Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 078
Guide XI-078

Candomblé

Brazil
A 37 · L 53 · M 1016 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Candomblé as Afro-Brazilian religious communities and their own networks describe it (RENAFRO, the Rede Nacional de Religiões Afro-Brasileiras e Saúde, and terreiro leaders speaking publicly), with Brazilian heritage recognition and academic ethnography as attributed context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI, APA 2022) and the ICD-11 dissociative trance codes.

What it is. Candomblé is an Afro-Brazilian religion organised in autonomous houses (terreiros), each governed by a mãe de santo (ialorixá) or pai de santo (babalorixá). Scholarship describes three "great nations": Ketu, Jeje and Angola. In Ketu houses the divinities are the orixás. [source: https://revistas.usp.br/salapreta/article/download/57024/60021/72229] The Jeje and Angola nations name their divinities differently (vodum and inquice/nkisi). [uncertain: not verified] Communities do not present Candomblé as a psychotherapy. They present it as a religion whose houses also care for their members. RENAFRO calls terreiros health-promoting spaces whose knowledge should be valued, and it campaigns against racism and intolerance. [source: https://fundobrasil.org.br/projeto/rede-nacional-de-religioes-afro-brasileiras-e-saude] A RENAFRO presentation describes terreiro health practices as "cuidado e zelo" (care and devotion). These include divination, herbal baths, blessings, and advice to use health services. In the same account, illness is seen as a break in the balance between the human and spiritual worlds, and health is linked to axé (vital force). [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]

Possession, as described. In public dance, devotees are said to become the "cavalos" (horses) of the orixás, so that the orixá is present through them. This is attributed to the tradition and described by an outside scholar. [source: https://revistas.usp.br/salapreta/article/download/57024/60021/72229] Ethnography of mães de santo in New York reports that the ori (head) is understood as the seat of consciousness and the main point of contact with the orixá. Some mental disturbances are attributed to spirits and treated with ritual means. People who feel an orixá "wants their head" often consult several doctors before reaching a priestess. [source: https://scielosp.org/pdf/icse/2019.v23/e180088/pt]

Who holds authority. Within a house, the mãe or pai de santo holds religious authority. One scholarly account notes that "sempre houve uma preponderância do poder feminino" (there has always been a preponderance of female power). Leadership is often hereditary but requires a long initiation. [source: https://revistas.usp.br/salapreta/article/download/57024/60021/72229] No single national body governs all houses. [uncertain: not verified] Brazil's federal heritage institute (IPHAN) recognised the Casa Branca do Engenho Velho (Ilê Axé Iyá Nassô Oká) in Salvador, founded around 1830 and considered the oldest Black religious centre in Brazil. Sources give the recognition as 1985, though 1984 (council decision) and 1986 (inscription) are also cited. [source: https://terra.bienal.org.br/Ile-Axe-Iya-Nasso-Oka-Terreiro-da-Casa-Branca] [uncertain: date varies by source] Rituals, songs, offerings (ebó), initiation and búzios divination belong to the house and its leadership. This guide does not describe them.

How change happens, from the therapist's side. The psychotherapist does not practise Candomblé. Clients improve when their own explanatory model is understood, when culturally normative experience is told apart from illness, and when care is coordinated with the terreiro leadership they recognise (only if they want this). Racism and religious racism also need to be addressed as clinical stressors. Trials of collaboration with traditional and faith healers come from West Africa, not from Candomblé. They show that shared care can reduce symptoms and harmful practices. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [synthesis: applying this to Candomblé]

2. Framework

Candomblé has no clinical phase model. The framework below is the psychotherapist's own course of culturally responsive care alongside a client's terreiro involvement. [synthesis: phase structure and session counts; CFI content per APA]

Phase A: Engagement and cultural assessment (sessions 1–3).

  • Goals: make it safe for the client to disclose religious affiliation. Many adherents expect contempt, because surveys of terreiros report widespread religious racism. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html]
  • Format: give the core CFI (16 questions, four domains), plus the Spirituality, Religion and Moral Traditions module and the Explanatory Model module as needed. The modules can be used at intake, later, or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] No APA form gives a standard time, and a figure of 15–20 minutes for the core CFI is [uncertain: not verified].
  • Move on when you can say, in the client's terms, what the problem is, what they think caused it, who they have consulted (including the terreiro), and what they want from you.

Phase B: Formulation and differential (sessions 2–5, overlapping).

  • Goals: decide whether experiences such as possession trance, a felt claim by an orixá, or spirit-attributed distress are normative within the client's house, or whether they meet criteria for a dissociative, psychotic, mood or other disorder. It can be both. Use DSM-5-TR cultural exclusions and ICD-11 6B62/6B63.
  • Move on when you have a written cultural formulation and a provisional diagnosis (or none) that does not rest on the CFI alone. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

Phase C: Shared plan and optional collaboration.

  • Goals: agree a treatment plan that fits the client's religious life. This covers scheduling around religious obligations and safety around herbal preparations (prescriber input). If the client asks, it also covers consented contact with their mãe or pai de santo.
  • Move on once the plan is written, the consent scope is recorded, and the risks are addressed.

Phase D: Ongoing therapy and integration.

  • Format: weekly or as indicated by the presenting disorder's own evidence-based treatment, with cultural review repeated at transitions (e.g. after initiation periods, conflict in the house, or experiences of religious racism).
  • End or step down when the presenting goals are met. The client's religious participation is never a treatment target unless the client makes it one.

Throughout: suicide and risk assessment as standard. Safeguarding takes priority if any practice involves restraint, beating, starvation, sexual abuse, accusations against children, or delay of urgent medical care.

3. Guiding principles

  • You work alongside, not inside, the tradition. Never diagnose spiritual causes, interpret búzios, suggest ebó, or recommend a house. [synthesis]
  • Authority sits with the client's house. Spiritual questions go to the mãe or pai de santo the client recognises, not to you or to a house you choose. [source: https://revistas.usp.br/salapreta/article/download/57024/60021/72229]
  • Attribute, do not adjudicate. Say "in your house, this is understood as…" and neither affirm nor dismiss orixás, spirits or axé. [synthesis]
  • Know psychiatry's history here. Brazilian psychiatry long pathologised terreiro trance. From the 1890s, Nina Rodrigues called the "estado-de-santo" a suggestion-induced, pathological mechanism, although he opposed police persecution. René Ribeiro (1950s) and Álvaro Rubim de Pinho (1960s–70s) later argued that most participants are psychologically healthy and that cultural trance has no pathological significance in itself. [source: https://www.scielo.br/j/rpc/a/rjPcHY7QXBWxfyWqBYHjyFw/?format=pdf] Practically, expect clients to anticipate being labelled as hysterical or psychotic.
  • Religious racism is a clinical stressor, not background. In the 2025 "Respeite o meu terreiro" survey of 511 terreiro leaders (RENAFRO and Ilê Omolu Oxum with Brazil's human-rights ministry), 76% of terreiros reported some violence, and fewer than three in ten affected houses filed a police report. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html] Practically, ask about it directly.
  • Examine your own religious stance. RENAFRO material notes that managers' and professionals' own religious positions can shape care, and lists stereotypes such as "macumbeiro" that adherents meet. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf] Practically, notice reactions before they leak into questions.
  • Do not ask for what is not yours to know. Initiates may be bound not to disclose ritual matters. Ask about meaning, effect and wishes, not procedure. [synthesis]
  • Use the client's words. Terreiro, orixá, mãe or pai de santo, axé, "fazer o santo". Avoid "macumba" as a label, "witchcraft" and "sect". [synthesis]
  • Collaboration only with consent and to the client's scope. Membership can be dangerous to reveal. Never contact a house without written consent. [synthesis]
  • No advice on baths, herbs or preparations. Ask what the client uses, then route interaction and safety questions to the prescriber or pharmacist. Never advise starting, stopping or changing a medicine. [synthesis]
  • Terreiro leaders often send people to health services. RENAFRO describes leaders advising adherents to use the SUS and pursuing health actions "em parceria com o SUS". Practically, treat the house as a potential ally, not a competitor. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
  • Touch is used only with explicit consent and is never sexual. Physical comfort practices of the house are not yours to reproduce. [synthesis]
  • Safeguarding overrides cultural deference. Harm is not protected by being framed as religious, and religious practice is not harm because it is unfamiliar. [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a Candomblé practice, and none reproduces terreiro ritual. [source: CFI and ICD-11 items as cited; other items marked]

4.1 Cultural self-examination before and during care

  • Purpose / when: before the first session with a client who is or may be a terreiro member, and whenever you notice discomfort, curiosity or fear. This matters because professionals' own religious stance shapes care. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
  • Steps: (1) Write down what you associate with Candomblé, "macumba", possession and "spirits". (2) Mark which associations come from media, church teaching or psychiatric training. Psychiatry's own history of pathologising terreiro trance is one source. [source: https://www.scielo.br/j/rpc/a/rjPcHY7QXBWxfyWqBYHjyFw/?format=pdf] (3) Identify any religious commitment of your own that would make neutrality hard. (4) Take this to supervision. If you cannot hold a respectful stance, refer on. [synthesis]
  • Example language (to a supervisor, illustrative): "I notice I tensed when she said her orixá claimed her. I want to check whether that tension is shaping my questions."
  • Watch for: hurried diagnostic questions about trance; making jokes or showing fascination; probing for ritual detail; your own faith framing the client's religion as spiritually dangerous. Working when: you can describe the client's beliefs in their terms without either endorsing or correcting them. [synthesis]

4.2 Opening the door to religious disclosure

  • Purpose / when: at intake, for every client, because adherents face widespread religious racism and may conceal membership. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html]
  • Steps: (1) Ask about religion and spirituality routinely, so no one is singled out. (2) Name the Afro-Brazilian religions explicitly among other examples. This signals that it is safe to say. (3) If the client discloses, thank them and ask what it means to them. Do not ask for ritual details. (4) Ask what they want recorded in the file. [synthesis]
  • Example language (illustrative): "Some people I see are Catholic, evangelical, Spiritist, from Candomblé or Umbanda, or none. Is religion or a religious house part of your life?" / "Thank you for telling me. Many people from terreiros have been treated badly in services. How would you like me to note this in your record?"
  • Watch for: hesitation, a vague answer ("I'm a bit spiritual") followed later by disclosure, or checking your reaction. Working when: the client starts using their own terms (orixá, mãe de santo, axé) unprompted. [synthesis]

4.3 Core Cultural Formulation Interview

  • Purpose / when: in Phase A, to understand the problem from the client's and their network's perspective. It covers meaning, sources of help and expectations of services. APA says it can be used by any clinician, in any care setting. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps: work through the four APA domains in your own words. (1) Cultural definition of the problem. (2) Perceived causes, context and support, including the role of cultural identity. (3) Self-coping and past help-seeking, including barriers. (4) Current help-seeking: preferences, and the clinician–patient relationship, such as perceived racism or language barriers. Record answers verbatim where possible. Clinicians may reproduce the APA form for use with their own patients, but modifying or translating it needs APA permission. Use the official Portuguese version if one exists. [uncertain: not verified] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • Example language (illustrative): "How would you describe what's been happening, in your own words, the way you'd explain it to people in your house?" / "Who have you already gone to for help, inside or outside the terreiro?" / "Is there anything about me or this service that might make it harder to talk?"
  • Watch for: the terreiro appearing as both a support and a stressor (house conflict, obligations, cost). Note any experience of racism in earlier care. The CFI informs understanding but must not be the only basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Working when: you can state the client's own name for the problem, their causal account, and what they want from you.

4.4 Supplementary modules: Spirituality, Religion and Moral Traditions; Cultural Identity; Social Network; Coping and Help-Seeking; Patient–Clinician Relationship

  • Purpose / when: when religion is central to the problem or the solution. Use them as add-ons or standalone tools, at intake or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • Steps: (1) Choose modules from what the core CFI flagged. The core form shows which module expands each subtopic. (2) For Spirituality, explore the client's role in the house, what the religion gives and asks, and any conflict between religious and other identities (family religion, workplace). (3) For Social Network, map the client's family of origin and their religious family in the house, if they use that framing. [uncertain: not verified] (4) Revisit after major religious transitions. [synthesis]
  • Example language (illustrative): "What does your house give you when things are hard? And are there times it asks more than you can give?" / "Does your family know about your religion? How is that for you?"
  • Watch for: conflict with evangelical relatives. This is a common source of distress, in line with surveys that name religiously motivated attackers. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html] [synthesis: clinical inference] Working when: the formulation shows where religious life protects and where it strains.

4.5 Exploring the explanatory model (Kleinman)

  • Purpose / when: whenever the client's account of cause differs from yours, for example a spiritual cause, an orixá's claim, an obsessing spirit, or an imbalance of axé. Kleinman, Eisenberg and Good (1978) set out eight questions, paraphrased here. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]
  • Steps: ask, in your own words: (1) what the client calls the problem; (2) what caused it; (3) why it started when it did; (4) what it does and how it works; (5) how severe it is and how long it will last; (6) what treatment they think they should get; (7) the main problems it has caused; (8) what they fear most. Then ask what the mãe or pai de santo has said, if the client has consulted them. Summarise back and ask where your perspective could fit beside theirs. [synthesis: the last two steps]
  • Example language (illustrative): "You said your mãe de santo saw this as your orixá calling you. How do you understand it yourself?" / "What would need to happen, spiritually and in your daily life, for you to feel this was resolved?"
  • Watch for: layered models (spiritual cause plus depression) are common and need not be resolved into one. Working when: the client accepts your role for part of the problem without feeling their religious account is being displaced. [synthesis]

4.6 Using cultural concepts of distress and the client's idiom

  • Purpose / when: DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes, revised to avoid stigmatising language. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] The DSM-5-TR list (ataque de nervios, dhat, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto, taijin kyofusho) includes no Candomblé-specific term. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] That list and its changes from DSM-5 are [uncertain: not verified]. Use the concept framework, not a label.
  • Steps: (1) Note the client's idiom, for example "o santo quer a minha cabeça" (the saint wants my head), an idiom reported in ethnography. [source: https://scielosp.org/pdf/icse/2019.v23/e180088/pt] (2) Classify it for yourself as an idiom, an explanation or a syndrome. (3) Use it in your clinical language with the client. (4) Do not equate it with a DSM diagnosis. Assess symptoms separately. [synthesis]
  • Example language (illustrative): "When you say the orixá wants your head, what does that feel like day to day: sleep, mood, thoughts?"
  • Watch for: overreading an idiom as a delusion, or underreading severe symptoms because they are voiced in religious terms. Working when: you can describe both the idiom's meaning and the symptom picture. [synthesis]

4.7 Distinguishing normative possession trance from disorder

  • Purpose / when: when a client reports possession, trance, loss of awareness or an alternate identity, or when family or another service has called terreiro trance "psychotic" or "hysterical".
  • Diagnostic anchors: under DSM-5, the possession form of dissociative identity disorder excludes disturbance that is "a normal part of a broadly accepted cultural or religious practice". Other specified dissociative disorder (dissociative trance) excludes trance that is a normal part of collective cultural or religious practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] DSM-5-TR keeps these points in substance, but the exact wording is [uncertain: not verified]. [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted, not part of accepted cultural or religious practice, recurrent or prolonged, and causing significant distress or impairment. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] A DSM-5-TR note that culturally sanctioned experiences should not count as psychotic symptoms is [uncertain: not verified].
  • Steps: (1) Establish the context of each episode. Ask whether it happens in the house, at sanctioned times, and recognised by the leadership, or whether it occurs unbidden at work, at home or alone. (2) Ask whether the client experiences it as wanted and meaningful, or as unwanted and frightening. (3) Ask about control and recovery: does it end as expected, with return to usual functioning? (4) Screen separately for psychotic symptoms outside trance, mood episodes, substance use, trauma, and neurological causes, especially new-onset episodes with injury or incontinence. Refer for medical assessment where indicated. (5) With consent, consult a cultural broker or the client's mãe or pai de santo about whether the episodes fit what the house expects. (6) Document your reasoning. [synthesis: steps]
  • Example language (illustrative): "When the orixá comes during a festa, how is that for you, and for the house?" / "Have there been times something like this happened outside the terreiro, when you didn't expect or want it?" / "Would it help if I spoke with your mãe de santo about how she sees these episodes, with your permission?"
  • Watch for: both errors. Pathologising: Brazilian psychiatry's history shows how readily trance was labelled pathological, while later psychiatrists argued that most participants are healthy. [source: https://www.scielo.br/j/rpc/a/rjPcHY7QXBWxfyWqBYHjyFw/?format=pdf] Missing illness: a religious frame can hide a first episode of psychosis or mania. The leadership may itself be concerned that something is not "the orixá". [synthesis] Working when: the formulation states clearly which experiences are normative, which are not, and why.

4.8 Asking about terreiro consultation and care without judgement

  • Purpose / when: at intake and whenever the plan changes. Clients may have consulted a mãe or pai de santo through divination, baths or offerings. Ethnography describes such consultations as comforting and as a place to voice distress. [source: https://scielosp.org/pdf/icse/2019.v23/e180088/pt]
  • Steps: (1) Ask whether they have consulted their house, and what they were told or advised. (2) Ask how it helped. (3) Ask whether any advice conflicts with medical care, such as stopping medicine or isolation that affects work or schooling. Do not ask how any rite was done. (4) Record it neutrally as "consulted religious leader; advised X". [synthesis]
  • Example language (illustrative): "Have you taken this to your house? What did they say, and did it help?" / "Is there anything they've asked you to do that you're worried might clash with your treatment here?"
  • Watch for: the client editing answers to protect the house. Reassure them that you are not judging. Working when: the client tells you about religious care as readily as medical care. [synthesis]

4.9 Informant interview with family or a member of the house

  • Purpose / when: when the client's account is limited (e.g. acute psychosis), or when family and house hold differing views. The CFI Informant Version (17 questions) is designed for a family member or friend. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
  • Steps: (1) Get the client's consent for each informant: blood family, house member, or both. (2) Ask the informant's relationship to the client first. (3) Cover the same four domains. (4) Expect conflict, for example evangelical relatives versus the house, and do not take sides. [synthesis]
  • Example language (illustrative): "I'm talking with you because [client] asked me to. I'd like to understand how you see what's been happening."
  • Watch for: relatives pressing you to label the religion as the cause of the illness. Working when: you have a picture of the network's views without having breached the client's limits. [synthesis]

4.10 Collaboration and referral with the client's house

  • Purpose / when: only when the client wants it. The aim is to coordinate support and safety and to reduce conflict between the treatment plan and religious obligations. RENAFRO describes leaders who advise adherents to use health services and who seek partnership with the SUS. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf] A RENAFRO coordinator describes terreiros as primary health agents for their own population and reports that SUS collaboration has stalled. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/46438/35511/148317]
  • Evidence (not Candomblé-specific): the COSIMPO cluster trial (Gureje et al., The Lancet 2020) tested collaborative shared care between traditional and faith healers and primary care in Nigeria and Ghana. It found a greater fall in psychosis symptoms and fewer harmful practices. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] In a Ghana prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric care reduced symptoms, but days in chains did not fall significantly. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] Collaboration alone does not remove harm.
  • Steps: (1) Ask whether the client wants contact, with whom (only the leader they recognise), and for what. (2) Get written consent that specifies what may be shared and what may not. (3) Approach respectfully: ask how the leader would like to be addressed and what they need from you. (4) Agree on practical points: scheduling, safety signs that should prompt contact, and medication continuity. Do not discuss spiritual diagnosis. (5) Review with the client after every contact. (6) Do not refer a client to a house. If the client wants to find one, that is for them and their community. [synthesis: steps]
  • Example language (illustrative, to a leader): "[Client] asked me to contact you. I'm their psychologist. I'm not here to comment on religious matters. I'd like to understand how we can both support them, especially around [sleep / safety / medication]."
  • Watch for: the leader being asked to vouch for or enforce treatment, which overreaches your role; confidentiality slipping inside a close community; and your own wish for the house to "fix" adherence. Working when: the client experiences care as joined up and reports less conflict. [synthesis]

4.11 Safety conversation about baths, herbs and other preparations

  • Purpose / when: whenever the client takes psychotropic or other medicines and also uses herbal baths, teas or other preparations from the house. RENAFRO lists herbal baths and remedies among terreiro care. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
  • Steps: (1) Ask what the client uses, without judgement and without asking for recipes. (2) Tell them their prescriber or pharmacist should know about anything taken by mouth. (3) With consent, inform the prescriber. (4) Never advise starting, stopping or changing a medicine or a preparation. [synthesis]
  • Example language (illustrative): "I'm not an expert in plants or medicines. Would you be willing to tell Dr [X] about the teas, so they can check nothing clashes?"
  • Watch for: stopping medication because of a spiritual reframing, or hiding use from the prescriber. Working when: the prescriber has the full picture. [synthesis]

4.12 Working with experiences of religious racism

  • Purpose / when: when the client reports insults, threats, police targeting, online harassment, or attacks on their house. The 2025 terreiro survey found these forms common and found that fewer than three in ten affected houses reported to police. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html]
  • Steps: (1) Name it as racism, not as "religious disagreement". RENAFRO frames intolerance alongside racism. [source: https://fundobrasil.org.br/projeto/rede-nacional-de-religioes-afro-brasileiras-e-saude] (2) Assess the trauma response and current safety. (3) Treat any PTSD, anxiety or depression with the indicated evidence-based therapy, adapted to include the religious meaning of the attack, such as desecration of the house. (4) Discuss reporting options without pressure. The client decides. (5) Ask whether the house or networks like RENAFRO offer support. (6) Address the impact of racism in earlier health care. [synthesis: steps 2–6]
  • Example language (illustrative): "What happened to your terreiro was an attack on you and your community, and on something sacred to you. How has it been since?" / "Has anything like this happened in health services, including here?"
  • Watch for: self-blame, hypervigilance about disclosing religion, and loss of the house as a support if it is damaged or closed. Working when: symptoms ease and the client reconnects with community support. [synthesis]

4.13 Integrating religious experience into therapy

  • Purpose / when: when meaningful experiences in the house (trance, a sense of an orixá's presence, initiation, the death of a leader) shape the client's sense of self, or when the client wants to bring their religious life into therapy.
  • Steps: (1) Invite the client to describe the meaning, not the rite. (2) Link the meaning to their goals: belonging, identity, discipline, grief. (3) Use the client's frame as a resource, e.g. the house as a support network or religious values as motivation. (4) Respect any limits on what they may disclose. [synthesis]
  • Example language (illustrative): "You don't need to tell me anything you're not supposed to share. I'm interested in what that experience means for you now."
  • Watch for: the therapist becoming an informant-seeker; and spiritual distress, such as fear of an orixá's displeasure, which belongs with the leadership while its emotional effects are yours to work with. Working when: the client experiences therapy and religion as compatible. [synthesis]

4.14 Accommodating religious obligations in the plan

  • Purpose / when: when initiation periods, festival cycles or other obligations affect attendance, schooling, work or medication routines.
  • Steps: (1) Ask the client to tell you in advance about periods when they will be unavailable, without describing them. (2) Plan session gaps, remote options or crisis plans. (3) With consent and if needed, coordinate with the house on safety, e.g. medication continuity and warning signs. [synthesis]
  • Example language (illustrative): "If there are times in the year when you'll be less available, let's plan around them so your care doesn't drop off."
  • Watch for: abrupt withdrawal from treatment presented as a religious requirement, which is a cue to talk with the client and not to assume. Working when: there are no unplanned gaps. [synthesis]

4.15 Safeguarding

  • Purpose / when: whenever there are signs of restraint, beating, starvation, sexual exploitation, coercion of a minor, accusations against children, or delay of urgent medical care, in any setting, religious or not.
  • Steps: (1) Assess the facts as for any other context. (2) Do not accept or reject "it's tradition" as a reason. (3) Follow local reporting law. (4) Where safe and if consented, involve the leadership, who may themselves oppose the harm. (5) Avoid stigmatising the whole religion in reports. [synthesis] The Ghana prayer-camp trial shows that harmful restraint can persist even when collaboration improves symptoms, so monitor directly. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]
  • Example language (illustrative): "I respect your religion. What you've told me about [X] is something I have to act on because of your safety, not because of your faith."
  • Watch for: reports made out of prejudice. Brazilian surveys describe police among past aggressors toward terreiros. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html] Working when: the risk is addressed without the client losing their community. [synthesis]

4.16 Language, cultural brokers and diaspora clients

  • Purpose / when: for Portuguese-speaking clients outside Brazil, or when the terms are unfamiliar. Diaspora houses adapt practice to local conditions, as in New York, where priestesses serve Brazilian, American, Hispanic and African American clients. [source: https://scielosp.org/pdf/icse/2019.v23/e180088/pt]
  • Steps: (1) Use a professional interpreter, and check that they are not hostile to Afro-Brazilian religions. (2) Ask the client whom they would trust as a cultural broker, and get consent. (3) Learn the client's terms from the client. Do not assume that Ketu, Jeje and Angola houses use the same terms. [synthesis]
  • Example language (illustrative): "I'd like to make sure our interpreter is someone you're comfortable with when we talk about your religion. Is that okay to check?"
  • Watch for: interpreters who mistranslate or moralise religious terms. Working when: the client corrects your terms comfortably. [synthesis]

5. Handling problems

The sources say little about clinical difficulties, so the guidance below is mostly [synthesis] unless cited.

  • Client will not disclose their religion, or discloses and then retracts. Expect this, given surveyed levels of religious racism. [source: https://www.diariodepernambuco.com.br/brasil/2025/12/11702331-racismo-religioso-76-dos-terreiros-no-brasil-sofreram-violencias.html] Keep the question open, ask what the client wants recorded, and do not pursue. Example (illustrative): "You don't have to answer. The door's open if it ever matters for what we're working on." [synthesis]
  • The client says the problem is entirely spiritual and therapy is pointless. Accept their model. Offer help with the parts they recognise, such as sleep, conflict and grief, alongside religious care. Example (illustrative): "Your house is working on the spiritual side. Is there a part of this, like the sleeplessness, where I could be useful at the same time?" [synthesis]
  • Conflict between the house's advice and the treatment plan (for example, stopping medicine or a period of withdrawal). Do not argue theology. Ask the client what they want. With consent, raise the practical issue with the prescriber and the leader. Never advise the client yourself to stop or change medicine. [synthesis]
  • Rupture after a perceived slight (using "macumba", calling trance "dissociation" in front of the client, or showing surprise). Name it, apologise specifically, and ask what it reminded them of. Religious racism in earlier care is a common background. [synthesis] RENAFRO material lists stereotypes adherents meet, such as "macumbeiro". [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
  • Possible psychosis presented in religious terms, with family pressing for one side. Complete the differential (4.7), including medical assessment. Hold both possibilities. Seek, with consent, the view of the client's leadership, who may recognise when something is not religious. If risk is high, act on risk first. [synthesis]
  • Client overwhelmed after an intense religious experience or a house crisis (a leader's death, a split, an attack). Stabilise with grounding and sleep and safety planning. Postpone meaning-making until the client is regulated. Ask who in the community can support them. [synthesis]
  • Your colleague or service pathologises the religion. Share the cultural formulation, cite the DSM-5-TR and ICD-11 cultural exclusions (4.7), and point to psychiatry's own history in Brazil. [source: https://www.scielo.br/j/rpc/a/rjPcHY7QXBWxfyWqBYHjyFw/?format=pdf] Advocate for the client's chosen path. [synthesis]
  • Client asks you to recommend a terreiro, a leader or a ritual, or asks what an orixá means for them. Decline warmly. These questions belong to their community. Example (illustrative): "That's for your mãe de santo, or for people you trust in the religion, not for me. I can help with how you're feeling while you look." [synthesis]
  • Suspected exploitation within a house (financial, sexual, coercive). Apply safeguarding (4.15). Keep the issue specific to the individual, not the religion. Support the client to keep other community ties. [synthesis]
  • Non-attendance during religious periods. Plan ahead (4.14). Treat missed sessions without notice as a cue to check in, not as resistance. [synthesis]
  • Your own discomfort or religious objection. Take it to supervision. If neutral care is not possible, refer with a warm handover and do not frame the referral as the client's problem. [synthesis]

Sources

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