Ritual in therapy
Thresholds, April 2019

Maggie Fisher explores the potential of ritual in therapeutic practice

'Therapy is not only a healing ritual; it is a transitional ritual.’ ¹

My long-standing interest in therapeutic ritual was rekindled powerfully recently when I was interviewed by a trainee psychotherapist exploring the subject for her research. The interview was both thought provoking and moving. Afterwards, I continued to reflect on ritual in therapy: ‘To think about ritual is to explore its place, power and potential in our lives and our society.’². This article seeks to explore therapeutic ritual and builds on previous articles I have written.^3,4

My work with ritual began many years ago with my own need to create a ritual to mark my father’s death. I spoke to a Benedictine Monk, Brother Francis, with whom I worked in palliative care and we co-created a ritual for me. We then worked together, further developing our understanding of ritual and I began to explore its potential in my therapy practice.

Another significant ritual for me was the funeral, some years ago, of a close Jewish friend. When she was dying, she wondered how her heritage could be included in her funeral, which she asked my husband to lead. We talked together about the Jewish ritual of placing a stone on a grave, representing the permanence of memory. At her funeral, each of us chose a stone from a basket of stones we had collected from a beach near her house and placed it with her in her grave. Her funeral was full of her; pictures of her and her music.

Al-Krenawi describes how the use of ritual in psychotherapy can include elements of performance, embodiment, authority and power to modify behaviour, but points out that there can be a spiritual aspect, and that inclusion of a client’s faith may be helpful.⁵ Cole proposed a definition for therapeutic ritual – ‘a structured set of actions developed collaboratively by the therapist and client to effect a transition from one psychological state to another’.6 She suggests that the transition may reflect a developmental stage, (like an initiation) or may be focused on intrapersonal or interpersonal change (such as releasing one’s anger toward another or focused on forgiveness) or that the transition may be a significant life event. She proposes that therapeutic ritual has five healing principles – centring or grounding, assessment, gathering energy for healing, directing the energy, gratitude and closure. Brother Francis and I defined ritual as ‘a sacred space for an individual, family or group to offer a safe meaningful way of journeying though difficulties to enable then to transform and integrate experience’.⁴ Ritual creates a new narrative. It brings a client’s ‘inner theatre’ to consciousness, enabling it to be understood and transformed.

Ritual can be used obsessively, aimed at creating safety through very tight control, and can dominate people’s lives. Ritual can be empty when it carries little or no meaning, becomes routine, repetitive, mechanical and robotic. My father’s funeral was an empty ritual for me. I did not recognise the man of whom the minister spoke. Ritual can be horrific in a ritual abuse context. Ritual abuse is a term used to describe the psychological, physical and/or sexual abuse of an individual or group within a religious, cult or secular ritual and is often both systematic and long term.

In recent years, I have trained in eye movement desensitisation and reprocessing (EMDR) and attachment-based trauma therapies. EMDR is an integrative psychotherapy which focuses on processing distressing memories, such as assault, road traffic accidents, torture, war trauma, disaster, abuse, neglect. In addition it has been demonstrated to be helpful for stress, anxiety, panic attacks, phobias, depression, complicated grief and pain.

It is thought that when a disturbing event occurs, it can be inadequately processed and stored in an isolated memory network, with the original images, sounds, smells, physical sensations, thoughts and feelings involved. EMDR aims to reprocess the memory and enable the brain to process the experience in a way that is similar to REM or dream sleep when eye movements may help to process unconscious material. In turn, it is thought that the distressing memory is transformed when new connections are made, with more positive and realistic information enabling a transformation of emotional, sensory and cognitive aspects of the memory and allowing it to be recalled from a new perspective. EMDR is specifically recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of post-traumatic stress disorder (PTSD).

A reflection on a ritual

I was not trained in trauma therapy when I worked with Brother Francis. In our article, we included a case study about Steve, a medically retired policeman who had complex PTSD.3 He was referred by his psychiatrist, having been involved in a traumatic incident at work which appeared to have triggered memories of his physical abuse as a child. He was constantly hypervigilant and had disturbing images and dreams from both his childhood and the incident. He experienced a lot of physical symptoms including vomiting and diarrhoea. When I first saw him, he had been taking beta blockers, antidepressants and sedatives for about three years. Much of our initial therapeutic work was around imaginary focusing on managing the haunting spectre of the person who attacked him, together with relaxation techniques to soothe his aroused system.

He sought to do something to mark his choice to move on. We discussed what he felt he needed to do. His ritual ultimately had three main themes – the expression of his grief, forgiveness and healing, both of himself and with his family. After his ritual, Steve was able to move on from his history, reduce and ultimately stop his medication and find a way forward with his wife and sons.

Talking about Steve when I was interviewed, led me to wonder how I might work with him if he were coming to see me now. Ritual in therapy was and still is, for me, something that is integrated into an individual’s therapy. It does not stand alone as an intervention, whereas EMDR may. I am fairly certain I would have offered Steve EMDR as it has such positive outcomes. He was also, I think, seeking healing beyond his PTSD.

If I had been able to offer Steve EMDR, he would probably have had relief from his physical symptoms more quickly and may even have been able to reduce his medication more quickly. I imagine a therapeutic ritual may have emerged in our work together after EMDR. While this is all guesswork, it is informed guesswork!

In EMDR, rhythmic movement is used to create bilateral stimulation to reprocess trauma. Therapeutic ritual too has rhythm of a kind. It has a structure, guided by the therapist and chosen by the client in order to process or reprocess trauma.

Therapy and ritual

Ritual is a container, a space in which pain can be worked through in a planned, agreed new way. I view my role in therapeutic ritual as a ‘ritual guide’. When planning a ritual with a client, I work with them to clarify their focus and aim to take into account the client’s emerging themes, who I may represent, sensory aspects, the symbols and movements needed, whether or not the client needs to be accompanied, by whom and why, and what they may need to do, both before and afterwards.

I have therapeutic ritual guidelines which I use with clients. They also serve to guide me, with additional notes to myself to consider who I may be or seem to be to the client and as an indication that if the ritual plan is not profoundly moving, something about it is not quite right. The intention, process and content of the ritual plan should all be reviewed.

Therapeutic ritual guidelines

Across time and culture, rituals have been used as rites of passage, both joyful and sad. Rituals, like dreams, imagery, artwork and other tools, can offer us a way of talking to our inner world. Ritual can take us beyond the limits of words.

Ritual can be a helpful way of:

exorcising pain and promoting healing, eg doing something new about an old soul pain
disentangling and transforming a ritual that needs to end
ritualising something that has been unfinished or unsuccessfully ritualised in the past; for example, the ending of a relationship through death or separation
facilitating, marking or celebrating a desire to make, or a move towards, an internal or external change.

Preparation for your ritual is perhaps as important as actually doing it – give yourself time for the form of your ritual to emerge. Asking yourself the following questions may be helpful:

What is my central focus or purpose? Letting go? Marking movement? Integration? Celebration?
Where do I feel I need to journey from and to, both practically and emotionally?
Do I need a witness or is this something to do by myself?
What symbols, objects, and readings might I need?
What sensory stimulation might I need? Something to taste? Something to smell? Something to focus on, perhaps a particular colour? Some music? Something or someone to touch? Do I need to touch my symbols, objects, helpers or witnesses?
Is there anything else I need to do or to have others do with, and/or for me?
Are any other movements needed?
Does the order reflect the journey I need to make, practically and emotionally?
What will I do before it?
Do I need to wear something specific?
How might I begin my ritual?
Where will it take place?
At what time of day?
How might I end my ritual?
What will I do afterwards?

It could seem that ritual is like psychodrama. In some ways, perhaps it is, but therapeutic ritual is not role play, an enactment or an ‘as if’ experience. It is a co-creation between therapist and client. It has depth of actual lived experience, is moving and has numinosity, and deep emotional resonance, when created carefully with attention to detail. If this kind of resonance were absent, I would strongly suspect that something was wrong and review the whole ritual; its intention, process and content, together with the fit between them all.

The creation of a ritual is as important as the ritual itself, to ensure it is as helpful as possible. In the preparation, the client is taking control of a situation they have often experienced as beyond their control. Having a clear intention and clarifying this in detail until the purpose is absolutely clearly defined, is an investment in the process and content of the ritual. Then, checking the dance between all three will help to ensure that the ritual has deep emotional resonance and can be effective.

Jane had complex PTSD, had been ritualistically abused in a cult and was under the care of a psychiatrist, who felt she was not stable enough for EMDR. I wondered about the possible place of therapeutic ritual in our work as potentially inappropriate or helpful. The process of exploring this was complex and therapeutic. It was a kind of disentangling of her experience of ritualistic abuse and a connecting with her capacity to create something healing for herself. I held in mind my awareness that her mother had been a cult leader to aim to ensure that my care for her was facilitative, not controlling, with my internal supervisor alert to the process and taking the work to supervision.

Following a hesitant start, Jane gathered momentum with a deep, moving sense of knowing about what she both needed and didn’t need. She needed symbolic cleansing and to do the opposite of what she had previously experienced in the cult. As her ritual planning progressed, she grew in confidence and had a sense of certainty. She chose heartfelt music, important healing symbols and to burn aromatherapy oils.

The burning of the oils was particularly important as their smell contrasted with her memory of the smell she associated with the ritual abuse she had endured and that had been a trigger for her frequent dissociative episodes. After her ritual, her smell-triggered dissociative episodes reduced considerably and she continued to burn the oils and touch a stone she had used in the ritual as a kind of reassurance; a reminder of her capacity to choose, to have control. The stone and oils helped to ground her at challenging times.

Avril came to see me as she was struggling to plan her retirement from a job she loved. Her retirement would mean more constantly facing her husband’s progressive multiple sclerosis. He lived with Avril at their home, which had undergone a major redesign. He was very disabled, in a wheelchair and receiving care. She felt powerless. When we worked with the idea of her power, she ultimately felt it was in her ability to walk; to walk away, to walk towards. This was perhaps particularly powerful for both Avril and me, as I am disabled. In some ways, this perhaps highlighted the power of her walking and was acknowledged between us.

We co-created a walking ritual. This was both simple and profound. She needed to wear walking boots. Her husband could no longer use or even wear his. She walked alone up a hillside she had never walked up before to see a beautiful view. A place of both pain and freedom. Avril used this ritual to mark her retirement. The view became a special place where she was able to have space.

Ritual may be helpful in therapy when clients are seeking a way of expressing thoughts or experiences that are beyond words. They may have found a ritual to have been unhelpful or not helpful enough in the past, or wish to mark the intention to end an obsessive ritual. Perhaps they are looking to disentangle and transform an abusive ritual. There could be a wish to move towards or celebrate an internal or external change. I have found ritual to be a profound way of facilitating healing and transformation in therapy.

Maggie Fisher is an integrative psychotherapist and EMDR therapist and is particularly interested in trauma and in ritual. She is a BACP senior accredited therapist/supervisor and a UKCP registered therapist/supervisor in private practice. Maggie has published a bereavement training pack, articles, a poem and has contributed to textbooks and conferences. Website: sussex-psychotherapy.co.uk

References

1. Goodwin E. Healing symbols in psychotherapy. London: Routledge; 2018.
2. Stephenson B. Ritual: a very short introduction. Oxford: Oxford University Press; 2015.
3. Fisher M, Brother Francis, OSB. Soul pain and the therapeutic use of ritual. Psychodynamic Counselling 1999: 5(1): 53–72.
4. Fisher M. Ritual and ceremony. Self and Society 2010: 37(3): 25–31.
5. Al-Krenawi A. Attitudes toward and perceived psychosocial impact of female circumcision as practised among the Bedouin – Arabs of the Negev. Family Process 1999: 38(4): 391–522.
6. Cole VL. Healing principles: a model for the use of ritual in psychotherapy. Counselling and Values 2011: 47(3): 184-194.