Pilgrimage · Atlas

1. Introduction

Version followed: pilgrimage as a cross-traditional religious observance, described through the institutions that authorise particular pilgrimages (for Hajj, Islamic religious authorities such as the Majlis Ugama Islam Singapura and the Saudi Ministry of Health for health entry rules; for the Camino de Santiago, the Pilgrim's Office of the Cathedral of Santiago de Compostela), plus public-health travel guidance (NSW Health; Saudi Ministry of Health; Windsor-Essex County Health Unit on the Maha Kumbh Mela). The psychotherapy side follows the DSM-5 Cultural Formulation Interview (CFI) supplementary modules, the IOCDF faith-leader guidance on scrupulosity and Vieten et al. (2013). [source: see Sources]

Pilgrimage is not a therapy. It is a journey to a place a tradition holds sacred, undertaken as a religious duty, vow, act of devotion, penance, thanksgiving, petition or search for meaning. Examples include Hajj and Umrah to Mecca in Islam, the Camino de Santiago and Marian shrines in Christianity, and the Kumbh Mela in Hinduism; other traditions have their own sacred sites. [source: MUIS khutbah; Venagalicia on the Compostela; WECHU advisory] [uncertain: not verified for traditions not named here]

How change happens, as the traditions frame it: the tradition, not the therapist, defines what the pilgrimage accomplishes. In Islam, Hajj is described as an obligation on "whoever is capable", citing Qur'an 3:97 [source: MUIS khutbah]. The Compostela certifies a pilgrimage made "in a Christian spirit" with religious or spiritual motivation [source: Venagalicia]. Research on walkers of the Camino reports reduced stress and negative affect and greater life satisfaction and sense of meaning after the walk, persisting at three months, in a master's-thesis study (not peer-reviewed) [source: UAB news item, 2024]; older pilgrims describe challenge, spirituality, gratitude, relationships and life transitions as motives [source: Nelson-Becker et al. 2023]. These are attributed findings, not claims that pilgrimage treats any condition.

The therapist's role is to work alongside the observance: understanding what it means for the client, assessing it culturally, accommodating it in treatment, routing physical-health questions (heat, exertion, crowds, chronic illness, medicines) to the client's doctor, watching for scrupulosity, supporting grief and meaning-making, and, if the client wishes, collaborating with clergy or chaplains. [synthesis, structured on Vieten et al. 2013 and the CFI]

2. Framework

Pilgrimage is a framework for the therapist's work alongside the observance, organised around the journey's natural phases. No source gives session counts for this work; the phases below are [synthesis].

Phase A: Discernment and assessment (when the client first mentions a planned or past pilgrimage).

Goal: understand the pilgrimage's meaning, obligation status and timing in the client's life; complete relevant CFI modules.
Format: woven into ordinary sessions; one or more sessions depending on salience.
Move on when: meaning, motives, supports and any clinical risks (mood, psychosis history, OCD, grief, medical conditions) are mapped.

Phase B: Preparation (weeks to months before travel).

Goal: coordinate with the client's doctor on fitness to travel, medicines and vaccinations; plan continuity of mental-health care; prepare for heat, exertion, crowds, separation from home and intense emotion.
Public-health sources advise a pre-travel visit to a GP or travel clinic well before departure [source: NSW Health]; Saudi health authorities say elderly and chronically ill pilgrims and pregnant women should consult their treating doctors before deciding [source: Saudi MOH 2016].
Move on when: the client has a doctor-cleared plan, a care plan for while away and agreed contact arrangements (if any).

Phase C: During the pilgrimage.

Goal: usually no therapy contact; if contact is agreed, keep it brief, practical and respectful of the rites' timing.
Move on when: the client returns.

Phase D: Return and integration.

Goal: make sense of the experience in the client's own terms; notice post-travel physical illness (route to doctor) and any mood shift, disappointment, guilt over rites, or unusual experiences.
Public-health guidance asks returning Hajj pilgrims who feel unwell with fever, cough or breathlessness in the weeks after return to see a doctor and mention their travel [source: NSW Health].
Move on when: the experience is integrated into the treatment focus or closed as a topic.

For clients who cannot go (illness, cost, age, safety), the framework becomes work with loss, permitted alternatives as their tradition states them (for Hajj, proxy pilgrimage, hajj badal, as described by MUIS), and meaning. [source: MUIS khutbah; synthesis]

3. Guiding principles

The tradition defines the rite. Practical meaning: ask what the pilgrimage requires and means, and who in the client's community decides; do not give rulings. [synthesis; Vieten et al. 2013, competency on not acting as spiritual director]
Respect across beliefs. Practical meaning: approach religious, spiritual and secular pilgrims with equal respect and check your own biases. [source: Vieten et al. 2013]
Know your own stance. Practical meaning: notice how your beliefs (religious or secular) shape reactions to vows, sacrifice or miracle accounts; disclose only if it helps the client. [source: Vieten et al. 2013]
Assess religion routinely. Practical meaning: include spiritual and religious history at intake and in the formulation, using the CFI. [source: Vieten et al. 2013; CFI supplementary modules]
Use the client's words. Practical meaning: the CFI asks clinicians to replace placeholders with the person's own term for their tradition; do the same for the pilgrimage and its rites. [source: CFI supplementary modules]
Physical health belongs to the doctor. Practical meaning: raise heat, exertion, crowding, chronic illness, pregnancy and medicines as questions to take to the client's doctor; give no medical or medication advice. [source: NSW Health; Saudi MOH; synthesis]
Ability is part of many traditions' own rules. Practical meaning: for Hajj, physical and financial capability and safety are conditions of the obligation as Islamic authorities state them; let the client's religious authority, not the therapist, apply them. [source: MUIS khutbah]
Distinguish spiritual experience from illness without pathologising. Practical meaning: intense experiences at holy sites can be normative; assess for psychosis, mania or depression when features suggest them. [source: Vieten et al. 2013; Fastovsky and Teitelbaum 2000]
Values-driven versus fear-driven practice. Practical meaning: listen to whether ritual is pursued from meaning, peace and gratitude, or from fear, guilt and obligation (a clue to scrupulosity). [source: IOCDF For Faith Leaders]
Know your limits and collaborate. Practical meaning: consult or coordinate with clergy or spiritual leaders, or refer, when questions exceed your competence. [source: Vieten et al. 2013]
Do not become the religious authority. Practical meaning: the therapist is not a confessor, guide or mufti; avoid dual relationships (e.g. travelling with a client's group). [synthesis]

4. Intervention inventory

These are the therapist's own procedures alongside the observance. None of them is a religious rite, and none is presented as treating physical disease. Example language is illustrative.

4.1 Exploring the meaning of the pilgrimage

Purpose / when: whenever a client mentions a planned, past or impossible pilgrimage. Establishes whether it is duty, vow, devotion, penance, petition, thanksgiving, mourning, life-transition marker or adventure. Older Camino walkers, for example, describe challenge, spirituality, gratitude, relationships and decision points [source: Nelson-Becker et al. 2023].
Steps: (1) Ask what the client calls the journey and use that name. (2) Ask why now and who else is involved (family, congregation, group). (3) Ask what the tradition says it accomplishes and what the client personally hopes for. (4) Ask what would count as it going well or badly. (5) Link answers to the presenting problem and formulation, with consent. [synthesis]
Example language (illustrative): "When you talk about going to Mecca this year, what does it mean for you, and for your family?" / "What are you hoping to bring back, or to leave behind?"
Watch for: obligation felt as crushing rather than meaningful; a vow made in crisis; hopes of cure or rescue that set up disappointment; pressure from others. Working if the client speaks more freely about faith and the formulation includes it.

4.2 Cultural Formulation Interview, including the Spirituality, Religion and Moral Traditions module

Purpose / when: structured cultural assessment at intake or when pilgrimage becomes clinically salient. The core CFI is supplemented by modules; Module 5 clarifies how spirituality, religion and other moral traditions bear on the problem. [source: CFI supplementary modules]
Steps: (1) Use the core CFI for the client's account of the problem. (2) Add Module 5, which explores, in paraphrase: identity and affiliations; the role of the tradition at home and in activities such as ceremonies and worship; whether practices, leaders or teachings help coping; and whether tradition-related issues add stress, distress, discrimination or conflict. (3) Substitute the client's own term for their tradition; if none, use a general phrase. (4) Explore each tradition the client names, since people can hold several. (5) For specific practices such as pilgrimage, ask about level of involvement and effect on coping. (6) Consider Modules 3 (Social Network), 7 (Coping and Help-Seeking) and 10 (Older Adults) or 11 (Immigrants and Refugees) where relevant. [source: CFI supplementary modules; do not reproduce items]
Example language (illustrative): "You said your faith helps you through hard times. Has the planned pilgrimage helped, or added to the pressure?"
Watch for: discrimination or family conflict linked to the journey; the CFI used as a checklist rather than a conversation (the module allows adjusting wording and follow-ups). Working if the formulation now names religious supports and stresses specifically.

4.3 Accommodation in scheduling and treatment

Purpose / when: during Preparation and around travel and return; also for religious calendars (Hajj falls in a fixed month of the Islamic lunar calendar; the Kumbh Mela runs over set weeks in its festival years). [source: MUIS khutbah, dated Zulhijjah; WECHU advisory]
Steps: (1) Map departure, rites and return dates. (2) Agree a pause or reduced schedule, and whether any contact while away is wanted (many clients will prefer none). (3) Plan continuity: crisis contacts at home and at the destination, the treating prescriber's involvement, and a written relapse-prevention plan. (4) Book a return session soon after the client is back. (5) Avoid scheduling exposure or intensive work immediately before departure. [synthesis]
Example language (illustrative): "Let's plan around your travel so the work fits your pilgrimage, not the other way round."
Watch for: the therapist treating the trip as avoidance or as a therapy goal; clients feeling they must justify a religious duty. Working if the client feels the plan respects both their faith and their care.

4.4 Routing health questions to the doctor (heat, exertion, crowds, chronic illness)

Purpose / when: whenever the client is planning a pilgrimage, especially if older, pregnant, chronically ill or on regular medicines. Public-health sources describe heat-related illness and heart disease and stroke as major causes of death among Hajj travellers, crowding as raising infection risk, and long walks near heavy traffic [source: NSW Health]. Saudi health authorities say elderly pilgrims with chronic conditions and pregnant women should consult their treating doctors before deciding to go, and warn about sun exposure, heat exhaustion and sunstroke [source: Saudi MOH 2016]. Pilgrims on the Camino also report pain and physical problems [source: UAB news item].
Steps: (1) Ask whether the client has seen their GP or a travel clinic, and encourage doing so well ahead of departure [source: NSW Health]. (2) Name the topics to raise with the doctor, without advising on them: fitness for heat, long walking and crowded rites; existing conditions; vaccinations required by the destination; medicines, supplies and documentation; what to do if unwell. (3) With consent, share relevant mental-health information with the doctor (for example, how heat, fatigue or disrupted routine affect mood or psychosis risk, and continuity of psychiatric medication). (4) Give no advice on medicines, doses or exemptions yourself. (5) After return, ask about physical illness and route any symptoms to the doctor. [synthesis built on the sources above]
Example language (illustrative): "Before we go further with the plans, have you had a chance to talk to your doctor about the heat and the amount of walking? That's their area, and I'd like you to have their advice."
Watch for: minimising risk because of religious longing; shame about being "not able"; medication stopped for travel. Working if the client has a doctor-agreed plan.

4.5 Exploring ability, exemptions and permitted alternatives with the client's authority

Purpose / when: when illness, age, cost or safety makes the journey doubtful. In Islamic teaching as MUIS presents it, Hajj is obligatory for those capable financially, physically and in terms of safety; people with chronic illness or high-risk elderly people are not obligated to go in person, and those with means but limited health may fulfil it through proxy pilgrimage (hajj badal). [source: MUIS khutbah] NSW Health notes that people with severe conditions are exempt from Hajj duties. [source: NSW Health]
Steps: (1) Ask what the client understands their tradition to require of someone in their situation. (2) Encourage the client to ask their imam, priest, rabbi or other authority; do not rule yourself. (3) Explore feelings about the answer (relief, grief, guilt). (4) For traditions not covered here, ask the client what alternatives exist. [synthesis]
Example language (illustrative): "What would your imam say about how this applies to someone with your heart condition? Would it help to ask him together with your doctor's advice?"
Watch for: guilt that persists despite a clear ruling (consider scrupulosity, 4.7); conflict with family over going. Working if the client can hold the tradition's own provisions without self-condemnation.

4.6 Preparing for crowds, separation and intense emotion

Purpose / when: for clients with anxiety, agoraphobia, panic, trauma or mood disorders who intend to travel. A survey of Hajj pilgrims found depression, agoraphobia and psychotic disorders among the commonest psychiatric conditions, with some pilgrims at suicide risk [source: Alzahrani et al. 2019/2021]. Some Camino walkers report the route as too crowded [source: UAB news item].
Steps: (1) Map expected stressors qualitatively: dense crowds, heat, fatigue, broken sleep, unfamiliar places, separation from home, strong emotion. (2) Review the client's existing coping skills and how they apply in crowded rites. (3) Plan who in the travel group knows about their condition, with consent. (4) Agree warning signs and what to do (contact group leader, local medical services). (5) Respect public-health guidance that rites can sometimes be done at quieter times, as the client's tradition and group allow [source: NSW Health]. [synthesis]
Example language (illustrative): "If the crowd gets overwhelming during the rites, what has helped you before, and who in your group could you turn to?"
Watch for: avoidance of the whole pilgrimage when the client values it; a plan that relies on the therapist being reachable. Working if the client can describe their plan in their own words.

4.7 Scrupulosity around ritual correctness

Purpose / when: when the client fears a rite was invalid, repeats rites, seeks reassurance about correct performance, fixates on minor details while neglecting core practice, or avoids pilgrimage to escape guilt. The IOCDF describes scrupulosity as OCD with religious or moral obsessions, and suggests motivation as a key clue: OCD-driven practice tends to come from fear, guilt or shame; values-driven practice from meaning, peace, hope or gratitude. [source: IOCDF For Faith Leaders] Pilgrimage rites with precise sequences, purity conditions or prohibitions are plausible targets. [synthesis; the IOCDF page does not address pilgrimage specifically]
Steps: (1) Assess for OCD with standard methods; map obsessions, compulsions (repeating, checking, reassurance, confession) and avoidance. (2) Distinguish the tradition's requirements from the client's additions, with the client's religious authority. (3) Build exposure and response prevention collaboratively, with exposures the authority agrees are religiously acceptable; for instance, reducing repeated confession or reassurance gradually [source: IOCDF, which describes gradual reduction of accommodation and of confession frequency]. (4) Ask family and leaders to respond with validation rather than reassurance, and to reduce accommodation consistently. (5) Avoid exposures during the pilgrimage itself unless clearly agreed. [steps 1, 3, 5 partly synthesis]
Example language (illustrative): "Your scholar has said the rite was valid. The doubt is still there. Could we treat that doubt as OCD talking, and practise not asking again?"
Watch for: the therapist offering religious reassurance; exposures that violate the client's faith; prayer used to neutralise thoughts (the IOCDF notes encouraging it can worsen OCD). Working if distress falls, rituals shorten and the client's practice feels more values-driven.

4.8 Monitoring mental state before, during and after; unusual experiences at holy sites

Purpose / when: for clients with a history of psychosis, bipolar disorder or severe depression, and for anyone returning with unusual experiences. Fastovsky and Teitelbaum describe "Jerusalem syndrome" as either superimposed on prior psychotic illness or a discrete form without earlier psychopathology, with onset near holy places, and stress the role of cultural and religious background. [source: Fastovsky and Teitelbaum 2000] Vieten et al. list distinguishing intense spiritual experience from psychopathology as a core competency. [source: Vieten et al. 2013]
Steps: (1) Before travel, agree early warning signs and a relapse plan with the client and prescriber. (2) After return, ask openly about spiritual experiences without assuming illness. (3) Assess function, sleep, mood, insight, risk and whether the experience fits the client's community norms (ask the client, and with consent family or clergy). (4) If features of psychosis, mania or depression are present, assess and refer urgently as usual; do suicide risk assessment per current standards (some pilgrims show suicide risk [source: Alzahrani et al. 2019/2021]). (5) If not, support integration. DSM-5-TR lists a religious or spiritual problem as a focus of clinical attention, code Z65.8.
Example language (illustrative): "Many people have powerful experiences at sacred places. Tell me about yours, and how it has been for you since."
Watch for: pathologising normative devotion; missing illness because it is religiously coloured. Working if the client feels heard and risk is clearly assessed.

4.9 Vows, penance and moral injury

Purpose / when: when pilgrimage was vowed in crisis, is undertaken as penance, or is linked to guilt, betrayal of values or a broken promise (for example, a vow the client cannot now fulfil). [synthesis]
Steps: (1) Explore the vow or wrong in the client's own moral language. (2) Separate guilt the client endorses on reflection from guilt driven by depression or scrupulosity. (3) Encourage consultation with the client's religious authority about release, commutation or alternatives the tradition allows. (4) Work with self-compassion and repair consistent with the client's values. [synthesis]
Example language (illustrative): "You promised to walk to the shrine if your son recovered, and now you can't. What does your tradition say about a promise like that, and who could you ask?"
Watch for: the therapist absolving or condemning; penance that becomes self-harm. Working if the client reaches a resolution their community recognises.

4.10 Grief, ritual and community support

Purpose / when: when pilgrimage carries mourning (walking for someone who died, carrying their memory), marks a life transition, or when the client grieves not being able to go. Camino studies describe life transitions, gratitude, relationships and a renewed sense of meaning [source: Nelson-Becker et al. 2023; UAB news item]. [uncertain: not verified for grief specifically]
Steps: (1) Invite the client to describe the person or loss they carry. (2) Explore the rituals, prayers and companions their tradition offers. (3) Identify community supports at home for after the return. (4) For those who cannot go, explore permitted alternatives (4.5) and other observances. [synthesis]
Example language (illustrative): "Who are you walking for? What do you want to say to them along the way?"
Watch for: expecting the journey to end grief; isolation after the group disperses. Working if the client feels connected to the person lost and to their community.

4.11 Integration after return

Purpose / when: first sessions after return.
Steps: (1) Ask about physical health first and route any symptoms to the doctor [source: NSW Health]. (2) Invite the narrative: high points, hardships (heat, pain, crowds, conflict), disappointments. (3) Explore what the client wants to carry into daily life and how it connects to therapy goals. (4) Note any post-return low mood, irritability or loss of meaning. [synthesis]
Example language (illustrative): "Now that you're home, what from the journey do you want to hold on to?"
Watch for: let-down after a peak experience; conflict with those who did not go; the experience being used to avoid ongoing problems. Working if insights translate into changed routines or relationships.

4.12 Collaboration with clergy, chaplains and group leaders

Purpose / when: when the client wishes, for questions of religious law, rite validity, exemptions, scrupulosity, or care during group travel. Vieten et al. include consulting and coordinating with clergy or spiritual leaders, and referral, among competencies; the IOCDF describes leaders reinforcing trust in the clinician and coordinating with the team. [source: Vieten et al. 2013; IOCDF]
Steps: (1) Get specific written consent: whom, what information, for what purpose. (2) Clarify roles: the religious authority advises on religious matters; the therapist on mental health; the doctor on physical health. (3) Agree consistent messages (e.g. no reassurance cycles). (4) Document and review. [synthesis]
Example language (illustrative): "Would it help if I spoke with your priest, with your permission, so we're giving you the same message about the confession worries?"
Watch for: a leader who discourages treatment or whose advice raises risk; the client feeling outnumbered. Working if the client experiences joined-up support.

4.13 Boundaries, self-disclosure and role

Purpose / when: throughout, especially with clients of the therapist's own tradition or community.
Steps: (1) Do not travel with, lead or guide a client's pilgrimage group. (2) Disclose your own religious commitments only when it serves the client. (3) Do not act as spiritual director; help the client use their own spiritual resources [source: Vieten et al. 2013]. (4) Seek supervision when your beliefs are stirred. [steps 1, 2, 4 synthesis]
Example language (illustrative): "I'm here as your therapist. For guidance on the rite itself, your sheikh is the right person."
Watch for: invitations to join the group; requests for blessings or rulings. Working if roles stay clear.

5. Handling problems

All guidance in this section is [synthesis] unless a source is tagged.

Client insists on going against medical advice. Do not argue religion or medicine. Explore the meaning of going, the tradition's own rules on capability and exemption (for Hajj, as Islamic authorities state them [source: MUIS khutbah]), and encourage a joint conversation with doctor and religious authority. Respect capacity; document; plan for safety while away.
Client stops or changes psychiatric medication to travel. Do not advise on medicines. Route promptly to the prescriber; explore the reasons (practicality, fasting during rites, stigma, wanting to go "pure").
Overwhelm in crowds or heat (reported on return or anticipated). Normalise as a common physical and emotional strain, check for panic or agoraphobia, and route physical symptoms to the doctor. Public-health sources describe crowding and heat as genuine hazards, not only psychological ones [source: NSW Health; Saudi MOH 2016].
Disappointment or spiritual emptiness after the journey. Validate; explore expectations; consider depression; invite the client to talk with their religious community about such experiences, which many traditions recognise.
Guilt about incomplete or "invalid" rites. Ask the religious authority for a ruling; if doubt persists despite it, assess for scrupulosity and use 4.7.
Unusual experiences or behaviour at or after a holy site. Assess as in 4.8; involve crisis services if risk is present. Avoid both dismissal and premature diagnosis [source: Fastovsky and Teitelbaum 2000; Vieten et al. 2013].
Family conflict over the pilgrimage (cost, who goes, safety). Use the CFI Social Network and Psychosocial Stressors modules [source: CFI supplementary modules]; consider a family session.
Rupture: client feels the therapist doubts or disrespects their faith. Acknowledge directly, repair, and re-anchor in the client's own meaning (4.1). Check your own bias [source: Vieten et al. 2013].
Client asks the therapist for a religious opinion or blessing. Decline warmly and redirect to the client's authority (4.13).
Pressure from a group or leader to travel, pay or perform beyond the client's means or health. Explore freely and without labelling the group; consider coercive dynamics if there are signs of isolation, financial exploitation or punishment for doubt; support the client's own decision.
Non-adherence to pre-travel plans (no doctor's visit, no relapse plan). Explore barriers (time, cost, fear of being told not to go); problem-solve; with consent, contact the GP.
Client cannot go at all (illness, cost, age, war). Work with grief and meaning; explore what the tradition permits in place of travel (for example, proxy Hajj as MUIS describes [source: MUIS khutbah]).
Returning ill. Physical symptoms after return, especially fever, cough or breathlessness after Hajj, go to the doctor, with travel mentioned [source: NSW Health].

Sources

Books and papers cited:

Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., and Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5(3), 129-144.
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
Alzahrani, A. S., et al. (2019 online; 2021 issue). Prevalence of psychiatric disorders in Hajj pilgrims using MINI as a diagnostic tool. Journal of Public Health, 29, 169-175.
Nelson-Becker, H., Pickard, J. G., and Sichling, F. (2023). Adventure and spiritual restoration: older adult motivations for undertaking a pilgrimage on El Camino de Santiago. Journal of Gerontological Social Work, 66(2).
az-Zuhaili, W. Al-Fiqh al-Islami wa Adillatuhu (as cited in the MUIS khutbah) [uncertain: not verified].

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