Puerto Rican and Cuban espiritismo

1. Introduction

Version followed: the psychotherapist's own culturally responsive work alongside Puerto Rican and Cuban espiritismo. Espiritismo is described as its scholars and practitioners describe it, mainly Puerto Rican sources (Núñez Molina 1991; Koss; Harwood 1977/1987; Garrison 1977), with fewer sources on Cuban espiritismo. Assessment follows the DSM-5-TR Cultural Formulation Interview (CFI), with DSM-5 (2013) supplementary modules and Informant Version.

What it is. Espiritismo is a Caribbean and Latin American spiritual and healing tradition that grew out of the Spiritism codified by Allan Kardec in France (his Book of the Spirits, Paris, 1857). It is not a psychotherapy, and the therapist does not practise it. Within the tradition, spirits of the dead are held to keep influencing the living. More evolved spirits ("de luz") are said to help growth, and less evolved or ignorant spirits are said to cause emotional and physical suffering. Reincarnation is held to allow spiritual progress, and some hardships are understood as "pruebas" (trials) tied to spiritual debts. Practitioners hold that anyone can become a medium by "developing faculties" [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559] [source: https://wrldrels.org/?p=20209].

Puerto Rico. Kardecism arrived in the second half of the 19th century, brought by middle-class Puerto Ricans who had studied in Europe. Spanish authorities treated it with suspicion. Some practitioners were arrested, and groups met in secret. Spiritists later campaigned for reforms in education, health and politics. Among poorer communities it blended with popular Catholicism, curanderismo and herbal medicine. Núñez Molina calls this blend "espiritismo folklórico" and describes it as the most popular form on the island [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. One timeline dates Puerto Rican interest in Kardecism to 1872 [source: https://wrldrels.org/?p=20209]. An encyclopaedia overview places its popularity in the early 1800s, which conflicts with the 1857 date of Kardec's book [uncertain] [source: https://en.wikipedia.org/wiki/Espiritismo]. A historical monograph covers 1860-1907, including how spiritist centros functioned, the stigmatising label "espiritero" and the push for a spiritist federation [source: https://escritores.org/libros/index.php/item/el-espiritismo-en-puerto-rico-1860-1907].

Cuba. Kardecism is placed in Cuba from the 1860s [source: https://wrldrels.org/?p=20209]. A secondary overview says it spread as people grieved the dead of the Ten Years' War. It also says it mixed with African-derived traditions to form espiritismo cruzado, whose central gathering is called the misa espiritual, and that it was suppressed after the Revolution but continues [source: https://en.wikipedia.org/wiki/Espiritismo] [uncertain: secondary encyclopaedia source; Cuban community and scholarly sources not verified]. The same source describes santerismo, a blend of espiritismo and Santería, among Cuban and Puerto Rican communities in New York and New Jersey. Santería is a distinct tradition with its own lines of authority.

How change happens (as the tradition and its scholars describe it). Within espiritismo, a problem is classified as "material" (organic or psychological, often referred to a doctor) or "spiritual". Spiritual causes are addressed through the work of mediums in a centro, and some afflicted people are guided towards developing as mediums themselves [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. Scholars have offered outsider interpretations of these processes. Koss described development as a medium as a form of cultural psychotherapy: trance lets guilt and conflict be voiced while responsibility is placed on the spirit, and membership widens social ties [source: https://revistas.upr.edu/index.php/rcs/article/view/9092/7490]. Garrison and Harwood described spiritism as functioning like psychotherapy for Puerto Rican communities in New York [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/044] [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/008]. These are scholars' readings, not the tradition's own account. For the therapist, change comes from understanding the client's explanatory model, respecting chosen sources of help, telling culturally normative spirit experiences apart from illness, and coordinating care when the client wishes [synthesis].

2. Framework

Espiritismo has no single leader or centre, and practice varies widely [source: https://en.wikipedia.org/wiki/Espiritismo] [uncertain: secondary source]. Authority lies with the leader of each centro (Koss calls the group leader the "Presidente") and with individual mediums and espiritistas [source: https://revistas.upr.edu/index.php/rcs/article/view/9092/7490]. Historically, federations were also sought in Puerto Rico [source: https://escritores.org/libros/index.php/item/el-espiritismo-en-puerto-rico-1860-1907]. Where Santería is involved, authority rests with that tradition's own elders and godparents (padrino or madrina), not with the espiritista [source: https://en.wikipedia.org/wiki/Espiritismo] [uncertain: secondary source]. No current licensing or regulatory body for espiritistas was verified [uncertain: not verified]. Only the client can say which centro or practitioner they recognise.

The tradition's own sessions, cleansings and mediumship development belong to its practitioners and are not described here. The framework below is the therapist's own work. No source gives a session count for it, so the structure is [synthesis] built on the CFI's intended use [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].

Phase A: engagement and cultural assessment (sessions 1-2) [synthesis]. Goal: hear the problem in the client's terms, including any spiritual explanation, without judgement. Format: the core CFI (16 questions, four domains) within the intake, plus the Spirituality, Religion and Moral Traditions module and the Explanatory Model module where spiritual causes come up. With consent, the Informant Version can be used with a family member. APA lists no administration time, and the field trial found that later interviews took less time [uncertain: minutes not verified] [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. Move on when you can state the client's explanatory model, their current and past help-seeking (including any centro, espiritista or botánica), and their care preferences.
Phase B: differential assessment and formulation (sessions 2-4) [synthesis]. Goal: decide whether spirit-related experiences are culturally normative, a cultural concept of distress, a disorder, or more than one at once. Check whether medical review is needed. Format: a cultural formulation, consultation with a cultural broker when unsure, and risk and safeguarding screening. Move on when you have a shared formulation the client recognises, and risk is assessed.
Phase C: collaborative care plan [synthesis]. Goal: agree how therapy, medical or psychiatric care, and the client's spiritual help will sit side by side. Format: a written plan. Contact with an espiritista happens only at the client's request and with written consent. Move on when roles are clear and the client knows the therapist will not ask them to give up their tradition.
Phase D: ongoing therapy and integration [synthesis]. Goal: evidence-based treatment for the presenting problem, using the client's own meanings (for example pruebas, spiritual development, protection) where they help. Repeat CFI modules when needed, which the modules allow "repeatedly" during treatment [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Revisit the plan if symptoms worsen, risk rises, or the client starts or stops attending a centro.
Phase E: review and ending [synthesis]. Review the gains in both systems of help, and agree how to come back to care.

3. Guiding principles

The therapist works alongside, never inside, the tradition. Do not run sessions, cleansings or mediumship work, or advise on them. Your role is assessment, psychotherapy and coordination [synthesis].
Attribute, do not adjudicate. Describe spirits, causas and protection as the client and tradition hold them, without stating them as fact or dismissing them. Write "client understands the cause as spiritual" [synthesis].
Use of espiritismo is not a marker of pathology. Garrison found that clients of Bronx centros did not show higher rates of physical, mental or emotional disorder than the general population [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/044]. So don't treat attendance as a symptom.
Expect parallel or sequential help-seeking. Several studies found that clients usually saw a doctor or clinic first and turned to a centro for related mood or non-organic problems [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/044] [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. So ask about every helper.
Spiritual guides can be gateways to care. In the South Bronx, children in families involved with espiritismo and/or Santería were 2.41 times as likely to use mental health services over three years. No association was found in Puerto Rico [source: https://doaj.org/article/9aa1505447c64d829a17ae21c424cd87]. So treat the healer as a possible ally, and don't assume this holds in every setting.
Healers differ; do not generalise. Núñez Molina found no empirical evidence that spiritist practices are generally anti-therapeutic, but notes that individual healers vary [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. So judge the specific practitioner the client describes, not the tradition.
The CFI supports judgement but is not a diagnosis. It is "not meant to be the only basis for a diagnosis" (paraphrase of APA) [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. So combine it with standard assessment.
Avoid both pathologising and missing illness. DSM and ICD exclude experiences that are part of broadly accepted cultural or religious practice, but involuntary, unwanted and impairing states can still be disorders [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html]. So assess distress, impairment and whether the client wants the experience.
Client choice governs collaboration. Contact a healer only when the client asks, with specific written consent [synthesis].
Never advise on medicines or herbal remedies. Route all questions about medication, herbs or botánica products to the prescriber or physician [synthesis].
Remember the history of stigma and secrecy. Spiritists were persecuted under Spanish rule in Puerto Rico, stigmatised as "espiriteros", and practice in Cuba was driven underground after the Revolution [uncertain: secondary source for Cuba] [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559] [source: https://escritores.org/libros/index.php/item/el-espiritismo-en-puerto-rico-1860-1907] [source: https://en.wikipedia.org/wiki/Espiritismo]. So expect clients to disclose slowly, and make it clear you are safe to tell.
Safeguarding comes before deference. Cultural respect never overrides duties when anyone is harmed or urgent medical care is delayed [synthesis].

4. Intervention inventory

Everything here is the psychotherapist's own work. The tradition's own practices (sessions, misas, cleansings, mediumship development, readings) belong to espiritistas and centros. They are named only so you can recognise them, never so you can perform them.

4.1 Cultural humility and self-examination

Purpose: to notice your own assumptions about spirits, mediumship, trance and "folk" healing before they shape the assessment. Use it before and throughout work with clients who may draw on espiritismo [synthesis].
Steps: (1) Write down what you were taught about spiritism, Santería and Caribbean religion. Note any stereotypes, such as the old slur "espiritero" [source: https://escritores.org/libros/index.php/item/el-espiritismo-en-puerto-rico-1860-1907]. (2) Separate your clinical questions (risk, impairment, distress) from your personal beliefs. (3) Read scholars' accounts, and remember that most are outsiders' accounts (for example Harwood, Garrison, Koss) [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/008]. (4) Take cases to supervision or consultation with a clinician from the community, when the client agrees [synthesis].
Example language (illustrative): "Many people I see get help from more than one place, including spiritual places. I'm not here to judge any of that, just to understand what helps you."
Watch for: feeling amused, alarmed or keen to "educate" the client. Taking an outsider ethnography as the client's own view. It is working when the client corrects you freely and brings spiritual material without being asked [synthesis].

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

Purpose: to clarify the problem from the client's and their network's point of view: its meaning, possible sources of help, and what they expect from services. APA says any clinician can use it in any setting [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Use it at intake with every client, and especially when a spiritual cause is mentioned.
Steps: (1) Download the official APA form. It may be reproduced by clinicians for use with their patients. Modifying or translating it needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (2) Cover its four domains in order: Cultural Definition of the Problem; Cultural Perceptions of Cause, Context and Support; Cultural Factors Affecting Self-Coping and Past Help Seeking; Cultural Factors Affecting Current Help Seeking [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (3) Under past help seeking, list every source named, including centro, espiritista, botánica, priest, Santería elder, doctor and clinic. (4) Under the clinician-patient relationship, ask openly about language barriers and experiences of racism or of not being believed. (5) Record answers in the client's words, in Spanish where the client used it [synthesis].
Example language (illustrative): "Sometimes people go to a doctor, a church, a centro or a family elder. Who else have you talked to about this, and what did they say?"
Watch for: the client describing the problem only in medical terms at first and spiritual terms later, as trust grows. That is common and fine. Clients may also fear you will think they are "crazy" for mentioning spirits. It is working when the help-seeking map is complete, and the client's own words for the problem appear in your formulation [synthesis].

4.3 Spirituality, Religion and Moral Traditions module, and other supplementary modules

Purpose: to explore in depth how espiritismo (and Catholicism, Santería or Protestant faith) shapes the client's identity, coping and expectations. The modules work as add-ons to the core CFI or as standalone tools, and can be used at the first evaluation, later, or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Use the module when spiritual material comes up in the core CFI. (2) Add the Explanatory Model, Coping and Help-Seeking, Social Network and Cultural Identity modules as needed. Add the Immigrants and Refugees module for recent migrants, including Cuban arrivals. Add the School-Age Children and Adolescents module for young people, and the Caregivers module for family carers. All twelve modules are listed by APA [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (3) Paraphrase the module's prompts in conversational language. Do not reproduce the form [synthesis].
Example language (illustrative): "You mentioned you go to a centro. What role does it play in your life, and in how you're dealing with this?"
Watch for: mixed or private affiliations. A client may be Catholic and attend a centro, or keep a family practice quiet. Don't force a single label. It is working when you know which community or practitioner the client trusts, and what that relationship means to them [synthesis].

4.4 Eliciting the explanatory model, including "material" and "spiritual" causes

Purpose: to learn what the client calls the problem, what caused it, and what treatment they think fits. In espiritismo, problems may be classed as material or spiritual [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. Use it in Phase A and whenever treatment stalls.
Steps: (1) Work through Kleinman's eight questions in your own words: the name of the problem; its cause; why it started when it did; what it does to the person and how it works; how severe it is and whether it will last; what treatment is needed; the main problems it has caused; what the person fears most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]. (2) Ask whether anyone, such as an espiritista or family member, has given an explanation, and whether the client agrees with it. (3) Note whether the client sees the problem as material, spiritual, or both. (4) Ask what they hope therapy adds to what they already do [synthesis].
Example language (illustrative): "Some people feel a problem like this has a material side and a spiritual side. How do you see it? What would need to happen for you to feel it's been dealt with?"
Watch for: models that blend causes (stress, a past life, a spirit influence, family conflict) without contradiction, and accept the blend. Watch also for a fearful model, such as a belief that someone sent harm, which can raise anxiety, isolation or conflict. Núñez Molina counts not inducing paranoia among the marks of an honest healer [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. It is working when you and the client share language for the problem and goals that both sides of care can support [synthesis].

4.5 Asking about consultation with espiritistas, centros and botánicas without judgement

Purpose: to make spiritual help-seeking safe to talk about, so you can coordinate care and spot risks. Use it at intake and at each review [synthesis].
Steps: (1) Normalise it. Garrison found centro clients were no more disordered than the general population, and that clinic and centro were often used in sequence [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/044]. (2) Ask what the practitioner recommended, and how the client felt about it. (3) Ask specifically whether the practitioner said anything about doctors, medication or therapy. Harwood reported that discouraging medication was common, while Garrison found no such cases among 20 clients on psychotropics, so ask and don't assume [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. (4) Ask whether any products or remedies from a botánica are being used. Do not advise on them. Pass the information, with consent, to the prescriber or physician, who can judge interactions and toxicity. Mercury sold in some botánicas has been flagged as possibly toxic [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. (5) Record without evaluative language [synthesis].
Example language (illustrative): "Has the espiritista said anything about your doctor or your medication? I ask so that everyone helping you is pulling in the same direction."
Watch for: sudden secrecy, which may mean the client expects disapproval. Watch for reports that the client was told to stop medication or avoid surgery: Núñez Molina notes isolated cases of healers discouraging needed care [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. It is working when the client tells you about new consultations without prompting.

4.6 Using DSM-5-TR cultural concepts of distress

Purpose: to recognise idioms, explanations and syndromes that DSM-5-TR describes as cultural concepts of distress, without forcing them into, or excluding them from, a diagnosis. DSM-5-TR says these "include idioms, explanations or perceived causes, and syndromes" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Use it when a Puerto Rican or Cuban client describes nervios, an ataque or susto.
Steps: (1) Note the client's own term. (2) Check the DSM-5-TR glossary entry. A secondary list of DSM-5-TR concepts includes ataque de nervios, nervios and susto, among others [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. The exact DSM-5-TR list and its changes from DSM-5 are [uncertain] [source: https://revistapsiquiatria.pt/index.php/sppsm/article/download/139/69]. (3) Read the manual's own text for each concept, including its related conditions, rather than relying on summaries. (4) Ask what the term means for this client, because meanings vary between people and families. (5) Assess separately for any co-occurring disorder, risk and impairment [synthesis].
Example language (illustrative): "When you say your nervios got bad, what happens? What does your family say it is?"
Watch for: treating the idiom as a diagnosis, or as proof that no disorder is present. Note when the client uses a spiritual explanation alongside the idiom. It is working when the term helps the client talk, and your diagnosis stands on standard criteria [synthesis].

4.7 Telling culturally normative spirit experiences apart from disorder

Purpose: to avoid pathologising mediumship, spirit contact or "developing faculties" while still recognising psychosis, dissociative disorder, mood disorder or medical illness. Núñez Molina notes that healers often read symptoms as signs of a developing gift rather than mental illness [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. Use it when a client reports hearing or seeing spirits, trance, or being told they have "faculties".
Steps: (1) Ask when and where the experiences happen. Are they confined to centro sessions, or spontaneous and spread through daily life? (2) Ask whether they are wanted or unwanted, controllable or not, and how the client's community views them. (3) Apply the manual exclusions. In DSM-5 the possession form of dissociative identity disorder excludes disturbance that is a normal part of broadly accepted cultural or religious practice. DSM-5-TR keeps this in substance, though the exact wording is [uncertain] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. Dissociative trance (other specified dissociative disorder) is likewise excluded when it is part of accepted collective practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. 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 [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. (4) Look for markers of disorder: impaired functioning, self-neglect, disorganised speech or behaviour, distress the client wants relief from, risk, and a course that departs from what the community expects. The DSM-5-TR note on culturally sanctioned beliefs and psychotic symptoms is [uncertain: not verified]. (5) When unsure, consult, with the client's consent, a cultural broker or a family member who knows the tradition. Ask how the community would view the experience, never how to perform it [synthesis]. (6) Arrange medical review when there are new neurological, cognitive or physical features [synthesis].
Example language (illustrative): "Is this something that happens mainly when you're at the centro, or does it come at other times too? Is it something you want, or something you wish would stop?"
Watch for: a family or practitioner calling worsening psychosis "development", or a clinician calling normal mediumship psychosis. Spiritist frameworks may not resolve every condition. A study of a Mexican Spiritualist temple found that psychotic episodes did not respond, but that is a different tradition, so read it as context only [source: https://link.springer.com/article/10.1007/BF00049159]. It is working when the formulation explains the experience in a way both the client and, where involved, their community find respectful, and any disorder is treated [synthesis].

4.8 Involving family: the CFI Informant Version

Purpose: to bring in the views of family members, who often hold or share the spiritual explanation and may have arranged the spiritual help. The Informant Version is for a relative or friend of the person seeking care, and starts with that person's relationship to the client [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Get the client's consent, and agree what can and cannot be shared. (2) Interview the informant separately or jointly, as the client prefers. (3) Compare explanatory models, and note where they agree or differ. (4) Use the Caregivers module for a carer's own burden [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (5) With minors, involve parents or guardians, and get the young person's assent [synthesis].
Example language (illustrative): "Your mother has been very involved. Would it help if I heard how she sees what's happening? You can decide what we talk about."
Watch for: pressure from family to attend, or to stop attending, a centro. Watch for differences between generations or between island and mainland, and for confidentiality limits. It is working when family and client support a shared plan [synthesis].

4.9 Collaboration and referral with espiritistas, when the client wishes

Purpose: to coordinate with a practitioner the client already trusts, so that care is consistent and the healer can work as a gateway to services. Zerrate et al. found a "gateway provider" pattern in the South Bronx and suggest building links between providers and spiritual groups [source: https://doaj.org/article/9aa1505447c64d829a17ae21c424cd87]. Harwood's concluding chapter examined possible relationships between spiritist therapists and health facilities serving Puerto Rican clients [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/008]. Koss-Chioino's 1992 book addresses mental health care and traditional healing in Puerto Rico [source: https://library.usi.edu/record/140191]. Details of specific 1970s therapist-spiritist collaboration projects in Puerto Rico are [uncertain: not verified]. Use this only when the client asks, or agrees after you raise it.
Steps: (1) Ask whether the client wants their therapist and practitioner to be in touch. Never make it a condition of care. (2) Get specific written consent: who, what information, for how long. (3) Clarify roles. You provide assessment, psychotherapy and coordination with medical care. The practitioner provides spiritual help as their centro recognises it. Neither directs the other's practice. (4) Share only what the client allows, and focus on safety, attendance and medical needs. (5) Do not refer the client to a practitioner yourself unless the client asks and the person is someone the client's own community recognises. Do not choose practitioners for clients [synthesis]. (6) Weigh the practitioner against Núñez Molina's proposed criteria for an honest healer: they recognise their limits, guarantee no results, charge little or nothing, credit the spirits rather than themselves, support medical care and medication, avoid inducing paranoia, do not advertise sensationally, and reject "brujería" [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559].
Example language (illustrative): "If you'd like, and only if you'd like, I could talk with the person at your centro so we're not giving you mixed messages. What would you be comfortable with me sharing?"
Watch for: a practitioner who asks for clinical details beyond the agreed scope, discourages medical care, or charges large sums for guaranteed results. Watch also for the client feeling caught between helpers. It is working when the client reports consistent messages from both and attends both as they choose [synthesis]. Evidence from other regions: in Nigeria and Ghana, the COSIMPO trial of collaborative care between traditional and faith healers and primary care workers for psychosis (Gureje et al., The Lancet 2020) reduced symptoms more than usual care and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]. In Ghana, the Ofori-Atta prayer-camp trial (Br J Psychiatry 212(1)) found that 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 studied espiritismo.

4.10 The interface with medical and psychiatric care

Purpose: to make sure physical illness and medication are handled by medical professionals, whatever spiritual explanation the client holds. Most healers do not oppose medical treatment for physical conditions, but isolated cases of discouraging needed care have been reported [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559].
Steps: (1) Ask about current medicines and any remedies or botánica products. (2) Never advise starting, stopping or changing a medicine or remedy. Route every question to the prescriber or physician, with consent. (3) If the client is thinking of stopping medication on spiritual advice, explore their reasons, and arrange a prompt review with the prescriber. (4) Refer for medical assessment if physical symptoms are being attributed only to spiritual causes and have not been checked [synthesis].
Example language (illustrative): "That's an important decision. Could we bring your doctor into it before anything changes, so you have the full picture?"
Watch for: missed appointments, relapse after stopping medication, and physical red flags. It is working when medical and spiritual care continue side by side [synthesis].

4.11 Integrating spiritist meanings into psychotherapy

Purpose: to let the client's own framework (pruebas, spiritual progress, spirit protectors, a calling to develop faculties) support evidence-based treatment rather than compete with it [synthesis]. Núñez Molina describes espiritismo as able to empower or to create dependence, and reports that healers often say their aim is to develop the client's own abilities [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559].
Steps: (1) Ask which spiritist ideas the client finds strengthening. (2) Link therapy goals to those meanings in the client's words, for example that facing a trial with support counts as growth. (3) Keep the method of your therapy (for example CBT, trauma-focused work, family therapy) intact, and use the meanings as motivation and context. (4) Explore any meaning that increases guilt, fear or passivity, and ask the client whether it helps them. (5) Never offer spiritual interpretations yourself, or claim knowledge of spirits [synthesis].
Example language (illustrative): "You've described this as a prueba. In this room, what would it look like to go through it with more support and less alone?"
Watch for: the therapist starting to interpret spiritually, a framework that justifies staying in an abusive situation, or fatalism that blocks change. It is working when the client feels their beliefs are respected and takes active steps [synthesis].

4.12 Language, interpreters and cultural brokers

Purpose: to make sure the client can describe spiritual and emotional experience in the language and register they use for it. Language barriers are part of the CFI's clinician-patient relationship domain [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: (1) Offer a professional Spanish interpreter. Avoid using family members, especially children. (2) Brief the interpreter that spiritual terms (causas, protecciones, faculties, pruebas) should be rendered as said, not translated into clinical terms. (3) For a cultural broker, choose someone the client agrees to and who is not their own practitioner, to avoid role conflict. (4) Record key terms in Spanish alongside your English notes [synthesis].
Example language (illustrative): "Please use whatever words feel right, in Spanish or English. If there's a word for this at the centro, I'd like to learn it."
Watch for: an interpreter who softens or dismisses spiritual content, and concerns about privacy in small communities. It is working when the client's terms appear in the record and they correct translations freely [synthesis].

4.13 Safeguarding where a practice or practitioner causes harm

Purpose: to protect clients and children while respecting legitimate practice. Núñez Molina reports isolated cases of healers discouraging needed medical care or surgery. He also reports a child's enuresis linked to a frightening ritual (Bird and Canino 1981), possible toxicity of some plants and of mercury sold in botánicas, and the risk of exploitative healers [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559].
Steps: (1) Screen in routine terms for harm: physical injury, exposure to toxic substances, financial exploitation, sexual misconduct, isolation, frightening experiences for children, and delayed medical care. (2) Ask what happened rather than about beliefs. (3) Follow your jurisdiction's child and adult protection procedures, and consult your safeguarding lead. (4) Name the harmful act, not the tradition, both in the record and with the family. (5) For toxic exposure (for example mercury), arrange urgent medical assessment through the physician or poison service. Do not give advice on the product [synthesis]. (6) Distinguish a practitioner's harmful act from the client's continued, safe participation in their centro [synthesis].
Example language (illustrative): "I respect that the centro matters to you. I'm concerned about what happened to your son that night, and I need to make sure he's safe."
Watch for: abuse explained away as tradition, and tradition misread as abuse. Watch also for fear that disclosure will bring the whole community under suspicion. It is working when the harm stops and the client stays engaged with care [synthesis].

4.14 Addressing stigma, colonial history and racism in services

Purpose: to acknowledge that spiritist practice has a history of persecution, stigma and secrecy, under Spanish colonial authorities and the Church in Puerto Rico and after the Revolution in Cuba [uncertain: secondary source for Cuba]. Clients may expect the same from clinicians [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559] [source: https://en.wikipedia.org/wiki/Espiritismo]. Scholars also link espiritismo to Puerto Rican identity (puertorriqueñidad) [source: https://journal.equinoxpub.com/FIR/article/view/14334].
Steps: (1) Ask, using the CFI relationship questions, about earlier experiences of being judged by services. (2) Name your openness explicitly. (3) Consider structural stressors raised in the literature, such as housing and poverty. Figueroa (1981) documented tenants who used spiritist gatherings to organise collective action [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. (4) Support advocacy and social resources alongside therapy [synthesis].
Example language (illustrative): "Some people have been made to feel ashamed for going to a centro. Has anything like that happened to you, here or elsewhere?"
Watch for: defensiveness, minimising, or testing the therapist. It is working when the client brings spiritual matters into sessions openly [synthesis].

4.15 Clients who combine traditions, and Cuban clients

Purpose: to respect the different lines of authority when a client's practice combines espiritismo with Santería (santerismo), Catholicism or, in Cuban practice, African-derived traditions (espiritismo cruzado) [source: https://en.wikipedia.org/wiki/Espiritismo] [uncertain: secondary source].
Steps: (1) Ask which tradition each practice or practitioner belongs to, and who the client looks to for guidance (a centro leader, an espiritista, or a Santería padrino or madrina). (2) Use the Cultural Identity and Immigrants and Refugees modules for recent Cuban arrivals, including experiences of practising in secret [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (3) Do not assume Cuban and Puerto Rican practice are the same, or that one practitioner speaks for another tradition [synthesis].
Example language (illustrative): "You mentioned both the misa and your madrina. Who do you turn to for which kinds of questions?"
Watch for: your own conflation of traditions, and confidentiality expectations specific to a tradition. It is working when your record names the right authority for each part of the client's spiritual life [synthesis].

5. Handling problems

Published clinician guidance on handling problems specific to espiritismo is thin [uncertain: not verified]. All responses below are [synthesis] unless cited.

Client won't discuss spiritual help (stuck, guarded). Don't push. Normalise multiple sources of help (4.5), and return to it after trust grows. Explain why you ask: coordination and safety, not judgement. Garrison's finding that centro use does not indicate greater disorder can be shared in plain terms [source: https://ehrafworldcultures.yale.edu/cultures/nk05/documents/044].
"My problem is spiritual, so therapy can't help" (resistance). Agree that the client sees a spiritual side. Ask what kind of help the spiritual side needs and what kind the material side needs, using the material/spiritual distinction the tradition itself uses [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. Offer therapy for the parts the client links to stress, relationships or mood.
Client stops medication on spiritual advice (non-adherence). Do not argue or advise. Explore the advice and its meaning, then arrange a prompt prescriber review. With consent, invite the practitioner to support medical care, since many healers do (4.10).
Escalating fear of spiritual attack or harm sent by others (overwhelm). Assess for psychosis, anxiety disorder and trauma, and assess risk. Ground the client in present safety. Ask whether their trusted practitioner sees it the same way. Avoid confirming or denying the spiritual claim. Refer urgently if there are psychotic features or risk.
Experiences after a centro session are distressing or won't stop. Assess whether they are involuntary, unwanted and impairing (4.7). Encourage the client to talk with the centro leader they trust about pausing, and arrange psychiatric review where there is risk or a possible disorder. The therapist does not advise on the session itself.
Family conflict over the tradition. Use the Informant Version (4.8). Hold a joint meeting focused on the client's wellbeing rather than on which belief is right.
Rupture: the client feels the therapist dismissed or exoticised their faith. Name it, apologise specifically, and ask what would repair it. Review your own reactions in supervision (4.1).
Rupture: the practitioner contradicts the treatment plan. Return to the client: what do they want? With consent, hold a brief role-clarifying conversation. Never criticise the practitioner to the client.
Suspected exploitation (large fees, guaranteed cures, isolation from family). Compare with Núñez Molina's criteria for honest healers [source: https://www.repsasppr.net/index.php/reps/article/download/42/420/1559]. Explore the client's own doubts, and follow safeguarding steps for financial or sexual abuse (4.13).
The therapist is asked to take part, give an opinion on the spirits, or recommend a centro. Decline kindly. Explain your role, and say the choice of practitioner belongs to the client and their community.
Suicidal ideation framed spiritually (for example joining the dead). Carry out standard risk assessment and safety planning, with lethal-means counselling about storage and removal. Involve supports the client trusts, which may include a spiritual adviser if the client wishes.
Child or adolescent presentations. Get assent and parental consent. Screen for frightening experiences or exclusion from school or care. Use the School-Age Children and Adolescents module [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Follow child protection procedures where harm is suspected.

Sources

Web sources

Books and articles cited

Harwood, A. (1977; reissued 1987). Rx: Spiritist as Needed: A Study of a Puerto Rican Community Mental Health Resource. Wiley; Cornell University Press.
Garrison, V. (1977). Doctor, espiritista or psychiatrist? Health-seeking behavior in a Puerto Rican neighborhood of New York City. Medical Anthropology 1(3) [pages uncertain].
Koss-Chioino, J. (1992). Women as Healers, Women as Patients: Mental Health Care and Traditional Healing in Puerto Rico. Westview Press.
Hernández Aponte, G. A. (2015). El espiritismo en Puerto Rico: 1860-1907 [publisher uncertain].
Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, illness, and care. Annals of Internal Medicine 88:251-258.
Ofori-Atta, A., et al. (2018). Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. Br J Psychiatry 212:34–41. doi 10.1192/bjp.2017.12.
Gureje, O., et al. (2020). Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial. The Lancet.
Further reading cited by Schmidt (2010); no claim in this guide rests on these works: Comas-Díaz, L. (1981). Puerto Rican espiritismo and psychotherapy. American Journal of Orthopsychiatry 51(4):636–645 (details as listed in Schmidt's reference list, UWTSD repository); Hohmann, A. A., et al. (1990). Spiritism in Puerto Rico: results of an island-wide community study. British Journal of Psychiatry 156:328–335 (same); Núñez-Molina, M. A. (1990). Therapeutic and preventive functions of Puerto Rican espiritismo. Homines 14(1):267–276 (University of Puerto Rico Mayagüez record); Delgado (1988), Groups in Puerto Rican spiritism: implications for clinicians, as Schmidt (2010) lists it [uncertain: publication details not verified].

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