Umbanda and Quimbanda

1. Introduction

Version followed: Umbanda and Quimbanda have no treatment manual. Here they are lived Afro-Brazilian religions with their own mediums, spirit guides and terreiro leaders. The clinical core is the psychotherapist's own culturally responsive work, built on the DSM-5-TR Cultural Formulation Interview (APA core CFI, with the DSM-5 Informant Version and Supplementary Modules). The professional frame for practice in Brazil is Conselho Federal de Psicologia (CFP) Resolução nº 7/2023 on the secular character of psychological practice. Descriptions of the religions follow Brazilian historians and anthropologists, and these are outsiders' accounts unless stated otherwise.

What it is. Umbanda is a Brazilian religion that took organised form in the early twentieth century, and scholars agree on that dating. It has no single founder or doctrinal authority. Many Umbandistas tell a founding narrative: in 1908 the medium Zélio Fernandino de Moraes received the spirit Caboclo das Sete Encruzilhadas, who asked why a spirit should be refused "por causa das origens sociais e da cor?" (p. 39). One historian treats this account as a normative, partly mythic founding narrative. Its authority grew after the first federations spread it. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] Brazil's Lei nº 12.644 of 16 May 2012 set up the Dia Nacional da Umbanda on 15 November. [source: https://www.planalto.gov.br/ccivil_03/_ato2011-2014/2012/lei/L12644.htm] The law does not explain why that date was chosen. Its link to the 1908 narrative is [uncertain: not verified]. [source: https://www25.senado.leg.br/web/atividade/materias/-/materia/98646]

In Umbanda, mediums receive spirit guides who give consultations, advice and consolation. The guides include caboclos (Indigenous spirits), pretos-velhos (spirits of enslaved Africans, often seen as elders) and exus. The consultations are described as charity (caridade). [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] Quimbanda is the cult of exus and pombagiras, the female counterpart of Exu. Some Umbanda houses count it as the "linha da esquerda" (left-hand line) within Umbanda. Others, especially in the "Umbanda Pura" current, reject it as "magia negra". [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] [source: https://wrldrels.org/?p=15092] Quimbanda holds an unusually prominent place in Rio Grande do Sul. [source: https://scielo.br/j/ra/a/gzLdkRv4fdP3dMtV8th9D3x/abstract/?lang=en]

How change happens, in the tradition's terms and in therapy's. Within the tradition, help comes from the guides' advice and spiritual work. One example is the work to "vencer demanda", which means removing obstacles and restoring a person's path. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] An ethnographer of preto-velho consultations found they work like "um processo terapêutico de autoconhecimento e de aquisição de confiança" (p. 492). Consulentes often used them alongside medical care, not instead of it. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] For the psychotherapist, change comes from treating the client's spirituality as clinical material to hear and value rather than set aside. [source: https://periodicos.ufmg.br/index.php/contextosclinicos/article/view/60567] It also comes from an accurate cultural formulation, careful differential diagnosis, and coordinating care with the client's terreiro when the client wishes. [synthesis] The psychotherapist does not lead, take part in or advise on consultations, passes, incorporation or spiritual work. Those belong to the terreiro and its mediums.

2. Framework

This is a framework for the psychotherapist's work alongside a living religion. It is not a manualised therapy. The phases below are [synthesis] organised around the CFI. No source sets a session count for culturally responsive work with Umbandistas or Quimbandeiros.

Who holds authority in the tradition. Each terreiro or tenda (house) is autonomous and is led by its dirigente. The leader is often called mãe de santo or pai de santo (mother or father of saint). [source: https://wrldrels.org/?p=15092] [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] Mediums are ranked in a hierarchy, and spirits are ranked by their degree of spiritual evolution. Assistants such as the cambono help mediums during consultations. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] Federations have existed since 1939, and the 1º Congresso Brasileiro de Espiritismo de Umbanda in October 1941 set the doctrine of "Umbanda Pura". [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] Federations do not govern every house. Which federation, if any, a given terreiro belongs to is [uncertain: not verified] for any particular case. Ask the client. Quimbanda houses are led by their own priests. [source: https://scielo.br/j/ra/a/gzLdkRv4fdP3dMtV8th9D3x/abstract/?lang=en] Nationally, the Rede Nacional de Religiões Afro-Brasileiras e Saúde (RENAFRO) represents terreiros on health councils and in dialogue with the SUS. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]

Phase 0: Preparation (before and between clients). Goal: examine your own religious position and any prejudice. Learn the legal and ethical frame, which in Brazil is CFP Resolução 7/2023 and the law on religious racism. Know local terreiro-health networks. Move on when you can name your own assumptions about "macumba", Exu and possession and set them aside in session. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf] [synthesis]

Phase 1: Engagement and cultural assessment (usually sessions 1 to 2). Goal: give the core CFI, with supplementary modules as needed. Elicit the explanatory model and learn what part the terreiro plays in the client's life and help-seeking. The time the CFI takes is [uncertain: not verified]. In the DSM-5 field trial, later interviews took less time. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] Move on once you can state the problem in the client's own words, including any spiritual explanation, and the client confirms your summary.

Phase 2: Differential formulation (sessions 2 to 4, or sooner if there is risk). Goal: tell apart experiences that are normative in Umbanda, such as incorporation of guides or developing mediumship, from dissociative, psychotic, mood, trauma or substance-related disorders. Use DSM-5-TR and ICD-11 criteria together with community informants. Move on once you have a working formulation that neither pathologises normative practice nor misses illness. [synthesis, drawing on sources in §4.7]

Phase 3: Shared plan. Goal: agree on goals that fit both the clinical formulation and the client's spiritual framework. Decide with the client whether to make contact with the terreiro, and if so, who makes it and what is shared. Move on when there is a written consent decision on contact with the terreiro, which can be no contact. [synthesis]

Phase 4: Ongoing treatment and integration. Goal: deliver the evidence-based treatment the formulation calls for, such as CBT, trauma-focused therapy or family work, while helping the client integrate advice from consultations and terreiro experiences. Watch for discrimination and safety issues. Session numbers follow the treatment chosen. [synthesis]

Phase 5: Review and ending. Goal: review outcomes in both clinical and the client's own terms and plan relapse prevention, including whom the client will turn to, the terreiro, services or both. Repeat CFI modules if the client's identity or religious life has changed. The modules can be given repeatedly during care. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]

3. Guiding principles

Secular practice and respect for belief. Base your work on science and ethics, and respect the diversity of beliefs. In practice: you neither promote nor discourage the client's religion. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf]
No religious racism. CFP Resolução 7/2023 forbids psychologists to promote religious intolerance or racism against African-origin, Indigenous and traditional communities. It also forbids using psychological tools to reinforce stigma. In practice: never call a guide "demonic" or treat terreiro membership as a symptom. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf]
Keep psychology and religion separate. The resolution forbids linking psychological concepts or techniques to religious beliefs and using the psychologist's title together with religious currents. In practice: do not present therapy as spiritual work, and do not "reinterpret" guides as therapeutic parts. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf]
Value knowledge from outside the mainstream. The resolution asks psychologists to consider the knowledge of traditional communities and the historical and cultural dimensions of spiritual experience. In practice: treat what the client learned in consultation as valid material for their life, not as error. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf]
Attribute spiritual claims; do not adjudicate them. In practice: say "in your house, the preto-velho said…", never "the spirit caused…" or "there is no spirit". [synthesis]
Authority stays with the terreiro. In practice: questions about ritual, mediumship development or spiritual obligations go to the client's dirigente. You give no opinion on them. [synthesis]
Racism shapes health. The PNSIPN recognises racism and institutional racism as social determinants of health and calls for recognising popular knowledge, including that of African-matrix religions. In practice: ask about discrimination at every assessment. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
The terreiro may be the client's main source of care. Terreiros can be "o único lugar de acolhimento e afeto" (p. 3) for excluded people. In practice: protect that relationship and do not compete with it. [source: https://pepsic.bvsalud.org/pdf/mental/v16n29/1679-4427-mental-16-29-0002.pdf]
Complementary care is the norm. In the ethnographic accounts, consulentes combined terreiro consultations with medical treatment, including treatment for depression. In practice: assume the client can use both, and ask how they fit together. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf]
Normative is not the same as healthy, and unusual is not the same as ill. Possession and trance are excluded from DSM-5-TR and ICD-11 disorder categories when they are part of broadly accepted cultural or religious practice. In practice: judge distress, impairment, control and cultural fit, not content. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.cambridge.org/core/product/C5AEA08C97D45DB2DE02BF65D11B250E/core-reader]
Quimbanda is not "the bad side". Exus and pombagiras have been widely demonised, but they can also be a source of empowerment for marginalised people. In practice: explore what the entity means to this client, without importing stigma. [source: https://wrldrels.org/?p=15092]
No ceremony, objects or substances from you. In practice: give no advice on offerings, baths, herbs, guias or ritual obligations, and route every question about medicines to the prescriber. [synthesis]
Consent governs any contact with the terreiro. In practice: share nothing with the terreiro, and nothing from it into the record, without specific consent. [synthesis]
Safety overrides deference. In practice: risk, abuse, exploitation or delay of urgent medical care are handled by standard safeguarding, whatever their religious framing. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions. None of them reproduces or stands in for a terreiro's consultations, passes, incorporation or spiritual work. Wording is illustrative unless quoted.

4.1 Cultural humility and self-examination

Purpose / when: Do this before you see Umbandista or Quimbandeiro clients, and again whenever you notice a strong reaction to religious material. Brazilian stereotypes of terreiro members include "macumbeiro" and "marginal", and these can shape care. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
Steps: (1) Write down what you were taught about Umbanda, Quimbanda, Exu and "macumba": by family, church, media and training. (2) Mark any of it that matches the stigma Exu and Pombagira carry, such as "she-devil" or "lower spirit". [source: https://wrldrels.org/?p=15092] (3) Check your practice against CFP Resolução 7/2023, Art. 3: no inducing belief, no reinforcing stigma, no religious racism. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf] (4) Take recurring reactions to supervision. [synthesis]
Example language (to yourself or a supervisor, illustrative): "When she said her pombagira helps her, I felt alarm. Where does that come from: her story, or my upbringing?"
Watch for: urges to correct, convert, rescue or exoticise the client, and over-interest in ritual detail the client did not bring. It is working when you can hear spiritual content with the same neutral curiosity you bring to any other life domain. [synthesis]

4.2 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: At intake, to understand the problem as the client and their network see it: its meaning, sources of help and expectations of services. The CFI supports clinical judgement and is not the sole basis for diagnosis. APA describes it as usable by any clinician in any setting. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: Follow the 16 questions in the APA form across its four domains: (1) cultural definition of the problem; (2) cultural perceptions of cause, context and support, including cultural identity; (3) self-coping and past help-seeking, and barriers; (4) current help-seeking, preferences, and the clinician-patient relationship. Clinicians may reproduce the form for use with their own patients. Translating or modifying it needs APA permission. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] In domain 3, ask about consultations at the terreiro as one kind of help-seeking (see 4.5). In domain 4, ask directly whether the client expects you to judge their religion. [synthesis]
Example language (illustrative): "In your own words, what is going on? I'd also like to know how your family and your house would describe it." / "Some people from terreiros have been treated badly by services. Has that happened to you, and is there anything that would make this a safer place to talk?"
Watch for: brief, guarded answers about religion, which may signal expected discrimination. Do not let the form override rapport. It is working when the client brings up spiritual explanations without being prompted later in the interview. [synthesis] Exact time per interview is [uncertain: not verified].

4.3 CFI supplementary modules and Informant Version

Purpose / when: To go deeper on a topic the core CFI raised. The modules work as add-ons or as standalone tools, at the first evaluation or later. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: Pick the modules that fit. Spirituality, Religion, and Moral Traditions covers terreiro membership, mediumship role and moral obligations. Explanatory Model is covered in 4.4. Cultural Identity covers race, Afro-Brazilian identity, migration, gender and sexuality, which matter for some pombagira mediums. [source: https://wrldrels.org/?p=15092] Social Network covers the terreiro as a support network. Coping and Help-Seeking, and Patient-Clinician Relationship, can also apply, as can Immigrants and Refugees for diaspora clients. Use the Informant Version (17 questions) with a family member or fellow member of the house only with the client's consent. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Example language (illustrative): "You mentioned your house is like a family. Could we spend some time on who is there for you, and what being a medium asks of you?"
Watch for: spiritual obligations felt as burdens, and conflicts between terreiro and family. It is working when your formulation includes the client's place in the house and what it gives and costs them. [synthesis]

4.4 Eliciting the explanatory model (Kleinman)

Purpose / when: Whenever the client's view of cause or cure differs from a biomedical one, for example when they speak of a "demanda" (an obstacle or spiritual attack to overcome), a need to develop mediumship, or a guide's warning. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781]
Steps: Ask, in your own words, Kleinman's eight areas: what the client calls the problem; its cause; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment it needs; the main problems it has caused; and what the client fears most. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] (Kleinman, Eisenberg and Good 1978, Annals of Internal Medicine 88; page range [uncertain]. [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]) Then compare the client's model with yours and negotiate a shared working model that keeps both. [synthesis]
Example language (illustrative): "What do you and your house call this? What started it, and why now?" / "So the preto-velho said there is a demanda, and your doctor says depression. Could we work on what both of those point to?"
Watch for: fear that naming a cause will offend a guide or the dirigente, and a sense that the treatment must be only spiritual or only medical. It is working when the client can hold both models without feeling they must choose. [synthesis]

4.5 Asking about terreiro consultations and help-seeking without judgement

Purpose / when: At intake and at every review. Consulentes often come to a terreiro in distress and after trying other help, for example after a suicide attempt or with depression or anxiety, and they receive advice and consolation from the guides. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf]
Steps: (1) Normalise the question. (2) Ask what guidance the client received and how they felt afterwards. (3) Ask whether the guidance involves any change to medical care, food, sleep, money or relationships. (4) Record the help-seeking pathway in neutral terms. Do not ask for ritual content, songs or details of spiritual work, and if the client offers it, do not record it. [synthesis]
Example language (illustrative): "Many people I see also go to a terreiro or church. Do you? What did they tell you there, and did it help?"
Watch for: guidance that conflicts with urgent medical care (go to 4.16). It is working when the client reports terreiro advice to you as readily as advice from a doctor. [synthesis]

4.6 Cultural concepts and idioms of distress

Purpose / when: When distress is expressed in religious or cultural idioms. DSM-5-TR covers cultural idioms, explanations or perceived causes, and syndromes, and revised its examples to avoid stigmatising or generalising language. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: (1) Write down the client's own term, such as "demanda" or "the path is closed", and the meaning they give it. (2) Ask whether others in the house use it the same way. (3) Treat it as an explanation or perceived cause, not a diagnosis. (4) Map it onto the symptoms and functioning you assess. The DSM-5-TR list of named concepts (ataque de nervios, nervios, susto and others) is reported by secondary sources and is [uncertain] as to exact contents. Several of these, such as ataque de nervios, may be relevant to Latin American clients. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] No DSM-5-TR concept is specific to Umbanda. [uncertain: not verified]
Example language (illustrative): "When you say there is a demanda against you, what does that feel like day to day: in your sleep, your body, your work?"
Watch for: idioms that sit on top of major depression, PTSD or psychosis. It is working when the idiom guides the conversation and your symptom assessment still happens. [synthesis]

4.7 Distinguishing normative mediumship and incorporation from disorder

Purpose / when: When a client describes receiving guides, hearing or seeing spirits, trance, or a calling to develop mediumship, or when someone else reports these as symptoms. The aim is to avoid both pathologising religious practice and missing illness.
Steps: (1) Criteria. Dissociative identity disorder in DSM-5 notes that identity disruption may be described as possession in some cultures. It excludes disturbance that is a normal part of a broadly accepted cultural or religious practice. DSM-5-TR keeps this in substance, but whether the exact wording is unchanged is [uncertain]. Dissociative trance under other specified dissociative disorder is excluded on the same grounds. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [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 and not part of accepted cultural or religious practice. 6B62 also requires recurrent episodes, or one lasting several days, with significant distress or impairment. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] (2) Pointers toward non-pathological experience (described by its author as "useful pointers", not validated criteria): no suffering or functional impairment; fit with the person's cultural background; no comorbidity; control over the experience; and personal growth over time. [source: https://www.cambridge.org/core/product/C5AEA08C97D45DB2DE02BF65D11B250E/core-reader] (3) Context. In a sample of 115 Spiritist mediums in São Paulo (not Umbanda), mediums averaged about four first-rank symptoms yet had a low prevalence of mental disorders and good social adjustment. [source: https://www.cambridge.org/core/product/C5AEA08C97D45DB2DE02BF65D11B250E/core-reader] A study that included Umbanda practitioners found fewer dissociative experiences and better control of abrupt mood shifts after taking part in rituals. Its results were pooled with Santo Daime. [source: https://teses.usp.br/teses/disponiveis/47/47134/tde-19072012-102245/en.php] (4) Ask about context and control: does it happen only in the gira or terreiro setting, or also at home, at work, or unbidden? Can the person enter and leave it? Does the dirigente regard it as part of mediumship development? [synthesis] (5) Do a full mental state and risk assessment whatever the religious framing. Consider psychosis, mania, PTSD, substance use and neurological causes. [synthesis] (6) With consent, ask a community informant, such as the dirigente or a senior medium, whether the experience fits what the house knows. Use the CFI Informant Version. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [synthesis]
Example language (illustrative): "When your guide comes, is it in the house, during the work, or does it happen at other times too? Can you choose when it ends?" / "Does your mãe de santo see this as part of your development, or is she worried too?"
Watch for: experiences outside ritual settings that are uncontrolled, distressing or impairing; a terreiro that is itself worried; sleep loss, disorganisation or self-neglect. These point toward a disorder that needs treatment alongside religious life. It is working when the client and, if consulted, the house agree with the formulation. [synthesis]

4.8 Working with exu and pombagira material (Quimbanda and the "left-hand line")

Purpose / when: When a client works with or consults exus or pombagiras, or fears them. These entities carry heavy stigma, and some Umbanda currents reject them. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] [source: https://wrldrels.org/?p=15092]
Steps: (1) Ask what the entity means to the client and their house. In one account, pombagira is linked to love, sexuality and independent femininity, and is a source of status and empowerment for some women, gay and transgender mediums. [source: https://wrldrels.org/?p=15092] (2) Look into identity, gender and sexuality themes through the Cultural Identity module, without assuming any of them. (3) If a client says they want, or have commissioned, spiritual work against someone, explore the anger, the conflict and any intent to harm. Assess risk to others as you would for any expressed wish to harm. Clients are reported to seek such help in some cases. [source: https://wrldrels.org/?p=15092] [synthesis] (4) If a client fears being the target of such work, assess anxiety, paranoia and real-world threats separately. [synthesis]
Example language (illustrative): "What is your relationship with her like? What does she help you with?" / "You said you want him to suffer. Let's talk about what he did and what you might do. I need to understand whether anyone is at risk."
Watch for: your own disgust or fascination; shame in clients who keep their exu work secret from family or a church; actual threats or plans of violence. It is working when the client can talk about this part of their religious life without fearing they will be labelled. [synthesis]

4.9 Collaboration and referral with the terreiro (only if the client wishes)

Purpose / when: When the client wants their dirigente informed or involved, when you need a community informant for differential diagnosis, or when terreiro and service advice seem to clash. RENAFRO's model sees the SUS and terreiros as exchanging knowledge, with terreiro care described as "cuidado e zelo" rather than treatment. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
Steps: (1) Ask whether the client wants contact at all. The default is none. (2) Agree in writing who will be contacted, what you will share, what you will not share, and for how long the consent lasts. (3) Let the client choose whether to be present. (4) In the conversation, ask the dirigente's view and say what the clinical concerns are. Do not ask for ritual information or for any ritual to be changed. (5) Agree on practical points of fit, such as attendance during an acute phase, warning signs, and whom to call. (6) Record only what is clinically needed. [synthesis] The evidence on collaboration comes from other traditions. In a cluster trial in Nigeria and Ghana (COSIMPO, Gureje et al., The Lancet 2020), collaborative shared care between traditional or faith healers and primary care reduced psychosis symptoms more than usual care, and harmful practices fell. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In a randomised trial in a Ghanaian prayer camp (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication lowered symptoms but did not significantly reduce days in chains. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] Neither trial involved Umbanda, and transferability is [uncertain].
Example language (illustrative): "Would it help if I spoke with your pai de santo, or would you rather keep the two separate? Either is fine." / (to a dirigente, with consent) "She values the house greatly. I'm concerned about her sleep and some frightening experiences at home. How does the house see what's happening?"
Watch for: pressure from either side, a dirigente who wants to override medical care, or a service that wants to restrict religious practice. It is working when the client feels both sources of care respect each other. [synthesis]

4.10 Integrating consultation advice and terreiro experience into therapy

Purpose / when: When the client brings advice from a guide or an experience at the terreiro into session. Ethnographic accounts describe preto-velho advice on self-love, volunteering and persistence, aimed at self-knowledge and confidence. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] A psychotherapy report with Umbanda mediums argues that spirituality should be heard and valued as part of the client's history and a possible health resource. [source: https://periodicos.ufmg.br/index.php/contextosclinicos/article/view/60567]
Steps: (1) Ask what the advice was and what the client made of it. (2) Link it to the client's own goals. (3) Plan concrete steps the client chooses, keeping the source as the client's own. (4) Do not turn guides into therapeutic techniques or "parts", which CFP Resolução 7/2023, Art. 3 VI, prohibits. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf] [synthesis]
Example language (illustrative): "The preto-velho told you to labour alongside him. What would that look like this week with the job search?"
Watch for: advice that increases risk or isolation, and your own temptation to rewrite the client's spiritual meanings. It is working when the client acts on goals that fit both their faith and the treatment plan. [synthesis]

4.11 Psychotherapy with mediums and terreiro leaders as clients

Purpose / when: When the client is a medium, cambono or dirigente. Psychotherapy with Umbanda mediums has been reported, with mediumship history treated as part of the life story. [source: https://periodicos.ufmg.br/index.php/contextosclinicos/article/view/60567]
Steps: (1) Explore the burdens of the role: obligations, caring for consulentes, and exposure to others' suffering. (2) Respect the confidentiality the client owes to their consulentes. (3) Watch for role strain, burnout and secondary trauma, and treat them as you would in any helping role. [synthesis]
Example language (illustrative): "You carry a lot of people's suffering in the work. Who looks after you?"
Watch for: reluctance to admit difficulty for fear of seeming spiritually weak. It is working when the client can take their own needs seriously. [synthesis]

4.12 Responding to religious racism and discrimination

Purpose / when: When the client reports attacks on their terreiro, insults, online hate, or being treated offensively or refused service because of their religion. Brazil's Ministério da Igualdade Racial defines racismo religioso as violent or derogatory acts expressing "discriminação e ódio" against terreiro peoples, their territories and symbols. [source: https://www.gov.br/igualdaderacial/pt-br/assuntos/guia-denuncias-racismo-religioso/cartilha-enfrentamento-ao-racismo-religioso.pdf]
Steps: (1) Name it as discrimination and validate it. (2) Assess trauma symptoms and safety. (3) If the client wants to report, give them the channels: police (190 or a boletim de ocorrência), specialised delegacias, Defensoria Pública, Ministério Público, Disque 100 and Fala.BR. Advise keeping evidence, including links and screenshots for online offences. (4) Explain the legal frame: the Constitution, Art. 5 VI–VIII; Lei 7.716/1989; and Lei 14.532/2023, which equated injúria racial with racism and protects religious freedom. [source: https://www.gov.br/igualdaderacial/pt-br/assuntos/guia-denuncias-racismo-religioso/cartilha-enfrentamento-ao-racismo-religioso.pdf] (5) Outside Brazil, use local hate-crime and equality routes. [synthesis]
Example language (illustrative): "What happened to your house was an attack on your religion, and it's against the law in Brazil. Would you like to think through whether and how to report it?"
Watch for: self-blame, hiding one's religion, and community-wide fear. It is working when the client feels less alone and acts by their own choice. [synthesis]

4.13 Families, religious conflict and community

Purpose / when: When relatives oppose the client's religion, for example from another faith, or the client hides membership from family. [synthesis]
Steps: (1) Map family beliefs with the Social Network and Spirituality modules. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] (2) In family sessions, set a rule that no one's religion is attacked. (3) Work on the conflict itself, such as autonomy, belonging and fear for the person, rather than on whose religion is true. [synthesis]
Example language (illustrative): "You both want her to be safe. Let's talk about what each of you is afraid of, without deciding whose faith is right."
Watch for: coercion, threats of expulsion, or forced religious practices. Go to 4.16. [synthesis]

4.14 Language, interpreters and cultural brokers

Purpose / when: With Portuguese- or Spanish-speaking clients outside Brazil. Umbanda is also practised in Uruguay, for example. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] Also when a client's terms are unfamiliar to you.
Steps: (1) Use a professional interpreter, not a family member or fellow member of the house, unless the client prefers otherwise and it is safe. (2) Brief the interpreter not to translate religious terms into negative equivalents, and to keep words such as caboclo, preto-velho, exu, pombagira and demanda in their original form. (3) With consent, a cultural broker who knows Afro-Brazilian religions can help with meaning. [synthesis]
Example language (illustrative, to an interpreter): "Please keep her religious words as she says them, and tell me if a word has no English equivalent."
Watch for: interpreter discomfort or moralising, and confidentiality in small diaspora communities. [synthesis]

4.15 Medicines, herbs and other substances: routing, not advising

Purpose / when: When the client mentions herbal baths, herbs or other terreiro care, which RENAFRO lists among terreiro practices, or asks whether to keep taking prescribed medication. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf]
Steps: (1) Record that the client uses terreiro care, without detail of what it involves. (2) Never advise starting, stopping or changing a medicine, and never advise on herbal use. Refer the question to the prescriber or a pharmacist, with consent. (3) If a client is stopping medication because of religious advice or their own wishes, tell the prescriber with consent, and assess relapse risk. (4) Ask about alcohol and other substance use as standard. Some participants credit ritual participation with their recovery from drug use, which can be a strength to support. [source: https://teses.usp.br/teses/disponiveis/47/47134/tde-19072012-102245/en.php] [synthesis]
Example language (illustrative): "That's a question for your doctor. Would you like me to let them know you're thinking about it, so you can decide together?"
Watch for: abrupt stopping of medication and hidden use of substances. [synthesis]

4.16 Safeguarding

Purpose / when: When any practice, in any setting, involves violence, restraint, sexual contact, financial exploitation, coercion, harm to a child, or delay of urgent medical care. Religious framing does not change the duty. [synthesis] The COSIMPO and prayer-camp trials show that harmful practices such as chaining can occur within healing settings. The prayer-camp trial is the example from that setting, not from Umbanda. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]
Steps: (1) Assess the risk directly. (2) For adults, act with the client: plan for safety and support reporting where they choose. (3) For children, or adults at imminent risk, follow local mandatory reporting duties. The specific Brazilian child-protection routes are [uncertain: not verified] here, so check them with your council. (4) Keep safeguarding separate from attitudes to the religion: report the act, not the faith. (5) Remember that terreiro communities are also targets of violence (4.12). [synthesis]
Example language (illustrative): "Your faith is yours, and I respect it. What you've described, someone touching you without your agreement, is not acceptable anywhere, and I want to help you be safe."
Watch for: your own bias in either direction: assuming abuse because a practice is unfamiliar, or missing abuse out of deference. [synthesis]

4.17 Documentation and diagnostic language

Purpose / when: In every record and letter.
Steps: (1) Attribute beliefs ("client reports that her guide advised…"). (2) Avoid stigmatising terms such as "macumba" or "black magic", unless you quote the client and mark it as a quote. (3) Code trance or possession disorders only when the criteria in 4.7 are met. (4) Record no ritual detail. (5) Do not share religious information without consent. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf] [synthesis]
Example language (illustrative, record): "Client is an active member of an Umbanda terreiro, which she describes as her main support. She attributes her low mood partly to a 'demanda'. No psychotic features. Experiences of incorporation occur only in ritual settings and are under her control."
Watch for: records that would expose the client to discrimination if read by others. [synthesis]

5. Handling problems

None of the sources gives specific guidance on therapeutic problems with Umbandista or Quimbandeiro clients. Everything in this section is [synthesis] unless a source is cited.

Guarded or silent about religion (expected stigma). Terreiro members face stereotypes, and religious racism is widespread. [source: https://cebes.org.br/site/wp-content/uploads/2014/04/jose-marmo.pdf] [source: https://www.gov.br/igualdaderacial/pt-br/assuntos/guia-denuncias-racismo-religioso/cartilha-enfrentamento-ao-racismo-religioso.pdf] Response: name your neutrality early, ask CFI domain 4 questions about the relationship with you, and do not push. Example (illustrative): "You don't have to tell me anything about your religion. If it matters to you, I'd like to understand it, not judge it."
"Only the guides can fix this" (stuck or non-adherent). Do not argue. Explore the explanatory model (4.4) and find common goals, such as sleep, work or safety. Offer therapy as complementary, as consulentes in the ethnographic accounts used medical care alongside the terreiro. [source: https://www.redalyc.org/journal/770/77075112012/77075112012.pdf] Example (illustrative): "Keep going to the house. Could we also work on the sleep, so you have more strength for everything else?"
The client asks your opinion on spiritual matters, such as whether a guide is real, whether to develop mediumship, or whether to leave a house. Do not answer the spiritual question. Explore the client's own reasoning, and refer questions about ritual to their dirigente or another house of their choosing. CFP Resolução 7/2023 bars inducing beliefs. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf] Example (illustrative): "That's not something I can judge. What does your heart and your house say, and what makes you unsure?"
Rupture after a perceived slight, for example you used "macumba" or seemed shocked by exu work. Name it, apologise specifically, ask what it felt like, and check whether trust can be repaired. Take your reaction to supervision (4.1).
Overwhelm during sessions, such as trance-like states, intrusive spiritual experiences or a client fearing a guide will arrive. Use grounding and orientation to the room. Ask the client what usually helps them come back. Assess whether this is dissociation from trauma or mediumship happening outside its setting (4.7). Do not attempt any ritual response.
Terreiro advice conflicts with treatment, such as stopping medication or avoiding hospital. Assess the risk. With consent, hold a joint conversation with the prescriber and, if the client wishes, with the dirigente (4.9). If urgent care is being delayed, safeguarding applies (4.16).
Fear of spiritual attack. Assess anxiety, trauma and paranoia, and check for real-world conflict or threats. Help the client use both the house's support and therapy. Do not confirm or deny the attack. Example (illustrative): "Whatever is behind it, you're living with constant fear. Let's look at what helps you feel safer, here and at the house."
Wish to harm another person, framed spiritually. Treat it as you would any expressed intent to harm. Assess plans and means and follow your duty-to-protect rules (4.8).
Exploitation within a house, whether financial, sexual or coercive. Umbanda presents itself as charity. [source: https://periodicos.unb.br/index.php/revistacalundu/article/download/25240/22219/49781] A request for large payments may therefore be a useful question to explore without condemning the religion. Support the client's choices and follow safeguarding (4.16).
Leaving a house, or conflict within one. Expect grief and loss of community. Map other supports, and do not encourage or discourage the client from finding another house.
Therapist-client religious difference, for example a therapist from a church that is hostile to Afro-Brazilian religions. If you cannot work without bias, refer with a full explanation and a warm handover. CFP Resolução 7/2023 makes discrimination a breach. [source: https://multimidia.gazetadopovo.com.br/media/docs/1682604493_resolucao-cfp-liberdade-religiosa.pdf]
Diagnostic uncertainty persists. Keep the formulation open, monitor function and risk over time, and seek a second opinion from a clinician experienced with Afro-Brazilian religions. Repeat the relevant CFI modules. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Secondary trauma after attacks on a terreiro. Use trauma-focused approaches, and link the client to community support and to reporting routes if they choose (4.12).

Sources

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