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 medi- ums 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 adjust- ment 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 con- ventional 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 schizophre- nia 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 cultur- al., 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 reli- gion 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,