Spiritists Compared to Mental Health Professionals in Puerto Rico and Brazil Alexander Moreira-Almeida and Joan D

Psychiatry 72(3) Fall 2009 268

Treatment in Puerto Rico and Brazil Moreira-Almeida and Koss-Chioino

Recognition and Treatment of Psychotic Symptoms: Spiritists Compared to Mental Health Professionals in Puerto Rico and Brazil Alexander Moreira-Almeida and Joan D. Koss-Chioino

This article expands psychosocial and cultural perspectives on the experience and expression of psychotic symptoms and the treatment of schizophrenia by exploring how Spiritism, a popular religion in Latin America, provides healing to persons with severe mental illness. Beliefs and treatment by Spiritist healers of persons with psychotic symptoms, some diagnosed with schizophrenia, are described. Reactions by mental health professionals (psychologists, mental health technicians and psychiatrists) to this alternative treatment are described. Qualita- tive data have been collected through in-depth interviews with 49 Spiritist mediums in Puerto Rico,and case histories of 22 patients and their family members, all of whom gave informed consent. In Brazil, interviews were conducted with a sample of 115 Spiritist mediums, with their informed consent. These mediums responded to semi-structured interviews and standard measures of social adjustment and mental health. As expected, beliefs and practices of Spiritist healers regarding psychotic symptoms, whether manifested by themselves or by clients diagnosed with schizophrenia or other disorders, differ substantively from conventional psychiatric constructs and treatment approaches. According to patients’ self reports and researchers’ observations, spirit healers often achieve positive re- sults with persons manifesting psychotic symptoms or diagnosed with schizophrenia in that symptoms become less frequent and/or social adjustment improves. We suggest psychosocial mechanisms to explain these findings and raise questions for future research.

Recent studies describe how persons with schizophrenia and other severe mental illness cope with their distress through religious faith and spirituality, especially when experiencing existential crises or when attempting to reestablish a sense of self (Sells, Stayner, & Davidson, 2004; Tepper et al., 2001; Wagner & King, 2005; Weisman, 2000). These studies are related to an increasing recognition of the relevance of spirituality to mental health issues (Moreira- Almeida, Lotufo Neto, & Koenig, 2006) and to a broader perspective on schizophrenia and

Alexander Moreira-Almeida, MD, PhD, is Professor, Núcleo de Pesquisas em Espiritualidade e Saúde, Federal Uni- versity of Juiz de Fora, School of Medicine, Juiz de Fora, MG, Brazil. Joan Koss-Chioino, PhD, is Professor Emerita at Arizona State University and Research Professor at George Washington University, Washington, DC. Address correspondence to Joan D. Koss-Chioino, Ph.D., 2753 Bon Haven Lane, Annapolis, MD 21401. E-mail: [email protected] or Alexander Moreira-Almeida at [email protected]. Moreira-Almeida and Koss-Chioino 269

psychosis, which has partly shifted in the last and disability. Differences between develop- four decades from investigating individuals ing and developed countries related to bet- subject to a common pathological process, ter versus worse outcomes (such as extent of to biopsychosocial models that include fami- symptom remission and social adjustment) lies, communities, and cultural contexts, as were not explained because accounting for well as consideration of both the expression cultural factors proved too complex. of the disorder and responses by relative/ Ethnographic studies of ethnic groups caretakers (Carpenter, 2006; Guarnaccia et in the United States have investigated cultural., 1992a; Katz et al., 1988; Lopez et al., al conceptualizations around expressions of 1999; Murphy, 1981). Although it is now schizophrenia, interpretations of the mean- widely accepted that there are core biologi- ing and valence of symptomatic behavior cal elements in these disorders, it is also ac- and the nature of the illness (Corin, 1998; knowledged that behavioral and expressive Garrison, 1978; Guarnaccia et al., 1992b; aspects vary with cultural context. In this Jenkins, 1988a; 1988b; 1991; Koss-Chio- exploration we raise questions regarding the ino, 1992; Koss-Chioino & Cañive, 1993; effects on severe mental illness when the cul- Swerdlow, 1992). These studies are based tural environment includes popular healing on direct observations of patterns of inter- systems as alternatives or complements to actions with and around the schizophrenic mental health treatment. patient (including evaluating the cultural The International Pilot Study of Schizo- relevance of standard diagnostic assessments phrenia (IPSS; Cooper & Sartorius, 1977) as in Guarnaccia and colleagues, 1992a), originally suggested three factors to explain and the actual or potential impact of these cross-cultural differences in outcomes for interactions on the nature and/or course of persons diagnosed with schizophrenia: 1) the disorder. As noted by Guarnaccia et al., variation in patterns of organization of fami- (1992a, p. 100), the content of “normal ex- lies and communities with regard to socio- periences and those labeled ‘madness’ vary economic arrangements, such as work and widely across cultures.” wages; 2) different biological bases of the Despite a considerable expansion of in- disorder in patients similarly diagnosed; and formation on the factors that may affect the 3) differences in treatment modalities, includ- course and prognosis of schizophrenia, set ing traditional medicine. Critics have pointed within a broader social and cultural frame, to the relative lack of detailed ethnographic relatively few studies systematically explore data on how social arrangements respond to the impact of treatment alternatives, such as and in turn affect severely mentally ill per- non-conventional treatments by spirit heal- sons (Cohen, 1992; Hopper, 1992). A more ers, and the role they may play in the course recent WHO study, the International Study of of the disorder. Although the complementary Schizophrenia (ISoS), recruited subjects from use of traditional and medical healers by per- the IPSS. It examined the long-term history of sons in psychotic states has been document- outcomes in developing countries compared ed for a number of societies for some time to developed countries and explored cultural (Koss-Chioino, 1999; Lambo, 1978; Redko, factors. For 2 years prior to enrollment in the 2003; Zacharias, 2006, among others), how study, more than 40% of the subjects had no the use of these treatment modalities, simul- psychotic symptoms and 60 to 70% worked taneously or sequentially, might impact on full time (Hopper et al., 2007). Those with the recognition and treatment of psychotic an episodic (as opposed to a chronic) course symptoms, and on the course of schizophre- had more favorable outcomes. More time in nia or other disorders, has rarely been sys- a psychotic state predicted future symptoms 270 Treatment in Puerto Rico and Brazil

tematically examined (Edgerton, 1980; Gar- Data Sources rison, 1978). There are a number of studies of religion and spirituality in relation to psychosis In Puerto Rico, the second author re- (e.g., Corin, 1998; Kelly & Gamble, 2005; corded the cases of 53 persons diagnosed Koenig, 2007; Sullivan, 1998), but reports of with schizophrenia (according to DSM-IIIR a recent study by Mohr and colleagues (2006) criteria [APA,1987])in three community and Huguelet and colleagues (2006) are of mental health clinics; twenty-two of these special interest. These researchers see the role patients consulted Spiritist healers. The of spirituality as a resource for finding mean- ways Spiritist healers recognized and treated ing and hope, as well as “a key component symptoms in identified patients were system- in the process of psychological recovery” atically observed; the Spiritist healing ses- (Mohr et al., 2006, p. 1952). To demonstrate sions where these patients were treated were this assumption, they recruited a sample of tape recorded. Cases treated by Spiritists 120 patients diagnosed with schizophrenia were then compared to conventional mental in four outpatient clinics in Switzerland in health treatment (provided by a staff of clini- a design that explored religious beliefs and cal psychologists, psychiatrists, and mental activities, religious and spiritual coping, and health technicians) of similarly diagnosed adjustment to life events. They found religion patients that were discussed in case review to be important in the lives of 85% of the pa- conferences between mental health profes- tients; 71% used religion as a positive way of sionals in the public health system and Spir- coping and 14% as a negative way of coping. itists (Koss-Chioino, 1992). The first author For two-thirds of the patients, religion gave conducted investigations of a sample of 115 meaning to their illness, mainly through pos- mediums recruited from randomly selected itive connotations. (See also Koenig’s [2007] Spiritist centers in São Paulo, Brazil. That broad review on religion and psychotic dis- study investigated medium-healers’ concepts orders.) regarding psychosis, and explored charac- This paper explores the use and effects teristics related to the mental health of those of the concepts and practices of Spiritism, a mediums who manifested identified “psy- popular religion in Puerto Rico and Brazil, chotic symptoms.” Through interviews and on the expression and labeling of psychotic standard questionnaires (Self-Report Psy- symptoms, the behavior of persons diag- chiatric Screening Questionnaire – SRQ; So- nosed with schizophrenia, and the form and cial Adjustment Scale Self-Report - SAS-SR; effects of spirit healing practices on persons Dissociative Disorders Interview Schedule – who seek help from Spiritists. It briefly con- DDIS; and Schedules for Clinical Assessment siders how mental health professionals in in Neuropsychiatry - SCAN) with Spiritist those countries have views that differ from healers, he was able to establish categories those of Spiritists. It is not a systematic com- that distinguished normal from abnormal parison of Spiritist phenomena in Puerto behavior in these persons, even though as- Rico and Brazil, but rather the presentation pects of their behavior resembled psychosis and integrated discussion of two groups of (Almeida, 2004; Moreira-Almeida et al., studies (carried out in Puerto Rico and Bra- 2007; 2008). Written informed consent was zil) that investigated how Spiritists frame obtained from patients, mental health profes- opinions and treat people reporting psychot- sionals, and mediums in both sets of studies. ic symptoms. Moreira-Almeida and Koss-Chioino 271

The descriptions of interactions be- discarnate personality could communicate tween mental health professionals and spirit through a medium). After comparing and healers in Puerto Rico, and between spirit analyzing mediumistic communications ob- healers and their patients, have been recon- tained through hundreds of mediums from structed from observations and case materi- different countries, Kardec organized the als collected in the Therapist-Spiritist Proj- information into a spiritualist philosophy ect in Puerto Rico (Koss-Chioino, 1992).1 he called “Spiritism.” Spiritism supports the Interactions have been investigated in Brazil survival of consciousness after death (called through documents on the historical rela- spirits), reincarnation, and the possibility of tionship between psychiatrists and Spiritists communication between living persons and (Moreira-Almeida et al., 2005), conceptual- discarnate spirits through mediums. There is izations of mental disorders reported by Bra- a strong emphasis on ethical behavior (in line zilian Spiritists (Moreira-Almeida & Lotufo with the essence of Jesus’s ethics) as the way Neto, 2005) and the mental health relevance to happiness and a balanced life (Kardec, of what might appear as psychotic and disso- 1986; 1996; 1999). ciative experiences among Spiritist mediums A few years after starting in France, (Moreira-Almeida, et al., 2007; 2008). These Spiritism spread to Europe and Latin Amer- data provide a wide phenomenological, in- ica. Since that time, it has waxed and waned teractive perspective in which schizophre- in social and political importance but has nia, psychotic symptoms and their popular remained a popular healing alternative for equivalents are described through patients’ persons from all social classes in Brazil and and healers’ reports, researchers’ observa- Puerto Rico. Organized groups of Spiritist tions, and historical documents. practitioners can now be found in at least 39 countries, including the United States (Inter- national Spiritist Council, 2008). Currently Background on Spiritism in Brazil is the country where Spiritism is most Puerto Rico and Brazil widespread and is one of the most important religions (Aubrée & Laplantine, 1990; Mor- eira-Almeida & Lotufo Neto, 2005). The Spiritism is a French branch of the healing centers and hospitals that identify as spiritualist movement that developed in Spiritist are usually organized and supported Western countries in the 19th century. It was by middle and upper class persons. developed between 1855 to 1869 by Allan In Puerto Rico the majority of the cen- Kardec (1804-1869), a pseudonym for a ters are embedded in lower class communi- French intellectual who performed a scien- ties and most frequently found in rooms or tific investigation on supposed manifestation annexes attached to believers’ homes. His- of spirits. After considering several possible torical and descriptive accounts of Spirit- alternative explanations, he thought that ism and its practices among Puerto Ricans at least some mediumistic experiences were on the island and in the northeastern United best explained by the survival hypothesis (a

1. Four studies were funded by the National Institute of Mental Health and sponsored by the Department of Health of Puerto Rico, Joan D. Koss-Chioino, P.I. 1979–1980 Therapist-Spiritist Training Project in Puerto Rico, National Institute of Mental Health (MH-15992-01), Health Department of Puerto Rico, Rio Piedras, Puerto Rico. 1976–1979 Therapist-Spiritist Training Project in Puerto Rico, National Institute of Mental Health (MH-14310-03), Health Department of Puerto Rico, Rio Piedras, Puerto Rico. 1969-1970 Social and Psychological Aspects of Spiritism in Puerto Rico, National Institute of Mental Health (MH-17997-01). 1968–1969 Social and Psychological Aspects of Spiritism in Puerto Rico, National Institute of Mental Health (MH-14246-01). See Koss-Chioino (1992; 1996) for details on the projects and the subject. I wish to acknowledge my appreciation to the Department of Health of Puerto Rico who sponsored the projects and to the National Institute of Mental Health who funded them. They are in no way responsible for what I report here. 272 Treatment in Puerto Rico and Brazil

States can be found in Koss (1975; 1976), adds a spiritual component to this model. As Koss-Chioino (1992),Garrison (1977) and is also the case for Puerto Rico, the persistent Harwood (1977). negative influences of disincarnated spirits In spite of a strong, initial opposi- (called “obsession”) or trauma experienced tion from medical societies and the Catholic in previous lives are considered etiological to Church (in Europe and Latin America), Spir- mental disorders, in association with psycho- itism has become an important but under- social and biological factors. The presence of studied aspect of Brazil’s health care systems an obsession is detected during mediumistic (Almeida, 2007; Moreira-Almeida et al., meetings when the obsessing spirit commu- 2005). There may be as many as ten thousand nicates through mediums or when a spiri- Spiritist centers that provide free counseling, tual guide manifests through a medium and emotional, spiritual, and material support, explains the cause of the patient’s problem. and free spiritual and medical treatments. All Given their “bio-psycho-socio-spiritual” Spiritist centers are entirely based on charita- model of mental disorders, Spiritist séances ble, voluntary work (Sampaio, 2004). In ad- for dis-obsession are recommended, as well dition, there are approximately 50 Spiritist as “passes” (laying on of hands), prayers, psychiatric hospitals (Figueiredo & Ferraz, and injunctions to live according to ethical 1998). All of these psychiatric hospitals of- principles. In treating a client considered fer a combination of orthodox medical/psy- obsessed, the focus is on dissuading the ob- chological care and Spiritist therapies. The sessing spirit of its purpose of doing harm level of integration of these approaches and to the distressed client by means of dialogue the importance attributed to Spiritist thera- between the medium(s) and the distress- pies varies among these different institutions causing spirit. The obsessing spirit is brought (Puttini, 2004). In contrast, in Puerto Rico, to the table and possesses a medium for this except for the project described below, there purpose. Another major aspect of Spiritist has not been a formally structured integra- healing is helping the patient regain his or tion of medicine and Spiritism, which can be her spiritual balance through fostering mor- traced to the influence and domination of the al growth, prayers, readings, and “passes” conventional medical model of treatment ac- (Moreira-Almeida & Lotufo Neto, 2005). cording to United States’ standards of care. Spiritist treatments are always (and There are medical doctors (approximately by proscription) free of charge, both in psy- 60, according to data collected over the past chiatric hospitals and Spiritist centers. Un- year) who are also Spiritists. However, those like Puerto Rico, where there is separation who have developed as spirit mediums keep between medical and mental health care ser- their medical and Spiritist practices separate vices and alternative healing practices, many and do not share their beliefs with colleagues Spiritist centers in Brazil also provide free or patients. medical treatment for physical or psychiatric ailments. In Brazil, compared to Puerto Rico, Kardecist Spiritist centers (as contrasted with Spiritist Concepts of Mental Umbanda, a Brazilian syncretic religion de- Disorder and Treatment veloped in the beginning of 20th century) tend not to include Catholic, indigenous Native American or African-derived religious beliefs The Spiritist view of mental disorders, and practices. However, they do speak about as derived from Kardec’s writings, accepts God and follow Jesus’ teachings. fully the biopsychosocial model for the etiology and treatment of mental disorders but Moreira-Almeida and Koss-Chioino 273

TABLE 1. Identification and Treatment of Schizophrenia by Spiritists Conceptual a. loco tranquilo vs. loco loco (quiet versus out of control crazy persons) b. fear of appearing crazy: social stigma and social conformity c. belief in the hereditary: one “has nerves” in the family d. two types of locura (craziness): 1. brain lesions 2. spiritual (one does not know oneself) Experience e. “mind” can be disordered, absent, goes blank, stalled, warped, running on, turned over (also many auxiliary complaints, such as depression, nervousness, family and marital problems) Causality f. spirit is interlocked with or hooked onto person g. severely “obsessed” h. a perennial thought invades the mind if person has a large emotional burden or great tension i. vulnerability subsequent to a “nervous shock” Treatment j. passes magneticos take off molesting spirit(s) k. healing mediums lend bodily energy to evict the obsessing spirit; intense empathic/emotional support l. restore patient’s own spirit m. tranquilizing rituals (use of balsamo-spirit magnetized water); calming by protector-guide spirits) n. reinterpretation of visions (corrective spirit experiences)

Is Mediumship related to Interestingly, frequency of full trance medi- Emotional Disorders? umistic experiences during last month cor- related with better social adjustment scores and lower numbers of psychiatric symptoms. The investigation of 115 mediums in Brazilian Spiritist mediums also differed Brazil found a mean age of 48 years, 76.5% from dissociative identity disorder patients were female, 46.5% had a college degree, and in most clinical features (Moreira-Almeida et all had a low prevalence of childhood abuse al., 2007; 2008). (Moreira-Almeida et al., 2007). Except for educational level, this profile is very similar Basic Conceptual to that of mediums in Puerto Rico. Mediums Differences between in the Brazilian study had a sound social ad- Spiritists and Mental Health justment score, a low prevalence of mental Professionals disorders, but a high level of dissociative and psychotic experiences. Although these mediums reported a high frequency of Schneide- A number of expressions having to rian First Rank Symptoms of schizophrenia, do with disturbed mental function describe these symptoms did not correlate with child- what psychiatry identifies as psychotic hood abuse, other psychiatric symptoms on symptoms: the mind is “stalled,” “turned the SRQ, or poor social adjustment. Such around,” “blocked,” “has departed,” or findings strongly suggest that reported ex- “gone blank.” The condition of “madness” is periences that look like psychotic or disso- often attributed by Spiritist mediums to hav- ciative symptoms among mediums are not ing a spirit interlocked or hooked onto a cli- necessarily indicators of mental disorders. 274 Treatment in Puerto Rico and Brazil

TABLE 2.

Therapist Cases Spiritist Cases (Reclassified) Complaint Frequency Complaint Frequency Schizophrenic disorders n = 53 Schizophrenic disorders n = 1 Sleep disturbances 46.0 Feels depressed 100.0 Hostility 47.0 Nervousness 100.0 Hallucinations 45.0 Family problems 100.0 Intranquility 38.0 Marital problems 100.0 Headaches/head problems 34.0 Crying jags 26.0 Nervousness 26.0 Feels depressed 19.0 Source: Compiled by author. ent. A distinction is made between “physical Experiences labeled hostility and hal- madness” (i.e., craziness caused by lesions in lucination/delusions in particular are of the brain due to injury or severe illness) and highest frequency in the symptom profiles “spiritual madness” (attributed to a failure of those diagnosed with schizophrenic disor- to know one’s own spirit or “who I am”). ders. As observed by the psychologists and a The former type of madness is often credited psychiatrist consultant to the research team, to heredity (see Table 1). the content of hallucinations and delusions However, we could not identify cases appears associated with deep fears over lack of schizophrenia using statistical measures of control and self-sufficiency, that is, the of symptom expression in the Puerto Rican ability to survive on one’s own. Spiritist sample compared to mental health The greatest conceptual difference patients. This led to understanding a signifi- between Puerto Rican Spiritists and mental cant difference between Puerto Rican Spiritist health professionals is that practicing Spir- perceptions of severe distress by “obsession” itist mediums do not identify a category of (roughly equivalent to severe emotional dis- symptoms or experience labeled “hallucina- order) and the ways schizophrenic disorders tions/delusions.” Bentall (1990) points out are perceived and diagnosed in mental health that several authors have questioned wheth- clinics. “Sleep disturbances,” “hostility,” er hallucinations need always be considered and “hallucinations/delusions” are the most pathological. He notes that in cross-cultural frequent complaints of women diagnosed studies hallucinations are not always indica- with schizophrenia in the mental health clin- tive of pathology but rather perceived to be ics. These complaints can be viewed as key valued experiences (see Al-Issa, 1978, for ex- discursive symbols in semantic and behav- ample). Guarnaccia and colleagues (1992b) ioral complexes that typify the experience of assert that for Puerto Rico, what may be schizophrenia in a community mental health identified as a hallucinatory experience needs sample in Puerto Rico. Although these com- to be assessed for cultural consonance, given plaints also appear in other symptom profiles the prevalence of the kinds of religious expe- of higher rank categories, in combination riences described earlier. they appear to express a common experience A key issue may be that of control over of schizophrenia among patients. (see Table the experience rather than the type of expe- 2). rience itself, which seems to be what Spir- itist mediums focus on when they decide if Moreira-Almeida and Koss-Chioino 275

the individual is obsessed by a spirit to the observing entity. In other words, the client’s point of being different from other distressed own spirit was not present in order to be persons. In the Puerto Rican study described credited with disordered thoughts! In some earlier, persons diagnosed with schizophre- cases, however, when visions of the spirit nia were recognized by Spiritist mediums as world do not conform to expectations (they spirit-obsessed and unable to control the ef- have a limited pattern), they are rejected as fect of the spirit on their bodies and behavior. “true” experiences of spirits. They are instead However, it appeared that not all spirit- ob- attributed to “mental confusion” introduced sessed persons were in out-of-control states. into the person’s mind by molesting spirits. As described in the case of Celia presented below, even those who were diagnosed as Kardecist Spiritism in Brazil: schizophrenic before seeing the spirit heal- Somewhat Different Views ers were not considered continually obsessed since they seemed to recover “normal” behavior after spirit treatment. It is worthwhile noting that the denial This view by Spiritists of the non-per- of the existence of hallucinations/delusions sistent role of what is labeled in psychiatry is not shared by prominent Brazilian Spirit- as hallucinatory behavior, and the attribu- ists or by the founder of Spiritism. Kardec tion of spirit agency to these experiences, has (1861) published a paper entitled “An essay important implications for persons labeled about the theory of hallucination” where he “schizophrenic.” It implies and focuses on recognized that hallucinations originate in the lack of agency and fault on the part of patients’ brains, but he also proposed a cat- the person suffering an emotional disorder; egory called “true visions,” considered to re- it also provides a cultural category (i.e., a sult from actual spirit perceptions. The main meaning) that negates the involvement of the difference between true visions and halluci- distressed person’s sense of self and identity, nations is that the former convey accurate since such persons are not considered respon- information unknown to the individual, in- sible for their behavior (which is attributed formation that is later confirmed. A similar to spirits). This view of the etiology of the ill- distinction was proposed by the psychiatrist ness also helps mitigate feelings of guilt and Ian Stevenson (1983). Hufford (2008) de- shame on the part of the sufferer, countering scribes “visionary experiences” as based on some of the stigma associated with severe perceptions that are not hallucinatory be- mental illness. cause they entail certain facts; that is, the For Spiritist believers, there is a non- person has an immaterial self that can leave physical reality composed of spirits who the body and still retain awareness. may manifest at any time. For example, one Brazilian mediums often expressed woman, whom we knew had been diagnosed concerns about discriminating if their per- with schizoaffective disorder, was described ceptions were products of their minds or by a medium as having her own spirit “out- actual spiritual experiences. However, many side her body,” “totally subjugated,” so that reported experiences that convinced them she was vulnerable to invasion by molesting that they have actual spiritual perceptions spirits. Distortions of reality expressed by (Almeida, 2004). this patient were not attributed to her, but Kardec, as well as prominent Spirit- instead to spirit invaders. Reality distortions ists in Brazil, did recognize the existence of are not perceived as “fixed false beliefs” or schizophrenia or organic psychoses and wrote unreal perceptions, given the Spiritist con- that the prevalence of obsession among men- cept of self as one’s own spirit--an integral, tally disordered patients is not infrequently 276 Treatment in Puerto Rico and Brazil

overstated. However, it is also assumed that Celia’s brother and his wife. Although en- many cases considered psychotic by psychia- raged when she was discharged, Celia could trists may be obsession caused by spirit in- not protest. This pattern was repeated twice fluences (Moreira-Almeida & Lotufo Neto, more, with other relatives adopting Celia’s 2005). children, until a fourth child was born, whom the mother agreed to raise. After that birth, Celia consented to having a tubal ligation. Family Matters Shortly afterwards Celia became very disturbed, exhibiting the whole gamut of psychotic symptoms (according to her records), Spiritist healers in Puerto Rico specifi- including delusions, visual hallucinations, cally recognize negative over-involvement in incoherence, illogical thinking, loosening of the parent-child relationship and the isolat- associations, and violent, aggressive behav- ing, painful (and fearful) dependence on an ior. Hospitalized at the main psychiatric hos- ambivalent or rejecting parent. With regard pital, Celia frequently engaged in fights with to one young woman, who appeared to be other patients and was strictly disciplined by in a psychotic state, a healer said, “If one attendants. Her mother was so upset at the doesn’t know oneself than it is like it is with way her daughter looked that she sought sev- machines ... [they] chew and chew and when eral 15-day passes for her. During the second they are empty there is the machinist who re- pass, her mother managed to take her to a turns to fill them again. This is the case with Spiritist center, even though Celia was very this sister; everything she has done is through delusional and had several negative symp- the machinist, who is her mother.” Another toms. The healers placed her at the center of healer, who also worked with this patient, their circle, gave her “passes,” and concen- pointed to her problems in failing to achieve trated on using their “body energy” to help autonomy, feeling abandoned and rejected, her. They said that she was in a “nervous cri- and rejecting her mother in turn. This healer sis outside of reality” and therefore subject harangued that neither mother nor patient to the deleterious effect of backward (illness was able to bring their deep anger to the causing) spirits. By the second session, she surface in order to deal with their conflict- appeared much calmer, and by the fourth ses- ridden and highly distressful feelings. sion she was giving appropriate answers to questions and had appropriate affect. One of The Case of Celia: An Illustration the medium-healers also saw her every eve- ning at her home. She prayed with her and The above comments refer to a gave her “passes.” During this time Celia’s 26-year-old woman who had her first psy- mother managed her daughter’s discharge chotic episode, post-partum, at the age of from the hospital and enrolled her in a day 16. She had been involved with an older care program at the mental health center. She man, a drug addict, whom she married. Her was continued on antipsychotic medication mother engineered a divorce, to which Ce- for about six months until her therapist, in lia (a pseudonym) did not agree. Mother in- coordination with the healers (Celia became sisted that Celia move in with her. Shortly a test case for coordination of mental health after the birth of a son Celia was hospital- and Spiritist treatment), stopped her medica- ized for twenty days at Bellevue Hospital in tion. She steadily improved over the course New York City. After being advised by the of a year but then began to skip sessions in attending doctor that Celia could not care both the Spiritist center and the day care pro- for an infant, her mother gave the child to gram. Upon questioning, Celia attributed her Moreira-Almeida and Koss-Chioino 277

improvement to the Spiritists. However, 15 is present (i.e., viewed by the mental health months after we first saw her she had anoth- system as in remission), he or she is not er love affair and some of her symptoms re- seen as disordered or crazy. As noted above, occurred, leading to a brief hospitalization in Puerto Rico, there doesn’t seem to be a and a return to medication. We followed her Spiritist equivalent of the concept of chronic for about five years. She continued to do well mental illness unless the patient is judged to and attended the Spiritist center regularly be mentally ill through heredity; this lessens but did not routinely attend day care. (We the impact of stigma on the patient and pro- could not get an accurate medication history, vides hope for the family. Moreover, Spiritist however.) healers express the idea that all persons are vulnerable to spirit invasion, but most are Issues: Treatment and Interface also capable of dealing with this vulnerability through awareness of the role of the spirits Puerto Rican Spiritists who work with in the sacred plan of universal life. The spir- persons diagnosed with schizophrenia specif- it-obsessed person loses both self-awareness ically recognize their emotional and cognitive and control over spirit manifestations. limitations. If the patient appears to be in a disordered state, they are not told that they Treatment Considerations are “in development” as a medium, nor are they asked to communicate with the possess- ing spirits usually brought to the session to These aspects of Spiritist treatment can be confronted by the sufferer. Instead, work be complementary to treatment provided by with patients expressing psychotic symptoms mental health professionals, as we demon- often takes on a distinctly maternal quality strated in an experiment in Puerto Rico where in two ways: 1) The healer may come to patients were cross-referred. However, treat- the home or even take the patient into their ment by Spiritists differed in one important home for brief periods, when the family re- aspect; many Puerto-Rican Spiritist healers ports difficulties in coping with their relative. did not approve of antipsychotic medication Moreover, there is often continuity in the and would advise patients to stop taking it. relationships between healers and patients They felt that when patients are “endroga- and their families over years. The relation- da” (intoxicated by drugs of any type) they ship is reactivated at the first signs of relapse are especially vulnerable to being taken over and heightened agitation in the patient. This (“obsessed”) by illness-causing spirits. Pa- treatment can be characterized as “sooth- tients’ own spirits are absent and the person ing” or tranquilizing the patient and taking is less able to “know who they are” because pressure off the family. 2) Special support is antipsychotic drugs “cloud the mind.” This provided to the families of patients, relieving practice differs somewhat from Spiritism in guilt or shame for them by crediting spirits Brazil where, although many Spiritists also with the illness. However, this does not re- disapprove of antipsychotic medications, lieve the family of the burden of presenting this is not the view of prominent Spiritists themselves to “be worked on” at the ses- involved in the mental health system (Morei- sion, which involves those spirits who have ra-Almeida & Lotufo Neto, 2005). Spiritist attached themselves to family members and mediums in Brazil often follow Kardec who may be affecting the patient. In these settings wrote: “Men have often mistaken for cases the patient receives support in terms of ac- of possession what were really cases of epi- ceptance within a special social network lepsy or madness, demanding the help of the that is not stigmatizing (Garrison, 1978). In physician rather than of the exorciser” (Kar- fact, between psychotic episodes, when the dec, 1996, p. 250). healers observe that the patient’s own spirit 278 Treatment in Puerto Rico and Brazil

Treatment Mechanisms Another recent set of studies (Breit- borde, Lopez, & Nuechterlein, 2009) dem- onstrated that there is a significant difference We have presented a brief descriptive between the perceptions of high EE and low overview of some of the many complexities EE caregivers regarding their ill relative’s of investigating the impact of Spiritist healing agency over the disorder; this difference pre- on persons with psychotic symptoms and/or dicted the course of the illness. High EE care- schizophrenic disorders. The fact that the givers feel that their ill relative has agency, spirit healers were willing to enter into con- that is, he or she can control the expression tinuous, close relationships with patients and of symptoms and the course of the illness. families made them an excellent community Spiritist healers believe and demonstrate to resource with much availability. They model both the family and the ill person that the uncritical acceptance, control, and lack of spirits have primary agency in almost all cas- fear for the families of patients. Much of es of illness (especially in schizophrenia or their work parallels guidelines suggested by other psychotic state, since one’s own spirit psycho-educational methods (such as those has been displaced by an obsessing spirit or based on the Expressed Emotion formula- spirits). This belief and the associated rituals tion) for treating families. The healers’ in- seem to relieve stress on the patient because fluence on family members’ perceptions and caretakers do not perceive their ill relative behavior towards the ill person may be a key as having agency over his/her illness and its to lower rates of relapse. course. In a recent study, Weissman and col- In Brazil, it might be noted that obses- leagues (2000; 2003) noted that among less sion by a molesting spirit is not as common acculturated Latino families of schizophren- a Spiritist etiology of what psychiatry labels ics, those relatives who responded with com- “severe mental illness” as in Puerto Rico. passion towards their ill family members Those who read Kardec find that the sufferer often offered to help them cope with their ill- is believed to maintain agency over all illness- ness. They accepted the illness as legitimate, es, even in cases of obsession. However, the viewed causality as due to interpersonal well-known Brazilian medium Divaldo Fran- problems or other stressors in the environ- co (2005, p. 111) comments: ”Allan Kardec ment, or attributed the illness to God but also divided obsession into three parts; 1) simple turned to religion in adjusting to the patient’s obsession which is a subtle disturbance, a illness. This is another confirmation of the form of confusion; 2) obsession through fas- role of religious beliefs in familial response cination, which can lead us to obsessive dis- to the difficulties experienced in association turbances with loss of logical reason and lu- with a relative with psychotic symptomatol- cidity; and 3) obsession through subjugation ogy. These attributions indicate that there are which can be compared to conditions such as positive emotions in the family and may, as is profound depression, schizophrenia, etc.”2 the case of the Spiritist healers, help sustain The difference between Puerto Rican low conflict in the family environment. mediums and those in Brazil seems to be that the Brazilian Spiritists are more involved in

2. It must be noted that the best known Brazilian Spiritists, such as Divaldo Franco, say that the spirits do not enter into mediums’ bodies but rather attach themselves to the perispirit (spiritual body) of those who suffer from obsession. Divaldo Franco (2005; p. 80), perhaps the best-known Spiritist medium in Brazil today, explains: “The spirits that disturb us . . . do not enter our body, as some people precipitously suppose. As the spirit irradiates itself throughout all of our circulatory system and the modeling field within all of our cells, it exteriorizes itself through the luminosity called aura.” Those who practice a type of Spiritism that includes AfroCaribbean beliefs and practices (for example, most of those mediums the first author studied in Puerto Rico) speak of their bodies as vessels (cajas) that receive the spirits on behalf of sufferers. The sufferers themselves are affected as Franco describes above. Moreira-Almeida and Koss-Chioino 279

Kardec’s original writings than most of the resolved. In this regard, the relationship be- Spiritists studied in Puerto Rico. Howev- tween the highly maternal, caring, personal er, we might note that Spiritist practices in support of a healer and relapse could be as- many centers of both countries are not much sessed. Does this kind of intervention affect influenced by Kardec’s writings. Spiritist me- the role, amount, and effect of medications? diums in the Puerto Rican study generally In Brazil many Spiritists have a more favor- followed the main tenets of Spiritism as set able view of psychiatric concepts and treat- forth by Kardec, but they also incorporated ments; it would be worthwhile to study and a wide range of folk beliefs and practices. A compare conceptualizations and approaches few centers in Puerto Rico, during the mid to mental disorders among Puerto Rican and and late 20th century, were similar to those Brazilian Spiritists and relate them to out- of the educated and professional classes in comes. These issues remind us to be aware of Brazil; centers with educated believers who differences in beliefs and practices within the follow Kardec’s ideas are currently expand- same religious healing traditions in different ing in both countries. cultures. Numerous other questions arise. What types of social interventions are most effica- Directions for cious with persons with schizophrenia? Al- Future Research though families may be over-involved, as EE studies suggest (in the presence of overt criticism and hostility), will a caring, extra- Apart from case material, we do not familial adjunct to the family, such as a heal- have studies that systematically measure the er who relieves their burden at certain times effect of healer intervention or the effect of of crisis and has a positive outlook, make a belief in intermittent spirit causality on out- difference in outcomes? comes (associated with a belief that severe In regard to spirit healing, which has mental illness may not be chronic, that is, been suggested to have therapeutic effects endure for a lifetime). This issue is important by several authors referred to in this paper because there may be an effect on outcomes (i.e., Harwood, 1977; Garrison, 1977; Koss- of feelings of hopefulness that Spiritists con- Chioino, 1992), the normalized, ritual role vey through their commitment to an inevi- in a healing center seems to assist the diag- table “progress of the spirit” and associated nosed patient to feel less stigmatized, and lack of belief that severe mental illness is consequently can possibly lead to better so- always chronic. This may encourage greater cial integration. This is aided by the various self-esteem in a patient following an episode, mechanisms we have discussed in this article, which, in turn, may contribute to a better such as helping family members to be less prognosis in the future (Koss-Chioino & critical of the emotionally ill member and Ca ive, 1993). To our knowledge, the only ñ leading significant family members to believe double-blind, controlled clinical trial aimed that spirits are responsible for their relative’s at assessing the efficacy of Spiritist medium- illness rather than assigning agency to the istic treatment has been carried out by Leão distressed person. Spiritist practices actually (2004; Leão & Lotufo Neto, 2007) who ran demonstrate that the ill member does not have the study on mentally disabled patients. full control over his or her symptoms since a On the other hand, although Spiritist spirit is obsessing him or her and he or she healers can be advised to permit the continu- is not self-motivated to behave in crazy and ation of medication, and do agree when its difficult ways. Moreover, we might consider role is explained, their temporary support that many patients are led to feel that their may have mixed effects if patients are with- hallucinations and delusions are valued and drawn from medication when an episode is therefore not necessarily a source for fear or 280 Treatment in Puerto Rico and Brazil

low self-esteem. Miller, O’Connor, and Di involvement and mental health, most show- Pasquale(1993) reported that slightly more ing salutary effects (Moreira-Almeida et al., than half of their patient sample believed 2006). However, the pathways to this asso- that their hallucinations had adaptive value. ciation are still poorly understood. From our Spiritist belief provides a socially acceptable observations of Spiritist treatment among meaning for the experience of hallucinations persons diagnosed with schizophrenia or ex- or delusions, and also provides a way to cope pressing psychotic symptoms, we have been with the discomfort raised by disparagement able to delineate a complex interplay of so- on the part of family members or the stig- cial, affective, and cognitive processes within ma of abnormality often invoked by mental a special type of culturally patterned, inter- health professionals. personal arena. There are hundreds of studies investigating the relationship between religious

REFERENCES

Al-Issa,I. (1978). Social and cultural aspects Breitborde, N.J., Lopez, S.R. & Nuechterlein, of hallucinations. Psychological Bulletin, 84, K.H. (2009) Expressed emotion, human agen- 570-587. cy, and schizophrenia: Toward a new model for the EE relapse association. Culture, Medicine Almeida, A.A.S. (2007). Uma fábrica de loucos: and Psychiatry, 33(1), 41-60. psiquiatria x espiritismo no Brasil (1900-1950) [An insanity factory: psychiatry x spiritism in Carpenter, W. T. Jr. (2006). Targeting schizo- Brazil (1900-1950)]. PhD dissertation. Depar- phrenia research to patient outcomes. Ameri- tamento de História do Instituto de Filosofia can Journal of Psychiatry, 163(3), 353-355. e Ciências Humanas da Universidade Estadu- al de Campinas (Unicamp. Available at www. Cohen, A. (1992). Prognosis for schizophrenia hoje.org.br/bves. in the Third World: A reevaluation of cross- cultural research. Culture, Medicine, and Psy- Almeida, A.M. (2004). Fenomenologia das chiatry 16(1), 53-75. Experiências Mediúnicas, Perfil e Psicopatolo- gia de Médiuns Espíritas. [Phenomenology of Cooper, J., & Sartorius, N. (1977). Cultural mediumistic experiences, profile and psychopa- and temporal variations in schizophrenia: A thology of spiritist mediums]. PhD dissertation. speculation on the importance of industrializa- São Paulo: Faculdade de Medicina, Universi- tion. British Journal of Psychiatry, 130, 50-55. dade de São Paulo. Available at www.hoje. Corin, E. (1998). The thickness of being: In- org.br/bves. tentional worlds, strategies of identity, and ex- American Psychiatric Association (1987). Di- perience among schizophrenics. Psychiatry, 61, agnostic and Statistical Manual IIIR. Washing- 133-146. ton, DC: American Psychiatric Association. Edgerton, R.B. (1980). Traditional treatment Aubrée, M., & Laplantine, F. (1990). La ta- for mental illness in Africa: A review. Culture, ble, le livre et les espirits. Paris: Éditions Jean- Medicine and Psychiatry, 4,167-189. Claude Làttes. Figueiredo, G. R.,& Ferraz, M. P. T. (1998). Bentall, R.P. (1990). The illusion of reality: Hospício, caridade e psiquiatria. Revista ABP- A review and integration of psychological re- APAL, 20, 1–8. search on hallucinations. Psychological Bulle- Franco, D. (2005). Understanding Spiritual tin 107, 82-95. and Mental Health. Baltimore, MD: Spiritist Society of Baltimore. Moreira-Almeida and Koss-Chioino 281

Garrison, V. (1977). The Puerto Rican Syn- Jenkins, J.H. (1988b). Conceptions of schizo- drome in health-seeking behavior in a Puerto phrenia as a problem of nerves: A cross-cul- Rican neighborhood of New York City. Medi- tural comparison of Mexican-Americans and cal Anthropology, 1, 64-185. Anglo-Americans. Social Science and Medicine, 26(12), 1233-1243. Garrison, V. (1978). Support systems of schizophrenic and nonschizophrenic Puerto Rican Jenkins, J.H. (1991). Anthropology, expressed women in New York City. Schizophrenic Bul- emotion, and schizophrenia. Ethos, 19(4), letin, 4, 561-596. 387-431. Guarnaccia, P.J., Parra, P., Deschamps, A., Mil- Kardec, A. (1986 [1861]). (trans. Anna Bla- stein, G., & Argiles, N. (1992a). Si Dios quiere: ckwell). The Mediums’ Book. Rio de Janeiro: Hispanic families’ experiences of caring for a FEB. seriously mental ill family member. Culture, Medicine, and Psychiatry, 16(2), 187-215. Kardec, A. (1996 [1857]). (trans. Anna Bla- ckwell). The Spirits’ Book. Rio de Janeiro: Guarnaccia, P.J., Guevara Ramos, L.M., Gon- FEB. zales, G., Canino, G.J., &Bird, H. (1992b). Crosscultural aspects of psychotic symptoms Kardec, A. (1999 [1859]). What is Spiritism? in Puerto Rico. Reasearch in Community and Philadelphia: Allan Kardec Educational Soci- Mental Health, 7, 99-110. ety. Harwood, A. (1977). Rx: Spiritist as Needed. Kardec, A. (1861). Essai sur la théorie de New York: John Wiley. l’hallucination. Revue Spirite, 4(7), 193-198. Hopper, K. (1992). Cervantes’ puzzle: A com- Katz, M.M., Marsella, A., Dube, K.C., Ola- mentary on Alex Cohen’s “Prognosis for schizo- tawura, M., Takahashi, R., Nakane, Y., Wyn- phrenia in the Third World: A reevaluation of ne, L.C., Gift, T., Brennan, J., Sartorius, N., & cross-cultural research.” Culture, Medicine, Jablensky, A. (1988). On the expression of psy- and Psychiatry, 16(1), 89-100. chosis in different cultures: Schizophrenia in an Indian and in a Nigerian community. Culture, Hopper, K., Harrison, G., Janca, A. & Sarto- Medicine and Psychiatry, 12(3), 331-335. rious, N. (Eds.). (2007). WHO Collaborative Project. New York: Oxford University Press. Kelly, M. & Gamble, C.(2005) Exploring the concept of recovery in schizophrenia. Journal Hufford, D. (2008) Visionary spiritual experi- of Psychiatric and Mental Health Nursing, 12, ences and cognitive aspects of spiritual trans- 245-251. formation. In J.D. Koss-Chioino (Ed.), Special Issue of The Global Spiral, on-line journal of Koenig, H.G. (2007). Religion, spirituality and the Metanexus Institute. September. psychotic disorders. Revista de Psiquiatria Cli- nica, 34(suppl.1), 40-48. Available at www. Huguelet, P., Mohr. S., Borras, L., Gillieron, C., hoje.org.br/bves. & Brandt, P.(2006). Spirituality and religious practices among outpatients with schizophre- Koss, J.D. (1975). Therapeutic aspects of Puerto nia and their clinicians. Psychiatric Services, Rican cult practices. Psychiatry, 38, 160-171. 57(3), 366-372. Koss, J.D. (1976). Religion and science divinely International Spiritist Council, 2008. Website: related: A case history of Spiritism in Puerto www.spiritist.org. Rico. Caribbean Studies, 16, 22-43. Jenkins, J.H. (1988a). Ethnopsychiatric inter- Koss, J.D. (1980). The Therapist-Spiritist pretations of schizophrenic illness: The prob- Training Project in Puerto Rico: An experiment lem of nervios within Mexican-American fami- to relate the traditional healing system to the lies. Culture, Medicine and Psychiatry, 12(3), public health system. Social Science and Medi- 301-329. cine, 14(B), 255-266. 282 Treatment in Puerto Rico and Brazil

Koss-Chioino, J.D. (1992). Women as Healers, Mohr, S. Brandt, P., Borras, L., Gilieron, C., Women as Patients: Mental Health Care and & Hugelet, P. (2006) Toward an integration of Traditional Healing in Puerto Rico. Boulder, spirituality into the psychosocial dimension of CO: Westview. schizophrenia. American Journal of Psychiatry, 163(11), 1952-1957. Koss-Chioino, J.D. (1999) Integrating mental health care and traditional healing in Puer- Moreira-Almeida A., Lotufo Neto F. (2005). to Rico: Lessons from an early experiment. Spiritist views of mental disorders in Brazil. In R.A. Hahn (Ed.) Anthropology in Public Transcultural Psychiatry, 16(61 Pt 1):5-25. Health (pp.279-299). New York: Oxford Uni- versity Press. Moreira-Almeida, A., Silva de Almeida, A.A., & Neto F.L. (2005). History of Spiritist mad- Koss-Chioino, J.D., & Cañive, J.M. (1993). ness’ in Brazil. History of Psychiatry, 16, 5-25. The interaction of popular and clinical diagnostic labeling: The case of embrujado. Medi- Moreira-Almeida, A., Lotufo Neto, F., & Ko- cal Anthropology, 15, 171-188. enig, H. G. (2006). Religiousness and Mental Health: A review. Revista Brasileira de Psiquia- Koss-Chioino, J.D. (2006) Spiritual transforma- tria, 28(3). Available at www.hoje.org.br/elsh tion and radical empathy in ritual healing and therapeutic relationships. In J.D. Koss-Chioino Moreira-Almeida, A., Lotufo Neto, F., & Grey- and P. Hefner (Eds.), Spiritual Transforma- son, B.(2007). Dissociative and Psychotic Ex- tion and Healing: Anthropological, Theologi- periences in Brazilian Spiritist Mediums. Psy- cal, Neuroscientific and Clinical Perspectives chotherapy and Psychosomatics, 76(1), 57-58, (pp.45-61). Lanham, MD: Altamira. 185. Erratum in: Psychotherapy and Psycho- somatics, 2007;76(3), 185. Available at www. Lambo, T.A. (1978). Psychotherapy in Africa. hoje.org.br/elsh. Human Nature, 1, 38-40. Moreira-Almeida, A., Lotufo Neto, F.,Cardeña, Leão, F. C. (2004). Práticas espirituais no tra- E. (2008). Comparison of Brazilian spiritist tamento de portadores de deficiência mental. mediumship and dissociative identity disor- [Spiritual practices used in an institution for der. Journal of Nervous and Mental Disease, mental disabilities]. Dissertação de Mestrado. 196(5), 420-424. Available at www.hoje.org. Dept Psiquiatria da Faculdade de Medicina da br/elsh. Universidade de São Paulo. Available at www. hoje.org.br/bves. Murphy, J. (1981). Abnormal behavior in traditional societies: Labels, explanations, and so- Leão, F. C. & Lotufo Neto, F. (2007). Spiritual cial relations. In R.H. Munroe, G.L. Munroe, practices in an institution for mental disabili- & B.B. Whiting (Eds.) Handbook of Cross- ties’ Revista de Psiquiatria Clínica, 34 (suppl. cultural Human Development (pp. 809-826). 1), 54-59. Available at www.hoje.org.br/elsh. New York: Garland. Lopez, S.R., Nelson, K.A., Snyder, K.S., & Puttini, R. F. (2004). Medicina e religião num Mintz, J. (1999). Attributions and affective espaço hospitalar espírita (Medicine and re- reactions of family members and course of ligion in spiritist hospitals). Ph.D. thesis. De- schizophrenia. Journal of Abnormal Psychol- partamento de Saúde Coletiva da Faculdade de ogy, 108, 307-314. Ciências Médicas da Universidade Estadual de Campinas (Unicamp). Available at www.hoje. Miller, L.J., O’Connor, E., & DiPasquale, T. org.br/bves. (1993) Patient’s attitudes towards schizophrenia. American Journal of Psychiatry, 150(4), Redko, C.(2003). Religious construction of a 584-588. first episode of psychosis in urban Brazil.Tran - scultural Psychiatry, 40(4), 507-30. Moreira-Almeida and Koss-Chioino 283

Sampaio, J. R. (2004). Voluntários: um estudo among persons with persistant mental illness. sobre a motivação de pessoas e a cultura em Psychiatric Services, 52, 660-665. uma organização do terceiro sector (Volunte- ers: A study about people’s motivation and the Wagner, L.C.,& King, M.(2005). Existential culture of a third sector organization). Ph.D. needs of people with psychotic disorders in thesis. Faculdade de Economia, Administração Puerto Alegre, Brazil. British Journal of Psy- e Contabilidade. Universidade de São Paulo, chiatry, 186, 141-145. São Paulo. Weisman, A.G. (2000). Religion: A mediator Sells, D.J., Stayner, D.A., & Davidson, L. of Anglo-American and Mexican attributional (2004). Recovering the self in schizophrenia: differences toward symptoms of schizophre- An integrative review of qualitative studies. nia? Journal of Nervous and Mental Disease, Psychiatric Quarterly, 75, 87-97. 188(9), 616-621. Stevenson I. (1983). Do we need a new word to Weisman, A. G., Gomes, L.G., & Lopez, S.R. supplement “hallucination”? American Journal (2003). Shifting blame away from ill rela- of Psychiatry, 140(12), 1609-11. tives: Latino families’ reactions to schizophrenia. Journal of Nervous and Mental Disease, Sullivan, W.P. (1998). Reconciling, regrouping 191(9), 574-581. and recovering: First person accounts of the role of spirituality in the course of serious men- Zacharias, S. (2006). Mexican Curanderismo tal illness. New Directions in Mental Health as ethnopsychotherapy: A qualitative study on Services, 80, 35-44. treatment practices, effectiveness, and mechanisms of change. International Journal of Dis- Swerdlow, M. (1992). “Chronicity,” “nervios,” ability, Development and Education. Special and community care: A case study of Puerto Ri- Issue: Complementary and Indigenous Healing can psychiatric patients in New York City. Cul- Practices, 53(40), 381-400. ture, Medicine, and Psychiatry, 6(2):217-235. Tepper, L., Rogers, S.A., & Coleman, E.M., et al. (2001) The prevalence of religious coping