Near-Death Experience Aftereffects & Integration

Issues: Therapeutic Implications

By
Cheryl L. Fracasso, Ph.D.
2014

Course Description
Near-Death Experience (NDE) aftereffects have been well established in the past
37 years of research. While research has indicated there are several positive aftereffects
that profoundly change experiencers post-NDE, there are also several integration issues
that can present a psychospiritual crisis that may require clinical intervention. What is
well established is that experiencers are profoundly changed spiritually, psychologically,
emotionally, and physiologically, which often times leads to confusion, depression,
anxiety, drastic changes in professional or personal relationships (and high rates of
divorce), and many questioning their sanity. This is compounded by the fact that many
are invalidated, disbelieved, stigmatized, and occasionally misdiagnosed when trying to
talk about their experience with family, friends, or practitioners. This course presents an
overview of various aftereffects of NDEs, with a focus on integration issues that may
present in a clinical setting that practitioners need to be aware of. Assessment strategies
to screen for NDEs are examined, along with disclosure barriers. A critical analysis of
differential diagnosis is presented, highlighting that V-Code 62.89 in the DSM-IV-TR
reserved for spiritual or religious problems is currently being underutilized. Ethical
issues in working with managed care are explored, along with several ways to increase
multicultural sensitivity when working with the NDE population. The course is
concluded with a brief overview of therapeutic strategies that can assist clinicians in
working with this population in order to increase the effectiveness of clinical outcomes.

PART 1
INTRODUCTION
This course presents a thorough overview of near-death experience (NDE)
aftereffects and integration issues that may present in a clinical setting. This is the second
HealthForumOnline continuing education course on NDEs by these authors. The first
course titled Near-Death Experiences: Implications for Clinical Practice (Fracasso &
Friedman, 2009, revised 2013) provides practitioners with a general introduction to
NDEs. Common elements and characteristics of NDEs are explored, along with incidence
and prevalence rates, cross-cultural comparisons, theories, and common aftereffects.
Differential diagnosis and diagnostic issues are introduced, and the course concludes with
a brief overview of recommended therapeutic strategies. This course is an extension of
the first, and was designed to increase practitioners level of competence when working
with the NDE population.
In this course, materials are presented in 6 main parts. Part 1 discusses the
burgeoning need for practitioner competence when working with the NDE population,
followed by a brief overview of pleasurable versus distressing (i.e., hellish) NDEs. Part
2 provides a critical analysis of aftereffects, ranging from positive and spiritually
transformative aftereffects to long-term post integration issues. Specific focus is
dedicated to examining integration issues associated with electromagnetic aftereffects
(EMEs), psychic and/or healing abilities, stress-related factors, and distressing NDE
aftereffects. Part 3 examines assessment and diagnostic considerations when working
with the NDE population, practitioner level of competence and knowing when to refer

4
clients and where, and ways to increase diagnostic accuracy by understanding the normal
course and outcome of NDEs. Part 4 critically evaluates therapeutic challenges that can
arise in a clinical setting, ranging from disclosure barriers to transference and
countertransference issues. Part 5 informs practitioners of various ethical issues that may
arise. Multicultural sensitivity is considered, along with ethical issues that may arise
when working with clients from diverse populations. A case study is presented for
reflection. Ethical issues with confidentiality and clients who may present with suicidal
ideation are presented as food for thought, along with ethical and diagnostic issues when
working with managed care. Part 6 concludes with recommended therapeutic strategies
that can enhance clinical competence when working with the NDE population.

The Burgeoning Need for Training

The widespread occurrence of near-death experiences

(NDEs) is unequivocal,

namely millions of people in the US have reported such experiences. This phenomenon is
also rapidly growing, likely due in part to advancing techniques of resuscitation in which
people are increasingly being brought back from the brink of death with NDEs to report.
As a result, NDEs have captured the attention of researchers from various scientific
fields, such as neurology (Greyson, 2010; Parnia, Spearpoint, & Fenwick, 2007) and
quantum physics (Laws & Perry, 2010), as well as have captured the attention of the
media, resulting in much public interest. What remains equivocal is whether NDEs can
ever be confirmed as objectively real (i.e., veridical to some external criteria for defining
reality) or whether they are to be relegated to merely being judged as subjective
experiences that do not necessarily indicate anything objectively factual. If ever accepted
as real, however, NDEs could provide a vehicle to openly address fundamental questions

5
that have long interested humankind, such as whether consciousness can exist
independently of a functioning brain and whether there might be an afterlife. NDEs seem
to imply these are possible and, if so, these would undoubtedly have radical implications
not only for science, but for every sector of human existence. Many scholars have
recognized the profundity of these types of questions, as well as how research on NDEs
may provide a unique avenue for their exploration (e.g., Carter, 2010; Fenwick, 2010;
Greyson, 2010; Fracasso & Friedman, 2011).
Presently, although there are many theories used to explain (or sometimes explain
away) NDEs, those based solely on reductionistic and materialistic views have
weaknesses that cannot yet fully account for the many puzzling extraordinary NDE
phenomena that are often reported. Most difficult to explain in a reductionistic and
materialistic way are numerous dramatic aftereffects on those having NDEs (NDErs),
such as reports of electromagnetic aftereffects, healing abilities, psi experiences, along
with profound changes in spiritual beliefs, values, and lifestyle (Fenwick, 2010; Greyson,
2010; Moody, 1975; Ring, 1980, 2006).
The published literature in this area indicates that people who report NDEs do not
meet clinical criteria for either post-traumatic stress disorder (PTSD) or any of the
dissociative disorders outlined in the Diagnostic and Statistical Manual of Mental
Disorders (4th edition, text revision; DSM-IV-TR; American Psychiatric Association
[APA], 2000; Atwater, 2003; Greyson, 1986, 2001, 2003; Parnia, Waller, Yeates, &
Fenwick, 2001; Parnia, Spearpoint, & Fenwick, 2007; van Lommel, van Wees, Meyers,
& Elfferich, 2001). Clearly, this is an important topic for psychologists and practitioners
in general, since this population may present unique psychosocial problems that may be

6
overlooked by practitioners not aware of various post integration issues associated with
NDEs, and as a result may potentially misdiagnose the NDE population due to lack of
knowledge about this phenomena (Fracasso, Friedman, & Young, 2010).
As of this date, most of the literature assessing clinical knowledge and attitudes
towards NDEs has been conducted by the medical community to assess nurses and
physicians level of knowledge, while only two studies to date have been found in the
published literature that assessed psychologists knowledge (Fracasso, Friedman, &
Young, 2010; Walker & Russel, 1989). The most recent study in the medical community
conducted by Cunico (2001) assessed 476 nurses knowledge and attitudes towards NDEs
in three hospitals in Italy using Thornburgs (1988) Near-Death Phenomena Knowledge
and Attitudes Questionnaire (NDPKAQ) and found that 34% of the nurses had
knowledge about NDEs and expressed a positive attitude towards the phenomenon.
Similarly, Moore (1994) assessed 143 physicians knowledge and attitudes about NDEs
using Thornburgs (1988) scale and found that only 16% of the physicians had knowledge
about NDEs, but that 65% expressed a positive attitude towards the phenomenon.
Furthermore, a significant number of physicians expressed that they did not believe the
NDE was a side-effect of medications and believed that the NDE was a real experience
which deserves further clinical attention (Morris, 1994). Consequently, this cohort of
physicians also believed that the occurrence of NDEs should be documented to facilitate
communication among medical staff and that there is a necessity for wide-spread clinical
training about the NDE phenomenon to enhance the quality of care delivered to this
population (Morris, 1994).

7
In the same vein, Hayes and Orne (1990) assessed 912 nurses knowledge and
attitudes about NDEs and found that 70% were aware of the NDE phenomena and
expressed positive attitudes towards patients who report this experience. However, a
majority of nurses expressed that their primary source of information on NDEs came
from the popular media and 96% stated they felt inadequately informed about the NDE
phenomena, along with implications for treatment with this population of patients (Hayes
& Orne, 1990).
As of this date, there are only two studies that could be located in the published
literature that assessed psychologist and mental health practitioners knowledge and
attitudes towards NDEs. Walker and Russel (1989) surveyed 117 psychologists to explore
their knowledge of and attitudes towards those who report NDEs, and found while a
substantial number of psychologists were open to explore NDEs clinically and had
positive attitudes towards them, a substantial number lacked sufficient knowledge about
the NDE and its various aftereffects.
Nearly 20 years later, Fracasso, Friedman, and Young (2010) did a follow-up
study on 18 licensed psychologists and mental health practitioners in Washington state,
and found that 100% of the respondents stated they had heard of NDEs, 22% reported
having had a NDE, 56% reported counseling a client who reported a NDE, and 44%
reported knowing a family or friend who had a NDE. The Near-Death Phenomena
Knowledge and Attitudes Questionnaire revised for psychologists (Walker & Russel,
1989) administered to participants indicated that while psychologists scored slightly
above the criterion variable of 60 on the Attitude Scale, the mean of 63.11 only indicates
a moderately positive attitude towards NDEs. Likewise, psychologists also scored fairly

8
low on the Attitudes toward Client Care Scale, with a mean of 54.78 and a criterion
variable of 50, which indicates a slight positive attitude towards providing care to this
population. However, psychologists scored substantially below the criterion variable of
12 on the Knowledge Scale with a mean of 6.61, which indicates that psychologists
substantially lack knowledge about NDEs and their psychological aftereffects. Based on
the analysis of their data, Fracasso and colleagues concluded it appears that
psychologists knowledge of and attitudes towards NDEs have remained relatively
unchanged in the nearly 20 years since the study conducted by Walker and Russel (1989).
Around the same time, Rebecca Jenny Moores (2010) examined 23 NDErs who
had childhood NDEs and found that 15 (65%) sought psychotherapy as an adult due to
various integration issues, and a substantial number reported psychotherapy was not
helpful. Presenting issues for seeking psychotherapy ranged from relationship issues (4),
grad school requirements (3), recall memories (2), struggles with psychic aftereffects (2),
suicide attempt (1), chronic health problems (1), emotional issues (1), and issues with
parents (1). Therapeutic approaches that were found most helpful were art therapy, sand
therapy, EMDR (eye movement desensitization and reprocessing therapy), and talk
therapy. However, 73% reported that psychotherapy in general was not helpful in
integrating the long-term effects of their NDE, which a majority reported they did on
their own over a long period of time. It should be noted, however, that the results of this
study should be interpreted cautiously because some participants did not divulge to the
therapist that they were seeking psychotherapy as a result of their NDE, so this highlights
the need for more tightly controlled and better designed studies that are exploring
psychotherapeutic outcomes specifically with clients/patients who report an NDE, and

9
the need for mental health practitioners to screen for NDEs during the assessment.
Limitations to this area of research, however, are that many may be reluctant to disclose
their NDE, and may present with various issues in a clinical setting that at first glance,
may not appear to be correlated to integrating their NDE. Thus, the purpose of this
training module is to highlight various issues that may serve as red flags, indicative that a
client/patient may be struggling with NDE aftereffects.

Brief Overview of NDEs

Following Raymond Moodys (1975) groundbreaking research on 150 case
studies, Ring (1980, 1992) was among the first to conduct scientific studies on the
aftereffects of NDEs. He compared 74 NDErs with 54 controls, and found that the NDErs
scored significantly higher in the following six categories compared to a control group:
physical sensitivities, physiologic changes, neurological changes, energetic changes,
emotional changes, expanded mental awareness, and changes in purported paranormal
function (Ring, 1992). Ring also found that 49% of NDErs reported an increased
sensitivity to lights, as well as various physiological changes (e.g., decreased rates of
blood pressure, body temperature, and metabolic rate). Furthermore, 59% of the NDErs
Ring studied reported an increase in experiencing energetic currents flowing through their
body, 58% reported an increase in mind expansion, 61% reported increased psychic
abilities, and 24% reported that they seemed to cause electric or electronic malfunction
(p. 277), compared to only 7% of his controls.
As an example of some of the long-term effects of NDEs, Atwater (2003) found
that out of 3,000 participants that were married, 78% divorced within seven years of the
experience due to drastic changes in lifestyle values. Likewise, Christian (2006) also

10
found higher rates of divorce due to drastic changes in lifestyle and spiritual values, while
Wren-Lewis (2004) found higher rates of personal distress, and Morris (1998) found
higher rates of depression. Atwaters (2003) 25 years of research with nearly 3,000 adult
and 277 children NDE experiencers suggests there are four phases of integration that
occur post NDE which occurs over a 15 year period and is marked by several red flags
for mental health practitioners to be aware of. According to Atwater, the first phase
occurs one to three years post NDE and is marked by confusion, significant rates of
depression, enhanced psychic abilities, a detachment from ego identity and individual
personality traits, and a loss of fear of death in adult experiencers. As noted above, phase
two occurs four to seven years post NDE and is marked by a rediscovery of relationships
with the community and family with a focus on service-oriented roles. However, Atwater
also found that 78% of adults divorced during this phase, and 33% of children
experiencers started drinking due to drastic changes in lifestyle values and lack of
validation from friends, family, and professional practitioners.
According to Atwater (2003), phase three occurs seven to twelve years post NDE
and is marked by a strong sense of spiritual values and desire to share ones story, while
rates of depression remain high in both adults and children experiencers as they struggle
to integrate the impact of this profound experience into their daily lives. Atwater noted
that phase four occurs approximately twelve to fifteen years post NDE and is marked by
a crisis of self which includes fluctuations in mood, high rates of depression and
grieving due to fears that the effects of the NDE are fading, in addition to increased
relationship problems. Likewise, Atwater found that 21% out of 277 children

11
experiencers attempted suicide during this phase, which makes it imperative for
psychologists to be aware of potential integration issues during these various phases.

Distressing NDEs
In the early years of NDE research, studies mainly reported pleasurable accounts
of NDEs that were marked by feelings of peace, joy, comfort, and bliss (Greyson, 2003;
Moody; 1975; Parnia et al., 2001; Ring, 1980; Sabom, 1982; Schwaninger et al., 2002;
Sutherland, 1992; van Lommel et al., 2001). However, the first accounts of distressing or
hellish type experiences emerged in 1978 when a cardiologist, Maurice Rawlings,
published his book Beyond Deaths Door. The book portrays several accounts of
distressing or terrifying NDEs reported by his patients, however, was virtually ignored by
the NDE community. Bush (2009) recalls that many in academic circles criticized
Rawlings for his methodological sloppiness, lack of statistical analysis, and stated his
work lacked objectivity due to his born-again Christian bias. Bush notes several other
studies that began emerging with accounts of terrifying or distressing experiences, such
as Garfields (1979) study of 47 cancer patients who reported NDEs that ranged from
pleasurable to terrifying; followed by Lindley, Bryan, and Conleys (1981) study which
found that out of 55 NDErs, 20% (11) reported negative or distressing experiences.
Bush (1983) was the first to publish 17 accounts of children NDEs, and found a
distressing hellish experience reported by one. In the childs own words:
God said it wasnt my time yet and I had to come back. I put my hand out and
God his hand out, and then God pulled his hand back. He didnt want me to stay.
On the way back, I saw the devil. He said if I did what he wanted, I could have
anything I wantbut I didnt want him bossing me around. (Bush, 1983, p. 187)

12
As Bush describes, the emotional cost of this experience for the child was high
because he thought God did not want him, but that the devil did. The childs mother later
reported several behavioral problems with the child, which resulted in being referred to a
psychologist who was not open to discuss the childs NDE and disregarded it as part of
the childs imagination. A few years later the childs mother was still not able to find a
psychologist willing to talk about the NDE, so the family moved to a new town hoping to
find an open-minded practitioner that could help reduce the childs ongoing distress.
Following this, Grey (1985) found that out of 39 experiencers 12% reported
terrifying or distressing NDEs. Grey also noted that the distressing/terrifying experiences
shared common elements with the pleasurable or radiant ones, but with different levels
of emotions and details. Approximately 7 years later, Atwater (1992) reported that out of
700 NDErs, 105 reported distressing NDEs. Atwater went on to claim that distressing
NDEs are reported by those who have deeply suppressed or repressed guilts, fears, and
angers, and/or those who expect some kind of punishment or accountability after death
(p. 156). However, some in the NDE community challenged this claim, highlighting that
many NDEs have occurred via a suicide attempt, and a majority of them have reported
blissful experiences (Greyson, 1986, 1991).
In 1995 Serdahely found that 33% (12) reported a distressing NDE. In Germany,
Knoblauch, Schmied, and Schnettler (2001) examined 82 NDErs and found that among
West German NDErs, 60% reported positive emotions and 29% negative; while amongst
East German NDErs, only 40% reported positive emotions and 60% negative (p. 25).
From this, the authors suggested that the contents of the NDE may be culturally
constructed.

13
Bonenfant (2001) was the next to researcher to report a distressing NDE reported
by a child (a six year old boy) who stated he saw both God and the devil. The parents
reported that the child had nightmares and extreme anxiety for months, and had a sudden
new interest in religious matters.
Bush (2009) reviewed the literature between 1975 through 2003 and found: In
all, although 9 studies with 459 experiencers found no accounts of distressing NDEs
(0%), 12 other studies involving 1,369 experiencers produced the accounts of 315 people
(23%) who reported NDEs ranging from terrifying to despairing (p. 70).
Greyson and Bush (1993) collected data for 50 distressing accounts over a period
of 9 years and found three distinct types of experiences. The most common type
contained classic elements of the pleasurable NDE, however experiencers interpreted this
as terrifying. The second type entailed features of nothingness and/or existing in a
limitless void. The third and least common type was the type of hellish experience that
corresponds to the hell construed by the popular imagination.
For a more detailed overview of distressing NDEs, visit Nancy Evan Bushs
website at: http://www.dancingpastthedark.com

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Table 1: Overview of Studies with only Pleasurable NDEs

Reported from 1975-2003
Researcher(s)

Total n

Incident Rates of
NDEs

Moody (1975)

150

*Total case studies

only reported

Ring (1980)

102

40%

Sutherland (1992)

50

*Total interviewed
only reported

Sabom (1982)

116

67%

Parnia et al., (2001)

63

11%

van Lommel et al., (2001)

344

18%

Schwaninger et al. (2002)

Greyson (2003)

174
1,595

23%
10%

Video of Distressing NDE

This is a video of Nancy Evans Bush who delivered her talk Untangling Hellish
Visions at the 2012 IANDS conference.
http://www.youtube.com/watch?v=8Gghhqcu-Es

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PART 2
NDE AFTEREFFECTS
It is well documented that there are several profound aftereffects commonly
associated with NDEs, including both positive as well as negative post-integration issues
that appear to occur over a period of 15 years or more (Bush, 1991; Christian, 2006;
Groth-Marnat & Summers, 1998; Insinger, 1991; Noyes, Fenwick, Holden, & Christian,
2009; Sutherland, 1992). Research has shown that in a substantial number of cases,
clinical intervention may be needed to help NDErs integrate their NDE into their daily
livesalthough many researchers view even these difficult aftereffects as positive postintegration growth opportunities in which shallow parts of the old self are left behind as
NDErs seek to integrate deeper values (Holden, 2009). Many researchers have found high
rates of divorce due to radical changes in lifestyle values (Christian, 2006), some became
suicidal during certain phases (longing to return to the peaceful realm experienced during
their NDE), while others struggled with depression, perhaps due to not having the
experience validated by friends, family, and/or practitioners (Bush, 1991; Groth-Marnat
& Summers, 1998; Noyes et al., 2009).

Positive Long-Term Aftereffects

Positive long-term effects of NDEs commonly cited in the literature include an
increased sense of purpose and meaning in life (Britton & Bootzin, 2004; Greyson, 1996,
1997, 2009; Moody, 1975; Noyes et al., 2009; Ring, 1980; van Lommel et al., 2001;
Zingrone & Alvarado, 2009), feelings of unity, love, and compassion towards all of life
(Greyson, 2001; Holden, Long, & MacLurg, 2006; James, 2004; Parnia et al., 2001), a

16
decreased interest in obtaining material wealth (Stout, Jacquin, & Atwater, 2006), a desire
to eat healthier (many reported eating more vegetables and desiring less red meat), a
decreased fear of death, and an increased desire to be of service to others (Brumm, 2006;
Christian, 2006; Kinnier, Tribbensee, Rose, & Vaughan, 2001; Moody, 1975; Morris &
Knafl, 2003; Ring, 1980; Sabom, 1982; Wren-Lewis, 2004). Many NDErs also reported a
decreased desire to consume certain chemicals found in some foods and/or addictive type
of substances, such as caffeine, alcohol, and nicotine (James, 2004; Ring, 1992).

Long-Term Post-Integration Issues

Some of the commonly cited long-term, post-integration issues include frustration
with finding ones purpose in life, confusion about the true meaning of life, high rates of
depression, anxiety, anger, as well as problems integrating the experience into his or her
daily life (ACISTE website, 2013; Christian, 2006; Duffy & Olsen, 2007; Greyson, 2001,
2007; James, 2004; Morris & Knafl, 2003; Olsen & Dulaney, 1993; Simpson, 2001;
Wren-Lewis, 2004). Furthermore, NDErs commonly report a growing sense of isolation
from others due to feeling different, and/or being reluctant to talk about the experience
out of fears of being rejected or ridiculed (Greyson, 2009). Mori Insinger (1981)
suggested this sense of isolation may lead to higher rates of depression, and these
findings are consistent with subsequent studies (Christian, 2006; Greyson, 2007; Greyson
& Harris, 1987; Morris & Knafl, 2003; Wren-Lewis, 2004). However, it should be noted
that depression and anxiety are normal responses to a NDE and the profound aftereffects
often take years to integrate; therefore, pathological conditions need to be differentiated
from the normal course and outcome of the NDE. Again, research has shown that NDErs
have a significantly high rate of divorce post-NDE, perhaps due to drastic changes in

17
lifestyle values, which may place strain on interpersonal relationships (Christian, 2006;
Greyson, 2009; Morris & Knafl, 2003; Wren-Lewis, 2004). Whether this is a sign of
pathology or one of moving toward healthier and more fulfilling relationships has not
been determined. Likewise, John Wren-Lewis (2004) found that positive life changes also
co-existed with higher rates of personal distress, making this picture confusing.
In a study conducted by Stout, Jacquin, and Atwater (2006), participants were
asked what their main struggles and challenges were post-NDE. Stout and colleagues
found six key themes consistently reported: 1) difficulty processing a radical shift in
reality, 2) difficulty accepting their return back to this life, 3) difficulties sharing their
experience with others and/or lack of validation or understanding from family and/or
friends, 4) a growing sense of isolation due to the inability to talk about the experience
with others, 5) challenges adjusting to heightened chemical sensitivities and intuitive
gifts, and 6) difficulty finding/living their life purpose and integrating new spiritual
values into daily life.
Other integration issues include a lack of boundaries post-NDE. Greyson (2007)
suggested this may be due to the state of unconditional love and Oneness that was
experienced during the NDE, and that many struggle with integrating back into a society
that predominantly lives by the belief that individuals are separate from each other. In
fact, Greyson noted many are not able go back to that prior way of living and thinking,
which may present several adjustment issues, especially because family or friends may
not understand their new values. Moreover, it is important to note that this sense of unity
and oneness is not just an intellectual belief for many, but rather, becomes a central part
of their new reality.

18
Other issues surround responses from family and/or friends. In addition to lack of
validation and sometimes being disbelieved, Greyson (1997, 2007) suggested some may
put the NDEr up on a pedestal expecting superhuman powers from them. The extreme of
either of these responses can put immense pressure on NDErs, leading them to not feel
understood, while reinforcing a desire to suppress the experience.
Table 2 presents an overview of positive aftereffects and long-term post-integration issues
that clients may present with in a clinical setting.

Table 2: Positive Aftereffects & Long-Term Post-Integration Issues

Positive Aftereffects
Sense of Belonging & Meaning

Integration Issues
Confusion

*increased sense of meaning and purpose

*inability to find ones purpose or meaning

in life

in life.
*confusion transitioning back into this
reality while trying to make sense of the
transcendent realm experienced during the
NDE
*confusion about aftereffects, such as
psychic and/or healing abilities, and
electromagnetic aftereffects
*confusion about having geomagnetic
sensitivity (being able to sense natural
disasters before they occur, such as
earthquakes, tornados, thunder storms,
hurricanes, and other natural disasters)

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New Understanding of Love

Anger

*love, compassion, and respect for all of

*many are angry they were not given a

life. Sense of unity with humans, animals,

choice and were forced to return to the

and nature

physical body and this reality

*many report missing the presence of the
unconditional love experienced during the

Altruistic Desires

NDE
Depression/Anxiety

*desire to be of service and to help others

*feeling radically different post-NDE, but

*many report making radical career

not understanding why

changes, leaving careers that were self-

*sense of isolation resulting from an

serving and moving into careers that serve

inability to share or communicate the

or help others

experience with others due to having no

*less concern with materialistic desires or

words to describe the transcendent realm

obtaining wealth

*feeling rejected and/or sad that they were

*healing and/or psychic related

told they had to go back to this realm

aftereffects that can be used to help others

*struggles with integrating back into a

world that is cold and lacks spiritual
values of unconditional love and oneness

Sense of Connection to Spiritual Source

experienced during the NDE

Invalidation & Stigma

*an insatiable desire to learn. Many

*many report feeling crazy and fear being

report an interest in learning about

ridiculed or labeled as crazy

quantum physics, nature, music, art,

*many who try to share the experience are

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spirituality, or anything that will satisfy

invalidated by family, friends, and/or

their quest for knowledge

professional staff, thus resulting in

*ongoing communication with

suppressing the experience

transcendent beings (angels, guides,

*for many, the NDE contradicts prior

deceased entities and/or loved ones)

religious/spiritual beliefs and this can cause

*desire to meditate and/or be in balance

fear when sharing the experience with

with nature and the environment

family, friends, or certain branches of

organized religion
*feelings of guilt and shame can result
when experiencers are invalidated and told
the NDE and its aftereffects are the work

Physiological Changes

of the devil
Radical Changes in Life Style

*desire to eat healthier: increased desire

*radical changes in spiritual beliefs, values,

to eat more fruits and vegetables,

and desires post-NDE can put a strain on

decreased desire for red meat and other

relationships, thus leading to higher rates of

unhealthy foods

divorce

*decreased desire for anything with

*radical changes in career can create a

chemicals or unnatural substances: lose

financial strain for some, as well as place

desire for caffeine, drugs/alcohol, and

strain on family relationships (i.e., a lawyer

tobacco

leaving private practice to become a social

Decreased Fear of Death

worker or to work in a soup kitchen, etc.)

Suicidal Risk Factors

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Profound Aftereffects & Psychospiritual Integration

Challenges
In addition to the post-integration issues discussed above, there are also several
profound aftereffects that may cause initial confusion or distress, and in extreme cases
may potentially lead to a psychospiritual crisis that may require clinical intervention. The
main aftereffects that present integration challenges are electromagnetic aftereffects
(EMEs), psychic and/or healing abilities, stress-related factors associated with these
anomalies, and integrating distressing NDE experiences.

Electromagnetic Aftereffects
Electromagnetic aftereffects (EMEs) are one anomaly that is starting to capture
the attention of researchers in the past few years, and are an especially fruitful area of
research since we are living in a society with increasing wireless technology and
electromagnetic fields that these technologies generate. Ring (1992) was among one of
the first researchers to explore this phenomenon, in addition to Atwater (2007), who
found that approximately 73% of over 3,000 NDErs reported EMEs. Reports of street
lights flickering on and off, microphones, tape recorders, or other electronic devices
going haywire in their presence, and various other problems with electrical appliances,
are only a few of the commonly reported issues. As an example, Ring interviewed one
NDEr who stated:
I have a difficult time as many computers malfunction and lights blow when I
walk under them. This has happened for years, and I tried to ignore this was
happening. I simply cannot wear a watch for long before it breaks down. I went

22
toa department store and walked in front of their brand new computer and it
quit workingWhen I held a fluorescent light in my hands, the entire bulb lit up,
like it was turned on. It seemed like there was a lot of static electricity. (p. 159)
Other researchers have explored EMEs (e.g., Bonenfant, 2005; Nouri, 2008), but
Atwater (2007) significantly extended Rings (1992) observations into this area. She
found that an astounding 73% of nearly 3,000 NDErs she studied reported EMEs, which
were not only stressful, but very costly (i.e., many reported having to consistently replace
and/or fix various types of technology). Atwater (2007) stated:
Of the experiencers I interviewed, 73% percent fit this profile and gave numerous
reports of electrical snafus such as microphones that fought them, recorders that
began to smoke, computers that crashed, television channels that flipped,
electronic memory systems that wiped out, or street lights that popped as they
walked by, None could wear watches anymore without consistently repairing or
replacing them. All of them reported a heightened awareness of electromagnetic
fields in general. Experiencers claim to have a new awareness of invisible energy
fields and a sensitivity to electricity and geomagnetic fields. Many claim to see
sparkles or balls of energy in the air, the aura (or energy) surrounding all things,
and to develop a sensitivity to meteorological factors such as temperature,
pressure, air movement, and humidity. (p. 109)
Nouri (2008) was the next researcher to explore this phenomenon in her
dissertation, where she reported that out of 36 NDErs, nearly 70% reported problems
with a range of appliances and technologies, which she separated into lights, cell phones,
computers, batteries/watches/clocks, and other technologies. Fracasso (2012) conducted

23
an in-depth qualitative analysis of 10 NDErs for her dissertation, and found that nearly
70% were also reporting EMEs, and noted emerging characteristics in those who reported
EMEs and those who did not. Namely, NDErs who reported EMEs also reported higher
rates of allergies, chemical sensitivities, geomagnetic sensitivity, and psychic aftereffects,
compared to NDErs who did not report EMEs. While the sample size was much too small
to make any inferences from the data, Fracasso (2012) suggested that future research
needed to focus on exploring these characteristics to test if these were predominant
characteristics in larger samples sizes, and hypothesized that those who reported EMEs
might also report higher levels of allergies, chemical sensitivities, geomagnetic
sensitivities, and psychic aftereffects, compared to NDErs who do not report EMEs.
Thus, a longitudinal study was launched in April 2012 by Principal Investigator
Cheryl Fracasso, and co-researchers Kenneth Ring, Harris Friedman, and Scott Young to
explore EMEs on a much larger sample size. Recently, Fracasso and Friedman (2012)
published the first in a series of reports from their current study, noting that out of 136
NDErs, 71% reported EMEs. While no formal quantitative data analysis has been
conducted yet, a preliminary report of the data indicates that a large percentage of those
who report EMEs are also reporting higher rates of allergies and chemical sensitivities, as
Fracasso (2012) hypothesized in her dissertation.

Stress-related integration issues with EMEs. Fracasso (2012) also noted

several stress-related integration issues EMEs were causing, which is also being found in
her current study (Fracasso & Friedman, 2012). Some of the integration issues commonly
reported thus far have been stress associated with the cost of constantly having to
replace/repair electrical appliances, issues with not being believed, the inability to

24
tolerate environments that have high levels of electromagnetic fields and/or florescent
lights, and a host of other problems with tolerating the increasing rates of electromagnetic
fields that nearly all technologies generate. One participant expressed the following in
regards to problems this has caused at her place of employment as well as by not being
believed by others:
For a long time I thought I was going nuts so it created it's own set of problems,
and it gets damn expensive getting things checked and fixed all the time, not to
mention people thinking youre nuts, or doing something weird. The stress at
work is unbearable some times, but I deal with it. It is sad that people think I am
not very smart and always seem surprised at how smart I really am. I just can't
operate electric things well, which in this day and age is not good or
fun. Additionally, computers and cell phones, as well as a few other devices
frequently act up, go out, or stop working for no apparent reason. I have been told
many times by the repair people that there is nothing wrong and have no clue why
it is doing what it is doing, and then they start to work. I can be doing something
on a computer no problem, and then for no reason it won't work and people can
see that I am doing things correctly, and have no idea why it is not doing it for me,
and then I will walk away and it works fine. I lose home-work and e-mails or
have 4 day delays getting an e-mail or dropped calls. My car battery goes out
faster then it should with no other electrical problems, same with wiper motors
and what not. The final thing is it is getting to the point I can not have anything
electric in my bedroom so I can sleep, and it is also affecting my work to the point

25
of being written up. I joke about it as well with people who know me, but it has
had an impact on my life.
Clearly, this experience is having a great impact on this participants life, to a
point where she is being written up at work due to consistent problems with being able to
use the cash register properly due to EME issues.
Another issue that participants reported was not being believed by others, which
often times resulted in suppressing sharing the experience, or at least trying to avoid
sharing it. Another participant shared:
As I started to talk about my experience and received negative feedback from
various people and organizations, my feelings changed and I became very
withdrawn, anxious, and felt different from others and sometimes alienated from
them. At some point I decided I would have to conform to what was expected of
me and put aside my feelings and experience and yet I still held on to it in some
deep part of me. It was not until I was around 39 years of age that something
triggered the full memory of my NDE and I am still trying to process it. I am
ashamed to admit that I have not lived up to the gift and knowledge that my NDE
gave me and became depressed and negative about life as I grew older. I am still
finding it difficult to integrate my experience, although gathering information and
reading books like PMH Atwater's, The New Children & Near-Death
Experiences, has helped greatly.
Another challenge that was reported by 60% (six) of the participants was feeling
nauseous, queasy, or dizzy in the presence of electricity or electromagnetic fields. One
participant described this as follows:

26
The worst is florescent lighting or electrical stores. I get severely sick in my
husband's electric car. Also, I can just say that I hate batteries of any kind and
complain of feeling sick or out of sorts with electrical stuff, so I don't use them
much. Going into a video/electronics store used to make me feel that I was going
to faint, and I still occasionally get ill when I am in there and have to sit down or
leave.
Other issues reported were problems with high rates of static electricity and
constantly being shocked. One participant shared the following in this regard:
I seem to generate or attract a lot of electricity myself and have to be careful
touching metal objects as I am always getting a small electrical shock. This can
happen when reaching for a can on a supermarket shelf, opening and closing a
vehicle door, or brushing the dog etc. I know this happens to other people but it
happens to me constantly. Also on windy days it becomes particularly bad with
clothes that I have been wearing (made from natural fibers) becoming alive with
electricity.

Psychic and/or Healing Abilities

Many researchers have noted psychic and/or healing ability aftereffects which
may cause integration struggles until experiencers learn how to balance or control these
experiences. Below is an overview of psychic and/or healing abilities noted by Fracasso
(2012) in her recent qualitative study. Fifty percent (five) of the participants reported

27
experiencing psychic and/or healing abilities after their NDE(s). A participant whom I
interviewed shared a compelling account of her experiences as follows:
Much of what has changed in my life is from my association with inter-stellar
beings who communicate with me and with my own growth through selfexamination. It has been a process, not something that immediately occurred after
I died. Additionally, my experience was blocked from consciousness because of
the nature of the death: I was over-medicated. It was not until 20 years later that I
had a spontaneous recall of being brought back to life in the recovery room by a
team of doctors, gagging and gasping for breath as they did whatever they did
under bright lights. Wherever I went while I was dead, I did not have a clear
channel of perception.
What is particularly compelling about this experience is two-fold. First, she did
not have a spontaneous recall of her NDE until nearly 20 years later and, second, she
reported experiencing ongoing communication with inter-stellar beings. This is similar to
reports in the literature where many NDErs reported being able to see and/or
communicate with angelic beings and/or spirit guides following their NDE(s) (Atwater,
2003; Clark-Sharp, 1995).
Other participants reported abilities to heal. For example, another participant
described her abilities as follows:
I am able to sense where energy blockages are and sense what people need to heal
them, and sometimes myself. I am a Reiki Level I practitioner. Also, when
speaking, or just thinking about a word, it immediately comes up on the radio or
TV.

28
Amber shared similar abilities and also chose to use her abilities to help heal
others. Amber expressed:
I now Tarot, do intuitive work, and healing touch work. Also, I have a belief that
there is Order in the Universe and that Love is Key to all evolution. That matter is
very heavy or dense spirit, and spirit is very light or higher vibrating matter. I am
also now vegetarian and feel connected to all kingdoms of beings very intimately.
Finally, I had many more experiences out of my body after the NDE. I grew up
with lots of paranormal activity around me, though. I was always curious about
whether people who grew up having paranormal activity were more probable to
have a later NDE.
Crystal also reported a similar ability to heal, although her experience was not
encouraged or supported by those around her when she was growing up. Crystal stated:
Others used to tell me that I had a calming and healing quality about me when I
was younger and I always felt that I had the ability to heal, although as a child this
was not always welcome by some.
Interestingly, Jade described an ability to slow down or speed up time since her
NDEs (four altogether), which is something that has only been rarely reported in the
NDE literature. Below is Jades fascinating account:
The issue with the watches/clocks. What happened for me was not
electromagnetic (I don't think). But after the NDEs I became aware of my ability
to speed up or slow down time as needed. This is not about the watch being
broken or the batteries going dead. In fact, it works best when I consciously do
NOT look at a clock or watch when I need to shift time. I just send the intention

29
of arriving at a certain time and it happens. I do not use this randomly. Probably
only one or two times a year - if that. But it is something I value highly as a gift of
my NDEs.
As stated above, the ability to speed up or slow down time is another area that
elicits the need for further research, as it has rarely been examined in the NDE literature.

PART 3
ASSESSMENT & DIAGNOSTIC CONSIDERATIONS
Mental Health Studies & NDEs
Over the past few decades, several studies have been conducted to assess NDErs
mental health. While many may experience higher rates of depression and anxiety, it is
important to note that this may be a normal reaction to an extraordinary event, and that
the profound changes that often accompany a NDE that may take several years to
successfully integrate. Therefore, Fracasso, Greyson, and Friedman (in press) highly
encourage practitioners to take this into consideration, and discourage the use of
diagnostic labels that may not be appropriate and applicable to many in the NDE
population. The American Psychiatric Associations (2000) Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; DSM-TR-IV) has created a specific
diagnostic label under V Code 62.89 for Spiritual or Religious Problem for issues that
do not qualify as a pathological disorder, which may more succinctly represent the NDE
and its normal aftereffects than other psychodiagnostic labels (see Lukoff, Lu, & Turner,
1998).

Dissociative and Post-Traumatic Stress Disorders

30
Researchers have found some NDErs report recurring auditory hallucinations that
they describe as internal voices (Bentall, 2000). However, Richard Bentall found that
97% who reported recurrent hallucinations found these experiences to be positive, and
that NDErs did not meet clinical criteria for dissociation, schizophrenia, or post-traumatic
stress disorder as outlined in the DSM-IV-TR (APA, 2000). Subsequent studies conducted
by Greyson and Mitchell Liester (2004) found the same results, indicating that NDErs
highly valued these experiences and functioned better psychologically as a result.
Other studies have focused on post-traumatic stress disorder (PTSD) and
dissociative symptoms following a NDE. Out of 194 NDErs, Greyson (2001) did find
higher rates of intrusive PTSD symptoms compared to non-experiencers, but not more
avoidance symptoms. Greyson suggested that avoidant-type behavior may be more
related to feelings of being different than others and not gaining validation, versus related
to trauma caused by the NDE. These findings are consistent with earlier findings from
Glen Gabbard and Stuart Twemlow (1984), who found that NDErs were psychologically
healthy and did not differ from normal controls. More recently, Parnia et al. (2007)
confirmed these findings and also reported that NDErs did not score significantly higher
than normal controls for PTSD or dissociative disorders.
However, more research is needed on those who report distressing NDEs. Richard
Bonenfant (2001) reported one case of a six year old boy who suffered PTSD following a
distressing NDE during a car accident. Bonenfant stated, The boys parents reported that
their son suffered from restlessness, anxiety, and nightmares for months following his
NDE (p. 93). While in this case it is difficult to determine whether the symptoms were
the result of the car accident or the NDE, distressing NDEs need to be explored further to

31
determine if the aftereffects present psychological challenges that differ from pleasurable
NDE accounts.

Schizotypal Personality Disorder and Psychotic Disorders

As for schizotypal personality disorder and other brief psychotic disorders, studies
have shown that NDErs differ in a number of ways. Schizotypal personality disorder
consists of perceptual and cognitive deficits that include pervasive interpersonal deficits
that are not seen in NDErs (Gabbard & Twemlow, 1984; Irwin, 1993; Locke & Shontz,
1983). David Lukoff. Lu, and Turner (1995) suggested that NDEs can be differentiated
from brief psychotic disorders by their acute onset following a stressful event, in addition
to their good premorbid functioning and positive attitude post-NDE.
To our knowledge, there are no studies in the academic databases presently that
have shown NDErs to meet criteria for any of the psychotic disorders. This is not to say
that this diagnostic category might not be applicable to some (perhaps pertaining to those
who had a mental health disorder prior to their NDE); however, as of this date, those who
had prior mental health disorders (especially of a psychotic nature) have not been
adequately studied to compare psychological functioning pre- and post-NDE. Moreover,
previous psychological diagnoses of any such psychotic disorders would need to be
differentiated from the NDE itself, as it is not common for NDEs to present with
psychotic aftereffects.

Childhood Antecedents & Personality Characteristics

Gabbard and Twemlow (1984) proposed NDEs are more likely to occur in
individuals who have personality characteristics prone to dissociation, absorption, or
fantasy-proneness. According to Gabbard and Twemlow, traits such as absorption allow

32
an individual to screen out the external world and focus on internal characteristics, which
make it more likely to experience a NDE under states of stress or trauma. Furthermore,
this theory proposed that individuals who report NDEs may be more prone to fantasizing
or daydreaming, and that the NDE is simply a psychological defense that may occur
under a high state of stress or trauma. However, several studies show contradictory
results and do not reveal significant relationships between NDEs and fantasy-proneness
personality traits (Britton & Bootzin, 2004; Brumm, 2006; Greyson, 2003; Wren-Lewis,
2004).
In addition, Ring (1992) compared 74 NDErs and 54 controls and found several
childhood antecedents in NDErs that he called the encounter-prone personality (p. 145).
While Ring found no statistical differences between the groups on fantasy-proneness, a
higher percentage of NDErs reported a sensitivity to alternate realities (p. 127), and
reported more psychic experiences as a child. Examples included awakening in the night
and seeing nonphysical beings, telepathic communication, premonitions, and other psirelated activity. Ring also found a higher percentage of NDErs reported childhood abuse
or trauma, and/or reported a stressful childhood due to severe illness. Ring suggested that
experiencing prior trauma or a stressful childhood may foster the development of
dissociative type of symptoms, leading to a sense of depersonalization and absorption
proneness, thus making some more susceptible to having a NDE. To our knowledge,
findings of this have not been researched further, so remain an area that needs to be
explored to assess whether these childhood antecedents are consistent in larger samples.

PART 4
THERAPEUTIC CHALLENGES

33
Research has indicated that there are both interpersonal and intrapersonal NDE
aftereffects that may occur in various stages, and about which mental health practitioners
could benefit from being aware. Some of the main issues involve disclosure barriers and
various integration issues that range from grief work, depression, divorce, career changes,
addressing any anomalous aftereffects (electrical sensitivity and/or ongoing psi-related
phenomena), and addressing distressing NDEs (Foster, James, & Holden, 2009).

Disclosure Barriers
Some initial barriers to working with a NDE client may surround reluctance to
talk about the experience due to fears of being labeled as mentally ill, as well as many
questioning their own sanity (Duffy & Olsen, 2007; Greyson, 1997; James, 2004;
Simpson, 2001). Cassandra Musgrave (1997) explored 51 NDErs attitudes post-NDE
and, among many positive aftereffects, found that 76% reported a reluctance to disclose
their experience due to fears of being ridiculed or rejected. Moreover, Regina Hoffman
(1995a, 1995b) explored disclosure tendencies and needs in 50 NDErs and found these
tended to occur in stages. The first stage entailed a sense of shock and surprise in trying
to make sense out of the NDE. Once the initial shock was handled, a need to have the
experience validated tended to occur. Following this, the impact the NDE had on their
lives started to become apparent, accompanied by the need to actively explore spiritual
and psychological implications of their experience. The final stage entailed how to
integrate this experience into their lives which, as Cherie Sutherland (1992) and many
other researchers have noted (e.g., Greyson, 2007; Greyson & Harris, 1987), can take
years.

34
Other researchers have suggested the initial reaction to a NDE plays a critical role
in the course and outcome of its aftereffects, which may require a team-oriented approach
to client care from the moment the NDE occurs (James, 2004). Because NDEs are
commonly happening in medical care facilities, there have been widespread training
efforts in this last decade focused on educating medical practitioners about NDEs, and
how to help a client who may have experienced one (Duffy & Olsen, 2007; James, 2004;
Simpson, 2001). Mental health practitioners can benefit from learning about some of the
guidelines medical practitioners have implemented in an effort to increase
communication among professionals, and to deliver proper treatment and referrals to the
NDE population.
In order to break through client reluctance to discuss their NDE and any
aftereffects, mental health practitioners can begin the dialogue by asking clients who have
survived a medical crisis if they remember anything during their period of
unconsciousness, and then assess client openness from there. Additionally, it is
recommended that clients be assured that many others have reported similar experiences
(while not discounting the uniqueness of their experience), and to educate them about the
nature of this phenomenon in order to reduce fears they may have about discussing their
experience.

Managing Transference & Countertransference

Managing transference and countertransference when working with the NDE
population is a salient issue that needs to be critically examined and reexamined
throughout the therapeutic relationship. Once a clinician and client have agreed to enter
into a therapeutic relationship together, there are many things that may surface during the

35
therapy session that may invoke strong, deep, heart-felt emotions about life and death for
both the client and therapist that may challenge psychospiritual growth. As clients begin
processing and discussing parts of their NDE, clinicians should be prepared for sudden
and/or spontaneous memories that may surface that transcend consensual reality, often
times beyond what the clinician may be able to comprehend. Some clinicians may find
aspects of what NDE experiencers (NDErs) are sharing surprising, or even shocking, so it
is important for clinicians to keep an open mind and to be aware of any thoughts,
feelings, or physical signs of bodily discomfort, which are often signs of
countertransference.
Countertransference situations may be triggered when clinicians have
spiritual/religious beliefs that conflict with what the client is sharing about their NDE.
For example, a client may be expressing a longing and desire to return to the light that
they experienced during their NDEdescribing it as the fullest and purest form of
unconditional love that is not comparable to any love experienced in this material realm.
A clinician who has never had a NDE may not be able to comprehend why this may be
such an important aspect of integrating the NDE, and may be prone to redirect the client,
misunderstand the client (i.e., think that they are expressing suicidal ideation, when it
fact, they are not), or engage the client deeper in an attempt to alleviate their own fears or
unresolved issues about life and death. To avoid these pitfalls, it is recommended that
clinicians keep the best interests of the client in mind at all times, ensuring that therapy is
a safe environment for clients to share and explore thoughts, feelings, and emotions
without judgment or unconscious motivations of the clinician.

36
Client discussion of anomalous experiences such as electromagnetic aftereffects
or psychic and/or healing abilities may be particularly vulnerable topics that can lead to
countertransference, especially if the clinician is struggling to believe what the client is
sharing. Therefore, as recommended during the assessment and diagnosis section of this
course, it is highly recommended that clinicians take all of this into consideration before
choosing to work with a NDE client. Otherwise, ethical issues can arise that violate a
clients rightsespecially revolving around the ethical principle do no harm and
respecting and valuing the clients right to autonomy. This may be difficult for a clinician
to achieve if there are too many aspects of the NDE that conflict with or challenge
personal biases, beliefs, values, and opinions. Moreover, it is important to keep in mind
that as of this date, the occurrence of NDEs challenges mainstream and materialistic
paradigms, and may very well challenge clinicians professional training and academic
background. However, what is important to keep in mind is that clinicians do not have to
agree with or believe what the client is sharing, but are obligated to recognize and respect
the fact that this is a real experience to the client and it is not the clinicians place to
convince clients that their experience is not real. Invalidating or trying to convince a
client to incorporate the clinicians view is not only an ethical violation of the APA Code
of Ethics (APA, 2003), but clinicians who engage in those sort of practices run the risk of
violating client rights to autonomy, and may cause harm to the client which is grounds for
a potential lawsuit. It should also be noted that clinicians who may be tempted to change
the clients mind about any aspects of the NDE (i.e., questioning its validity or trying to
explain it away), or who attempt to pathologize it, are probably not the best

37
candidates to work with this population and should consider referring clients to
competent practitioners knowledgeable about NDEs and their aftereffects.

PART 5
ETHICAL ISSUES
Multicultural Sensitivity: Working with Diverse Client
Populations: What Does this Mean?
A. multiculturalism is defined as any relationship between and within two or more
diverse groups (Correy, Correy, & Callanan, 2011, p. 115). This includes values, beliefs,
and actions influenced by the clients ethnicity, gender, race, religion/spirituality,
socioeconomic status, sexual orientation, political views, geographic region, and
historical experiences with the dominant culture.
B. multicultural counseling: using therapeutic strategies or interventions that are
consistent with the life experiences and cultural values of clients: balances using
individualism versus collectivism in assessment, diagnosis, & treatment
C. cultural diversity competence: a practitioners level of awareness, knowledge, and
interpersonal skills when working with individuals from diverse backgrounds

Challenges Connecting With Diverse Client Populations

A. cultural tunnel vision: assuming ones cultural values and beliefs are the
norm
B. traits of culturally encapsulated counselors
--defines reality according to one set of cultural assumptions

38
--insensitivity to cultural variations among individuals
--accepts unreasoned assumptions without proof, or ignores proof
--fails to evaluate others viewpoints
--trapped in one way of thinking, resists adaptation, and rejects
alternatives
C. psychology--Western assumptions and bias: may not be applicable or useful to
many cultures
1. understand clients cultural backgroundidentify resources in clients
family or community and use them to deliver culturally sensitive services
2. understand clients historical background with the dominant culture
(African American, Native American, Asian, and so on) and how/why they
may be distrustful due to unequal treatment in the past
3. understand why some cultures underutilize therapeutic services (i.e.,
Asian Americans who may reach out to their cultural community first,
and seek therapy as a last resort; Native Americans who may have tried
other cultural healing modes that didnt work, or reached out to family and
did not get help
4. lack of assertiveness is not always a sign of dysfunctional behavior, as
not all cultures will respond well to talk therapy
D. Eastern versus Western values
1. Eastern: places high value on broader social contexts such as families,
groups, and communities

39
2. Western: strong emphasis on individualism, patriarchal nuclear family, measurable and
visible accomplishments, self-reliance and motivation, individual choice and
responsibility, keeping busy

Case Study: Asian Female

Mari is a 61 year old Asian female who had her NDE in the summer of 1970 due
to an attempted suicide via pills (she tried to overdose by taking about 50 anti-histamine
pills). Mari states she grew up in Japan with very strict parents, and when she met her
boyfriend in college her parents deeply disapproved of him, thus causing her to break up
with him. She states she was deeply depressed following this and did not want to live
anymore. She also shared that suicide and abortion runs very high in the Japan culture,
and that her parents told her they had tried to abort her when they first found out her
mother was pregnant. According to Mari this is a common practice in Japan when parents
become aware that they may be carrying a female. Another interesting aspect of Maris
NDE is that she stated that she was in a field full of flowers with incredible peace. Mari
states that this also seems to be common with other Japanese who have had NDEs. She
did not experience telepathic communications or see a light, but knew she was dead.
Suddenly she was then back in her body and very upset that her attempted suicide did not
work.
Following this Mari states she noticed immediate changes. She reports having
several precognitive experiences, and extensive communications with entities, spirits, or
people who have passed on. She states she found these experiences somewhat scary, but
was curious at the same time. Mari shared a profound experience that happened the day
her friend died of cancer. Mari stated that her friend and 3 entities physically appeared

40
to her while she was sleeping one night and woke her up. Her friend physically touched
Maris hand and said she was just coming back to say thank you before she left. Mari
started crying during the phone call at this point. A few days later when Mari was at her
friends funeral she said she looked at her hands, and they were the exact hands that
touched her during the visit that one night. Mari describes being very confused by these
experiences at first and wanted them to stop. So she sought the help of a spiritual person
in Japan who told her to put silver taped with medical tape on the base of her spine
(around the area of the stomach, but on the back). According to this spiritual person, this
is where souls are able to enter and connect, and using tinfoil would block them from
being able to connect with her. Mari was also told that she would eventually notice tiny
holes in the tinfoil from the spirits leaving. Mari tried this and stated the entities
eventually stopped coming to her as often. Mari did not describe these entities as evil,
but rather as there to try to help her. She states she spent many years depressed and when
in that frame of mind post-NDE it somehow opened the door for these entities to want to
come to her to help. She describes being more healed and balanced all these years later,
and in a much more positive frame of mind, thus not needing these entities to help her
anymore. She states this is one of the things she had to learn post-NDEwas how to love
herself and to become more independent.

Ethical Issues in Working with Managed Care

A. low income clients may be reliant on health insurance to obtain services
B. Sessions are limited, brief therapies are emphasized, and a diagnosis that is
approved by the insurance company is required to be reimbursed

41
1. confidentiality issues: clients records will be reviewed by insurance
company
2. diagnosis could permanently follow them
3. ethical issue of not abandoning clients
C. V-Code 62.89 is not reimbursed by insurance companies

PART 6
INCREASING CLINICAL COMPETENCE
Therapeutic Suggestions
Several treatment approaches have been recommended by practitioners who have
worked with the NDE population, which are predominantly focused on helping clients
integrate this experience into their daily lives. Although empirical research needs to be to
test the efficacy of these methods, the below strategies were put together by a panel of
NDE researchers who have spent years working with the NDE population (Atwater,
2007; Greyson & Harris, 1985). Below is a recent list of strategies outlined by Greyson
(1996, 1997, 2007).

Therapeutic Approaches Immediately Following a NDE

Appreciate unexpectedness. Because clients have not had time to prepare (due to
not expecting a traumatic experience to happen), a key to working with NDE clients is an
appreciation of the unexpectedness of the experience.

42
Reorientation. Immediately following the NDE clients may be extremely
confused and disoriented. Researchers suggest that grounding techniques geared towards
stimulating verbal and tactile senses may help them become more aware of body
consciousness.
Clarify and reflect. Avoid interpreting the meaning or reason the NDE occurred,
and instead listen attentively and help the client clarify and reflect on the experience.
Diagnostic labels. Immediately following a NDE if a client does have another
psychological disorder make sure they understand the NDE is a distinct phenomena not
related to their other diagnosis.
Education. Provide NDErs and their family and friends literature on NDEs to
ensure them many others have reported this experience and that the experiences they are
dealing with are not abnormal. However, ensure that normalizing the experience does
not discount the uniqueness of their experience.
Avoid victimization. Avoid a sense of victimization by encouraging the client to
grieve for the loss of the ego (or shallower parts of the old self that they may choose to
leave behind).
Expression of ineffable. Help clients try to express the ineffability of the
experience through non-verbal therapies such as hypnosis, guided imagery, or art therapy.
Here and now approach to therapy. Using a here and now approach to therapy
may help clients integrate the experience into their daily lives. Helping them realize what
the experience means and how this impacts daily living can help them make sense out of
the experience and facilitate growth.

43
Couples or family counseling. Because of the high divorce rate amongst the
NDE population it is important to offer couples or family counseling early on to help
family members understand the dramatic lifestyle changes the NDEr may undergo. This
can help the client gain validation and support from family and/or friends, and may
reduce the later onset of feelings of alienation and isolation, which can result in divorce.
Support groups. Refer the NDEr to support groups such as IANDS so that they
can explore problems and solutions with other experiencers. Researchers suggest this
may help reduce the sense of bizarreness about the experience.
Spiritual crisis. For those who present with psychospiritual crisis, grounding
techniques such as mindfulness meditation or yoga have been found to be effective in
helping clients get reoriented to the here and now. Additionally, meditation may help
clients relive the experience and gain new insights into how to integrate the experience
into daily living.

Long-Term Therapeutic Approaches

Before entering into a therapeutic relationship with a client who has undergone a
NDE, Greyson (1996, 1997, 2007) points out it is important for mental health
practitioners to realize that the NDE and its after-effects may impact the therapists own
psychospiritual growth. Therefore, Greyson suggests it is important for the therapist and
client to both discuss what their expectations are in therapeutic relationship, as well as
desired outcomes. Below are some useful techniques (Greyson, 2007).
Limits on therapeutic relationship. Researchers found it is important to clarify
at the onset of therapy that the NDE is distinct from other problems and to clarify specific
issues resulting from the NDE. If a client presents with various issues, it may be helpful

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to refer to the client to another therapist to help with non-NDE related problems to avoid
a conflict of interest when helping clients integrate the NDE.
Trust. It may take clients a little longer to trust even the most sensitive and
compassionate mental health practitioners due to the contrasting difference between
experiences encountered during the NDE and consensual reality. Likewise, therapists
may struggle with believing things shared by the client and so it is imperative for mental
health practitioners to be aware of their own thoughts, feelings, and biases.
Flexibility in frequency and length of sessions. In order to establish rapport
with NDE clients, rigid adherence to traditional therapeutic approaches which encourage
an objective, analytical stance should be avoided. Researchers have found this only
serves to distance the client and may interfere with fostering clients psychospiritual
growth. Likewise, length and frequency of sessions should be more flexible to allow
clients to explore ineffable concepts and overwhelming emotions that may result.
Encourage grief work. Due to the dramatic impact NDEs commonly have on
lifestyle values, beliefs, and attitudes, it is recommended that mental health practitioners
should help clients grieve parts of their ego that may been radically transformed, or
died as a result of the NDE.
Free association of anomalous details. Researchers suggest therapists should
encourage clients to explore anomalous details of the experience on numerous levels such
as through dream analysis, guided imagery, art therapy, and/or meditation. By
encouraging clients to engage both right and left brain hemispheres may help clients
describe ineffable experiences and may provide insights into specific problems of
integration.

45
Explore life purpose. Because many clients struggle with being sent back, and
questioning their life purpose, exploring these new life values can help reveal underlying
problems the client may be struggling to integrate. For example, many report they chose
to come back to life, and it may be helpful to explore why they chose to come back.
Additionally, feelings of guilt and remorse may be related to their return, so these are
important areas to explore with the client.
Explore fears of unwanted after-effects. It is important to help clients
distinguish the NDE versus the after-effects of the NDE. This can help clients reject or
resist negative after-effects without having to devalue the NDE itself.
Explore family dynamics. Due to drastic changes in lifestyle values and beliefs,
this can often dramatically alter relationships with family and/or friends, and leave clients
feeling alienated and isolated. Therefore, some researchers have found it helpful to make
home visits and/or encourage family therapy.
Support groups. While it is important for clients to gain validation from other
experiencers, because of the transcendent nature of the NDE one downside to group
therapy with other experiencers is that it can sometimes encourage clients to devalue
worldy matters which can lead to further problems. Therefore, therapists can help clients
reaffirm the importance of the here and now and what can be learned from the
experience.
Encourage constructive action. Once clients have integrated the after-effects of
a NDE and internalized new beliefs, values and sense of life purpose, it is important to
encourage them to help others. Experts who have worked with NDErs suggest the

46
therapeutic work is done when clients have found a way to actualize a sense of
unconditional love experienced during the NDE and share it with others.
In summary, once NDErs are able to adapt the various stages of integration into their
daily lives and reach out and help others, Greyson (1996, 1997, 2007) suggests the
therapeutic relationship should potentially come to a close.

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Referral resources
American Center for the Integration of Spiritually Transformative Experiences (ACISTE)
website: http://www.aciste.org
American Psychological Association: Ethical Principles of Psychologists and Code of
Conduct (including 2010 amendments) (2003)
website: http://www.apa.org/ethics/code/index.aspx
American Psychological Association: Guidelines on Multicultural Education, Training,
Research, Practice, and Organizational Change for Psychologists- American
Psychological Association (2002)
website: http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx
International Association for Near-Death Studies (IANDS)
website: http://www.iands.org

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