill, and the ability to catch lost souls. It was at this point the hunter became a shaman. This account illustrates the process by which the initiates' identity is reformulated. He is also literally saved from death by the wolf who initiates him into shamanism. This narrative is characteristic of death-rebirth phenomenon in shamanism. The symbolism associated with liminal states and transformation are often those same symbols associated with death, destruction, pollution, or decomposition. The status of shaman is so distinct and laden with specific meaning, duties, and responsibility that a total death of former identity is sometimes necessary. The association of death and destruction in liminal states, albeit symbolic in most cases, is consuming and anxiety provoking for those individuals who experience it. Turner describes a neophyte ashe or she may be treated, for a long or short period, as a corpse is customarily treated in his or her society''. Neophytes in the liminal phase are ascribed characteristics of the dead, including various skills and modes of being, existing, thinking, and experiencing. They are sometimes forced to lie down in positions that the dead are usually placed, dyed black, or likened to earthen states. After considered symbolically dead, the initiates are regarded in terms modeled on processes of gestation and parturition. The neophytes are likened or treated as embryos, newborn infants, or sucklings by symbolic reference. The essential feature is ''that the neophytes are neither living nor dead from one aspect, and both living and dead from another. Their condition is one of ambiguity and paradox, a confusion of all the customary categories''. Emma describes her own experience as a similar confusion of categories: When I was experiencing all the mental illnesses, I felt like this was the will of God, or some higher order. Even though it was awful, it seemed like a divine experience. I think I could have stopped, or lessened the effects, but I made a conscious choice to continue on because I felt like I was gaining a special kind of knowledge on illness and healing. In a way, this access to knowledge made it seem like my old way of being and knowing was so base and low; this was a new, higher, and truer way. I felt all at once like I was being destroyed and born. According to Turner, ''undoing, dissolution, decomposition are accompanied by processes of growth, transformation, and the reformulation of old elements in new patterns'. Spiritual emergencies are marked by these experiences. The resolution of a spiritual emergency is described byas the integration of new ways of knowing or understanding (oneself, others, the universe at large, etc.). Perhaps it is necessary for there to be a ''death'' of some part of the self in order to open space for new concepts or ways of being (rebirth). A major difference between Western ayahuasca users and traditional shamanic initiates, is that there is no culturally supported symbolic meaning to shape Westerners' death rebirth experiences. An essential aspect of the rebirth process is an acquisition of knowledge that might be akin to a sort of gnosis. The terms ''gnostic'' and ''gnosticism'' are derived from the Greek word meaning ''knowledge.'' According to Stephan Hoeller, gnostic understanding: Is not rational knowledge; even less is it an accumulation of information. The Greek language distinguishes between theoretical knowledge and knowledge gained through direct experience . . . gnosis involves an intuitive process that embraces both selfFknowledge and knowledge of ultimate, divine realities.Emma describes her access to ''knowledge'' on healing and spirituality as a spontaneous occurrence. ''It wasn't as if I was learning,'' she says, ''it felt more like realizing. Realizing certain realities about myself and the world that I already knew on some deeper level.'' Turner echoes these sentiments, suggesting: The arcane knowledge of ''gnosis'' obtained in the liminal period is felt to change that inmost nature of the neophyte, impressing him, as a seal impresses wax, with the characteristics of his new state. It is not a mere acquisition of knowledge, but a change in being.Kalweit explains when one emerges from ritual ''death'' he or she is ''capable of seeing life and nature undistorted, because the mask of earthly ignorance and delusion was removed from his eyes'. These theorists argue that for one to be open to a deep level of knowledge acquisition, it is necessary for the previous self (and its beliefs, concepts and ideas) to die or be swept away, leaving a clean slate. Before the state of illumination, however, one must undergo the pain and suffering characteristic of liminal states. Both Emma and Carol Kats conceptualize their suffering as necessary to their self-realization as healers. It is important to point out that Emma considers her spiritual emergency mostly resolved. In the height of distress, however, she did not yet have this level of clarity. To get a better sense of how one feels before one fully works through a spiritual emergency, I will turn to Sophie's experience. Sophie is in the process of making meaning of the severe depression she has suffered as a result of drinking ayahuasca. Unlike Emma who now considers her spiritual emergency evidence that she has talent as a healer, Sophie attributes part of her distress to a feeling of worthlessness. Specifically, she fears that she has not been chosen for the shamanic path, and her lack of success reflects this: I needed to know if what I was going through was part of the path, was it a type of initiation? Would I grow from it? Or was it just meaningless suffering? Maybe I'm just mentally ill (though I never had these symptoms before) maybe it's my body chemistry changing as I age? Shamanic skill is usually attributed to natural ability and spontaneous knowledge acquisition. A shaman's ability to heal comes both from himself and from a divine source. In many cultures, direct knowledge is transmitted into shamans through songs, dances or chants. Isaac Tens, a Gitskan Indians shaman, describes his shamanic initiation: My body was quivering. While I remained in this state I began tossing. A chant was coming out of me without my being able to do anything to stop it. Many things appeared to me presently: huge birds and animals. These were visible only to me, not to others in my house. Such visions happen when a man is about to become a shaman; they occur of their own accord. The songs force themselves out complete without any attempts to compose them.The acquisition of knowledge through magical songs is considered sacred; the songs themselves come directly from the spirit world. Luis Eduardo Luna and Pablo Amaringo state that in the Amazon one's body most be purified through special diets (as Sophie had done) in order to communicate with the spirit realm while drinking ayahuasca: Only in this way will the neophytes acquire their spiritual helpers, learn icaros (power songs), and acquire their yachay, yausa, or maririFphlegm the novice receives at some point during his initiation, either from the senior shaman or from the spirits. Particularly important are the icaros, learned either during the visions produced by psychotropic plantFteachers, or in the dreams following ingestion of these trees or a number of other plants. The icaros constitute the quintessence of shamanic power. The icaros and the phlegmFboth of which have material and immaterial qualitiesF represent a transference of the spirits of each plant, with all their knowledge and anthropomorphic manifestation, into the body of the shaman.Liminal periods are marked by knowledge acquisition, and more specifically, acquiring knowledge that is specific to the advanced state the initiate is moving toward. The movement out of liminality is marked by a negotiation and integration of knowledge. It is also the acceptanceFby oneself and by oth-ersFof a new identity. If a spiritual emergency can be considered a liminal period, then it follows that appropriate treatment and resolution of the crisis involves ideally an integration of the material that was previously a source of distress. Integrating and making meaning of distressing material that is characteristic of a spiritual emergency can be a long and difficult process. I argue that sensitive clinical treatment can effectively aid in this process. As mentioned previously, it is imperative that clinical treatment focus on the meaning of the spiritual crisis, rather than diagnosing a pathological condition. It is also not necessarily important to determine whether or not certain experiences ''truly'' or ''really'' occurred. Many visions, thoughts, and experiences during ayahuasca ceremonies are rich metaphorical lessons. Some Westerners do not believe they actually communicate with spirits, for example, but nonetheless experience intensely profound and symbolic lessons in the ceremony. The concept of ''illusion'' holds great value in terms of personal growth in a ritualized space. According to psychoanalyst Donald Winnicott, from birth 5 ''the human being is concerned with the problems of the relationship between what is objectively perceived and what is subjectively conceived of'. Powerful ayahuasca ceremonies that lead to spiritual emergencies are often brought on by experiences that are difficult to negotiate in terms of objectivity. Emma describes such an experience: During the ceremony I had a vision of a door suspended in the air above [the shaman]. A divine energy flowed from the door into [the shaman]. He was holding my hands as I sat directly in front of him. I experienced this divine energy, which I consider the closest to God I have ever been. I knew intuitively that the energy had to flow through [the shaman] before it could move into me because it was just too awesome and powerful for me to experience. I think I would have gone mad if I had access to that much energy and power. Even the small amount I could feel was mind-blowing. Now that the ceremony is over, I guess maybe I am ''supposed'' to say it was metaphorical, or just a hallucination brought on by a drug. But I believe this really happened. Even though this was one of the most meaningful experiences of my life, it was a major part of my spiritual crisis. I guess even though I feel it really happened, there was nothing objective to prove it. I can't compare or discuss this situation with anyone because it is so personal and separate from some shared reality we can all relate to in everyday life. Winncott might have used the term ''illusion,'' which he felt is integral to personal growth, to make sense of Emma's narrative. ''Illusion,'' in this context, does not mean that an experience is simply unreal, but rather the intermediate area between creativity and objective perception. In psychoanalysis there is little focus or even relevance on discerning ''actual'' events from ''false'' events. The focus is explicitly on meaning. I argue that an effective clinician helping a patient overcome a spiritual crisis will recognize the significance of meaning making. In Will's case, he was unable to share his insightsFand his distressFwith his wife. She divorced him mainly because she found his experiences with ayahuasca odd and abnormal. Will explains: She just didn't understand. I tried to explain to her over and over that I wasn't just using drugs to get high or something. On the contrary, I was really learning about myself, and the world. It was a spiritual thing for me. I know it's hard to understand, but because she didn't get what I was doing with ayahuasca, it was like she didn't get me anymore. She blames the divorce on the ''drugs,'' but it's me who she is unable to understand. I don't know, someday I will go to the Amazon. I want to find a shaman to work with. I really think that I ended up in the hospital because there was basically no one in my world who understood what ayahuasca is all about. I mean nobody in the entire culture! It seems crazy to talk about it now, but I felt so alone that I really thought suicide was the best option. Will's experience articulates the extent to which his distress was exacerbated by lack of cultural support. p e r s o n a l a n d s p i r i t u a l t r a n s f o r m a t i o n i n p s y c h o t h e r a p y In the West, mental illness is always considered negative and undesirable. ''We seeas something invading us: a virus, a process that incapacitates, paralyzes, and destroys out body internally, as an unnatural state of affairs, that should be suppressed by every conceivable means''. In some cases, sickness and suffering might more aptly be considered a process of physical and psychic transformation. Cases of spiritual emergencies or spiritual crises, in particular, should be considered an opportunity for healing, learning, and personal growth. Sickness is an indication or signpost of an imbalance. If the illness is not manifest, one would have no way to realize this imbalance. Perhaps it is necessary to experience pain and distress in order to gets one's attention. Dr. Dawna Gutzmann, a psychiatrist I interviewed, considers distressing psychological symptoms an ''opportunity'' to restore health and balance: Symptoms are a call for growth. Just look at fairy tales. These are stories of crisis, but in the end the character (and the reader) gain some specific knowledge as a result. In my practice, I see a crisis as a chance for a patient to manifest his or her full potential. Gutzmann's philosophy on crises reflect my argument that a spiritual crisis, in and of itself, is a powerful source of knowledge that can lead to personal growth. It is imperative to point out, however, that this philosophy does not reflect accurately that of general psychiatry. As medical doctors, most psychiatrists feel a responsibility to diagnosis their patients with an illness that has a name, a course of treatment, and a DSM code to bill for insurance. 6 I conducted an interview with Dr. Thomas Kramer, a psychiatrist and clinical director of the University of Chicago Counseling Center, in order to get a clinician's perspective on ayahuasca leading to spiritual emergencies. Kramer argues that the ''stress-diathesis model'' gives a satisfactory explanation. The premise of this model is that mental illness occurs when an individual with a diathesis (biological/genetic predisposition) is under stress. Kramer's take on individuals suffering spiritual emergencies following ayahuasca ceremonies is that: A lot of folks who go through these rituals have a certain innate diathesis that they might never have discovered had they not gone to a strange place, in a strange culture and pumped themselves full of stuff that distorts their perceptions and loosened their hold on reality. Kramer argues that those individuals who manage effectively the stress associated with drinking ayahuasca probably do not have a diathesis and therefore are not as vulnerable to developing psychological symptoms such as anxiety or depression. While I argue in this article that spiritual emergencies can ultimately lead to personal growth, I do not believe that ayahuasca is risk-free, nor is it appropriate for everyone to use. Interestingly, Sophie herself questions the role a neurochemical effect might have had on her spiritual emergency. She wonders if perhaps she has a latent condition which was exacerbated by the stress of a powerful ayahuasca ceremony: I believe my spiritual crisis/emergency may well have gone hand in hand with a chemical imbalance induced by the ceremonies and diet. The next morning I crashed. The world became empty and hopeless. I cared about nothing and no one. Not my job, not my family and not my [apprenticeship]. I remember wondering if I'd maybe permanently screwed up my serotonin levels. I never suffered from depression before this. That acute crisis after the ceremony was the first crack in my armor around my heart and in my self. Over time, the crack widened and new cracks formed until I felt I was crumbling to pieces. It is clear, given this account, that Sophie was profoundly depressed and needed support. Although she felt she needed professional clinical help, she was hesitant to seek this help from ''conventional'' clinicians for fear they would not take her spiritual path as a shamanic apprentice seriously. It is essential in a spiritual crisis concurrent with psychological symptoms that one comes to understand his or her distress as a process of transformation. Sophie says, ''this ayahuasca ceremony lead to a crack in the armor around my heart.'' There is an immense amount of data in this one statement. For example, a therapist might simply infer that Sophie values a high level of emotional protection and is uncomfortable being too exposed. Throughout this article, I have stressed the essentiality of ritual ''death'' and ''rebirth'' as a mechanism for gnosis, and ultimately, transformation. Certainly a curandero would argue that Sophie could not learn from ayahuasca if she had armor built up around herself. She experiences pain from the ''crack,'' but I suggest there is a larger process at work. Sophie, herself, reports that more ''cracks'' formed over time until she felt she was crumbling to pieces. Like the ethnographic accounts on non-Western shamanic initiates who had to ''die'' before they were open to receive shamanic knowledge from the spirit realm, Sophie too is enduring the painful process of deconstruction. Although Sophie is a Peruvian curandero's apprentice and her experience is certainly synonymous with indigenous death-rebirth accounts, she feels that the clash of culture between herself and her teacher creates tension. Certainly Western culture wouldn't begin to understand [my distress] and so I am caught between worlds without sufficient support. I still wonder if some chemical imbalance, due to my particular body chemistry, metabolism, wasn't triggered. I also wonder how much being female in a mostly male world of shamans and apprentices matters. Maybe I'm just not cut out for this path. That doubt has never left me. Spiritual/religious experiences that are not supported by one's cultural worldview can contribute to a spiritual emergency or state of crisis. Sophie feels estranged from her Peruvian teacher in many ways, due to cultural difference, but also estranged from her own culture, again speaking to the liminality inherent in such situations. Fortunately, an increasing number of clinicians are becoming aware of the need to deal with religious and spiritual issues in therapy. The new DSM-IV code (Religious or Spiritual Problem) reflects this awareness. Both Kats and Gutzmann agree their peers are recognizing this need but state that clinicians must usually seek out this training on their own. There is little, if any, formal training offered in religious and spiritual issues in clinical graduate programs and psychiatric residencies. Kramer feels that psychiatrists get the least training in these issues (as opposed to social workers and psychologists). Some clinicians, such as Kats and Gutzmann, advertise themselves as clinicians specializing in religious and spiritual issues. Both state they sought additional training. 7 I have suggested that theory on liminality accurately frames spiritual crises following ayahuasca ceremonies. Ayahuasca can induce a variety of mystical experiences that are inconsistent with Western worldviews. Radical and sudden shifts in one's belief system may lead to a marked period of psychological distress. Distress from spiritual crises should not be considered indicative of mental illness, necessarily, but rather a normal reaction to a stressful event. I argue that the distress, in and of itself, can be a process of transformation. Periods of transformation that may come about following ayahuasca ceremonies can be considered liminal periods, where one's former beliefs are challenged. If successfully worked through and integrated, he or she reemerges with a changed identity. As Turner describes, the function of the liminal space is to deconstruct one's former identity so he or she may acquire knowledge and training necessary to move fully to a state or identity. Given that the use of ayahuasca and shamanic practices are not sanctioned and culturally supported in the industrialized West, it becomes important for ayahuasca users who develop psychological distress to find other avenues for support. I suggest that sensitive and properly trained psychotherapists can effectively help in the meaning-making necessary to work through spiritual crisis. While spiritual crises concurrent with psychological distress can potentially be quite severe, it is imperative that clinicians working with those who suffer from them focus on interpreting meaning rather than diagnosing a disorder. Ideally, those who suffer from spiritual crises following ayahuasca ceremonies will work with clinicians to explore deeply both the psychological and spiritual meaning of the event. Upon this analysis, one has immense potential for knowledge and healing. 3. The term ''shamanistic'' is used for shamanic-like activities carried out by somebody other than a shaman, whereas ''shamanic'' activities are carried out by an actual shaman. 4. She states that these hallucinations were markedly different from experiences she had previously had while drinking ayahuasca. The previous experiences that might be described as hallucinations could be discerned as ''part of the ayahuasca experience.'' These hallucinations were considered real. 5. This theory grows from Winnicott's assertion that infants first conceptualize the mother's breast as part of itself, and that the negotiation and comprehension of ''subjective'' and ''objective'' are essential to child development in this early stage of infancy (1971:11). 6. All clinicians I interviewed expressed frustration with the necessity of assigning patients diagnostic codes to bill for insurance. The result is that insurance companies have a major role in defining mental illness. 7. Carol Kats, LCSW, worked as a medical social worker for eighteen years before starting a private practice devoted to working with clients on religious and spiritual issues. She states that in addition to ''being born with the gift of intuition'' she sought training in shamanism and other traditions to develop that intuition and to work with clients on a spiritual level. Kats describes herself as an Intuitive Counselor or an Intuitive Healer. Dawna Gutzmann, MD, describes herself as a psychiatrist who incorporates spiritual awareness into her private practice. She has sought additional training beyond conventional psychiatry in Jungian/Transpersonal psychology, body-centered therapy, Robert Hakomi psychotherapy, psychosynthesis (Asosioli), Internal Family Systems Theory, energy medicine, acupressure, flower essences, Chinese herbology, cranial-sacral therapy, biodynamic energy and other ''fluid mind/body interface principles.''
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