Ayahuasca churches (Santo Daime, União do Vegetal)

1. Introduction

Version followed: the churches' own published self-descriptions (União do Vegetal, Brazil and USA sites; ICEFLU, the Santo Daime line based at Céu do Mapiá), with attributed scholarly and legal context (G. William Barnard's Santo Daime timeline for the World Religions and Spirituality Project; Labate and Feeney on Brazilian regulation; US federal rulings). The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules. Psychedelic-assisted therapy and general psychedelic integration are covered in Domain VII; this entry does not repeat them. Amazonian vegetalismo and ayahuasca ceremony outside the churches are covered in guide 107.

What it is. The "ayahuasca churches" are Brazilian religions that began in the Amazon in the twentieth century and receive a sacramental tea containing DMT inside their own religious services. They are religions, not therapies, and they are not a technique a psychotherapist performs, recommends or arranges. Two are covered here:

• Santo Daime. ICEFLU (Igreja do Culto Eclético da Fluente Luz Universal, formerly CEFLURIS) describes itself as an "eclectic Christian universalist tradition" whose doctrine was founded by Mestre Irineu; it is based in the village of Céu do Mapiá, Amazonas, and names Padrinho Sebastião Mota de Melo as its patron and founder of Céu do Mapiá, and Padrinho Alfredo as current spiritual leader [source: https://www.santodaime.org/site/en]. In Barnard's timeline, Raimundo Irineu Serra was born in Maranhão in 1890 (traditionally 1892), held the first official work at his home in Rio Branco, Acre, on 26 May 1930, and died in 1971; the Alto Santo line, concentrated in Acre, continues from his centre, while Padrinho Sebastião's followers separated in 1973 and formed CEFLURIS, which spread abroad after 1990 [source: https://wrldrels.org/?p=3309]. The two lines are distinct communities with separate authority.
• União do Vegetal (UDV). The UDV states that José Gabriel da Costa (Mestre Gabriel), a rubber tapper born in 1922, first drank the tea it calls Hoasca in 1959 and announced the União do Vegetal on 22 July 1961 in the forest near the Brazil–Bolivia border; the Centro Espírita Beneficente União do Vegetal was registered in 1971 in Porto Velho and its General Headquarters moved to Brasília in 1982 [source: https://udv.org.br/en/udv-creation/the-origin-of-the-udv/]. It describes its purpose as the improvement of the human being through moral, intellectual and spiritual virtues [source: https://udvusa.org/our-history/].
• Barquinha is named by scholars as a further Brazilian ayahuasca religion [source: https://wrldrels.org/?p=3309]; its founder, dates and present organisation are [uncertain], so this guide gives no detail on it.

Who holds authority. In the UDV, leadership ("the Direction") is formed by the Cadre of Mestres and the Body of Counsel created by Mestre Gabriel, with an elected General Representative Mestre [source: https://udv.org.br/en/udv-creation/the-origin-of-the-udv/]. In ICEFLU, authority rests with its spiritual leadership at Céu do Mapiá and its institutions [source: https://www.santodaime.org/site/en]; Alto Santo centres hold their own authority [source: https://wrldrels.org/?p=3309]. Local church leaders, not therapists, decide who may take part.

Legal status, as sources state. Brazil: CONFEN recommended in 1986–87 that ayahuasca be removed from the prohibited list [source: https://wrldrels.org/?p=3309]; CONAD set up a multidisciplinary working group (Resolution 5, 2004) whose 2006 report became CONAD Resolution No. 1 of 25 January 2010, recognising religious use while prohibiting commercialisation, therapeutic use, tourism and advertising, and combination with illicit drugs [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]. Labate and Feeney note that the earlier ban on use by under-18s came from a 2002 resolution and that use in pregnancy remained debated [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]. United States: in Gonzales v. O Centro Espírita Beneficente União do Vegetal (decided 21 February 2006; opinion by Chief Justice Roberts, Justice Alito not participating) the Supreme Court held under the Religious Freedom Restoration Act that the government had not shown a compelling interest in barring the UDV's sacramental use at the preliminary-injunction stage [source: https://www.law.cornell.edu/supct/html/04-1084.ZS.html]. In Church of the Holy Light of the Queen v. Mukasey (D. Or., Judge Panner) the court ruled for the Oregon Santo Daime church on 18 March 2009, finding under the Religious Freedom Restoration Act that the government had not shown a compelling reason to prohibit its ritual use, and set the injunction terms the next day [source: https://leagle.com/decision/infdco20090811447] [source: https://www.bialabate.net/blog-archive/news/understanding-the-santo-daime-case-correction]. As Labate and Meyer report them, the terms required the DEA to expedite the church's importer application; required records of handlers, quantities imported and batch samples, locked storage, and reporting of the amount served and number of participants per ceremony; and required the church to tell participants with a history of psychosis to seek medical help and to warn them of possible adverse reactions [source: https://www.bialabate.net/blog-archive/news/understanding-the-santo-daime-case-correction]. Barnard reports the ruling as barring the DEA from penalising that sacramental use [source: https://wrldrels.org/?p=3309]. Later appeal history is [uncertain]. Status in other countries varies and is [uncertain]; outside these rulings the substance may be illegal.

How change happens. The churches frame their practice as spiritual and moral development within a religious community, not as treatment, and Brazilian regulation excludes therapeutic use [source: https://udvusa.org/our-history/] [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]. For the therapist, change comes from understanding the client's religious life on its own terms (through the CFI and explanatory model), keeping the client medically and psychiatrically safe, distinguishing religious experience from illness, and, when the client wishes, coordinating with the church's own leadership [synthesis].

2. Framework

This is a religious tradition, not a phased therapy. The framework below is for the psychotherapist working with a member, a prospective member or a former member [synthesis, built on the CFI materials cited].

The CFI can be used at the first evaluation, later in care or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. The time it takes is [uncertain]; the DSM-5 field trial found later interviews took less time [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].

3. Guiding principles

• You stand alongside the religion, not inside it. Do not lead, recommend, arrange or attend services as part of therapy; describe the churches only as they and scholars describe them [synthesis].
• Religion, not treatment. Brazil's 2010 resolution excludes therapeutic use [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]: do not frame membership as a treatment option.
• Authority belongs to the church. Questions of doctrine, participation and conduct in services go to the client's own mestres, padrinhos or leaders [source: https://udv.org.br/en/udv-creation/the-origin-of-the-udv/] [synthesis].
• Each church is distinct. UDV, ICEFLU, Alto Santo and Barquinha are separate communities; do not generalise from one to another [source: https://wrldrels.org/?p=3309].
• Attribute, do not adjudicate. Spiritual beliefs and experiences are reported as the client and church hold them, neither confirmed nor dismissed [synthesis].
• The client's explanatory model comes first. Use the CFI so the client defines the problem in their own terms [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
• The CFI informs, it does not diagnose alone [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
• Medicines go to the prescriber. Never advise starting, stopping or changing a medicine; MAOI interactions are the prescriber's to manage [source: https://www.iceers.org/en/ayahuasca-safety-profile/].
• Screen for vulnerability without moralising. Prolonged psychotic reactions are rare and occur mainly in susceptible people [source: https://revistas.usp.br/acp/en/article/view/144864].
• Normative is not the same as harmless, and unusual is not the same as ill. DSM-5-TR and ICD-11 exclude experiences that are part of accepted collective religious practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299].
• Legal sensitivity. Legal status differs by country and by church; keep records factual and minimal [synthesis].
• Consent governs every contact with the church [synthesis].
• Safeguarding overrides cultural deference [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own. None involves conducting, describing or advising on the churches' services, hymns, sacrament or its preparation.

4.1 Cultural humility and self-examination

• Purpose / when: Before and during work with any member; especially when you notice strong views about psychedelics, "cults" or Amazonian religion [synthesis].
• Steps: (1) Note your assumptions (e.g. that the tea is "just a drug", or that it is inherently healing). (2) Separate what you know from the churches' own published accounts from media or retreat-industry images. (3) Remember that ayahuasca tourism and commercial retreats are distinct from these churches, and that Brazilian regulation prohibits tourism and commercial use [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]. (4) Seek supervision or consultation if your reactions shape your questions.
• Example language (illustrative): "I don't belong to your church, so I'll be relying on you to teach me what it means to you."
• Watch for: Leading questions about "drug use"; enthusiasm that encourages participation. Working: the client corrects you freely and says more about religious meaning over time.

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

• Purpose / when: First evaluation of any client for whom church membership may matter; repeat later if the picture changes. 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-SectionIII.pdf].
• Steps: Work through the four domains in your own words: (1) cultural definition of the problem; (2) perceived causes, stressors, supports and the role of cultural identity (here: church membership, line, local centre); (3) self-coping and past help seeking (including help sought from church leaders); (4) current help-seeking preferences and the clinician–patient relationship [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. The form 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]. Record answers in the client's words.
• Example language (illustrative): "Sometimes people understand their problems in terms of their faith or their community. How would you describe what's been happening, in your own words?" / "Have you talked with anyone in your church about this? What did they say?"
• Watch for: Reluctance to mention membership because of legal fears or past stigma; whether the client sees the church as part of the problem, part of the solution, or neither. Working: the client volunteers religious meanings without prompting.

4.3 Supplementary module: Spirituality, Religion and Moral Traditions

• Purpose / when: When membership is central to identity, when experiences in services are part of the presenting problem, or when the client faces a moral or religious conflict [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
• Steps: (1) Ask about the client's tradition, line and local community, and how long they have belonged. (2) Ask what the tradition teaches about suffering, healing and right conduct, as the client understands it. (3) Ask how religious practice affects the problem and vice versa. (4) Ask about conflicts with family or others over membership. Paraphrase; do not read the module verbatim unless you use the APA form itself.
• Example language (illustrative): "What does your community teach about difficult times like this one?" / "Is there anything about your practice that feels in tension with what you're going through?"
• Watch for: Doctrinal statements you cannot evaluate: note them as the client's, refer doctrinal questions to their leaders. Working: you can state the client's religious frame accurately back to them.

4.4 Explanatory model (Kleinman) and the Explanatory Model module

• Purpose / when: To understand how the client names and explains the problem, and what they expect from you and from the church [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf].
• Steps: Cover, in your own words, Kleinman's eight areas: what the client calls the problem; what caused it; why it began when it did; what it does and how it works; how severe and how long-lasting it is; what treatment they think they should receive; the chief problems it has caused; what they fear most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Then ask where the church and where therapy fit in that model.
• Example language (illustrative): "What do you think set this off, and why now?" / "What do you hope therapy can do that your church can't, and the other way round?"
• Watch for: A spiritual explanation alongside a medical one is common and not a contradiction. Watch for expectations you cannot meet (e.g. that you will "interpret" visions). Working: a shared formulation that names both frames.

4.5 Mapping community and authority

• Purpose / when: To know which church, line and local centre the client belongs to and who holds authority there, before any collaboration (4.12) or safeguarding decision [synthesis, drawing on the churches' published structures].
• Steps: (1) Ask which church (UDV, ICEFLU Santo Daime, Alto Santo, Barquinha, another) and where. (2) Ask who leads their local group and how decisions about participation are made. (3) Distinguish a recognised church centre from an independent or commercial ceremony; ask the client how their group relates to the wider church [synthesis]. (4) Record only what is clinically needed.
• Example language (illustrative): "Who in your community would you go to if you were struggling?" / "Is your group part of a larger church, or independent?"
• Watch for: Groups using the church name without recognition; leaders who discourage medical care. Working: you know whom the client trusts and how the community is organised.

4.6 Asking about participation without judgement (help seeking)

• Purpose / when: At intake and when medicines, symptoms or life events change. Clients may withhold membership because of legal status or fear of being seen as "using drugs" [synthesis].
• Steps: (1) Normalise the question within a broader one about religion and other help. (2) Ask about frequency and recency in general terms only; do not ask about or record preparation, amounts or sourcing. (3) Ask about any non-church use (retreats, tourism, other substances) separately, since risks differ [source: https://www.iceers.org/en/ayahuasca-safety-profile/] [source: https://revistas.usp.br/acp/en/article/view/144864]. (4) Explain what you record and why.
• Example language (illustrative): "Some of my clients take part in religious services where a sacrament is used. I ask everyone, so I can keep you safe with any medicines and understand what matters to you."
• Watch for: Shame, defensiveness or legal fear; a client who uses "church" to describe a commercial retreat. Working: open disclosure at later sessions when circumstances change.

4.7 Medication-interaction liaison (route to prescriber)

• Purpose / when: Whenever a member or prospective member takes, or may be prescribed, any medicine. The tea's harmala alkaloids inhibit monoamine oxidase, and combining MAO inhibition with SSRIs or other serotonergic medicines is contraindicated [source: https://www.iceers.org/en/ayahuasca-safety-profile/]; medical complications have been reported [source: https://revistas.usp.br/acp/en/article/view/144864]. Callaway and Grob (1998) warned that combining ayahuasca's MAO-inhibiting harmala alkaloids with serotonin reuptake inhibitors may induce a serotonin syndrome with a potentially grave outcome, and advised caution when combining ayahuasca with certain medicines [source: https://pubmed.ncbi.nlm.nih.gov/9924842/] [source: https://knowledge-mapping.heig-vd.ch/view/2036]. The UDV's own pages state that its Medical-Scientific Department (DEMEC) has supported research and that a 1996 biomedical study (the Hoasca Project) found the tea not harmful; those pages give no guidance on medicines or psychiatric conditions [source: https://udv.org.br/en/scientific-research/hoasca-tea-is-harmless-to-the-health/] [source: https://udv.org.br/en/blog-en/hoasca-as-theme-of-research-and-publications-the-role-of-the-udv/]. So do not assume a church has screened for interactions; route medicine questions to the prescriber [synthesis].
• Steps: (1) List all medicines, supplements and other substances the client uses. (2) Tell the client plainly that interactions exist and that only their prescriber or pharmacist can advise. (3) With consent, inform the prescriber that the client takes part in religious services where an MAO-inhibiting sacrament is used. (4) Never advise starting, stopping, tapering or timing medicines around services; if the client plans to stop a medicine for this reason, urge them to speak to the prescriber first and document that you did so. (5) Revisit at each medicine change.
• Example language (illustrative): "I can't advise on medicines, but I know this sacrament can interact with some, including common antidepressants. Would you be willing for me to let your doctor know, or to raise it yourself this week?"
• Watch for: Unsupervised stopping of antidepressants or mood stabilisers; new prescriptions the client has not mentioned to the church or the prescriber. Working: the prescriber is informed and the client has a plan made with them.

4.8 Psychiatric-vulnerability conversation

• Purpose / when: At intake and when symptoms change. Reviews report that prolonged psychotic reactions are rare and seem to occur mainly in susceptible people, and advise that people with a personal or family history of psychotic disorders avoid ayahuasca [source: https://revistas.usp.br/acp/en/article/view/144864]; ICEERS lists severe psychiatric disorders, especially those prone to psychosis, as a contraindication [source: https://www.iceers.org/en/ayahuasca-safety-profile/]. Risk in bipolar disorder (mania) is [uncertain].
• Steps: (1) Take a personal and family psychiatric history, including psychosis, bipolar disorder, suicidality and trauma. (2) Share the published risk information factually, without telling the client to leave or stay in their religion. (3) Encourage the client to discuss their history with their own church leaders, who decide participation, and with their prescriber. (4) Agree early-warning signs and a crisis plan (see 4.11).
• Example language (illustrative): "Research suggests people with a personal or family history of psychosis are more vulnerable to lasting reactions. That's information for you, your doctor and your church leaders to weigh; my job is to help you stay well."
• Watch for: Pressure from others to continue despite warning signs; the client hearing the information as an attack on their faith. Working: the client makes an informed, documented decision and knows whom to call.

4.9 Distinguishing religious experience from disorder

• Purpose / when: When a client reports visions, voices, altered states or spiritual messages, during or after services, and you must judge whether these are part of accepted collective religious experience or signs of illness.
• Steps: (1) Ask when and where the experiences occur: confined to services and understood by the community, or spilling into daily life? (2) Ask how fellow members and leaders view them (use the Informant Version, 4.13, if possible). (3) Check the diagnostic exclusions: DSM dissociative identity disorder excludes disturbance that is a normal part of broadly accepted cultural or religious practice, and dissociative trance under other specified dissociative disorder excludes trance that is part of accepted collective practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]; DSM-5-TR keeps these points in substance, exact wording [uncertain] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. ICEERS likewise notes that challenging experiences during a session do not by themselves indicate psychopathology [source: https://www.iceers.org/en/ayahuasca-safety-profile/]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require that the state 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]. A DSM-5-TR note on culturally sanctioned beliefs and psychotic symptoms is [uncertain]. (4) Look for markers of illness that do not depend on content: persistence outside services, loss of insight, functional decline, sleep loss, disorganisation, risk to self or others, distress the client wants relief from. (5) Consult a cultural broker or, with consent, a church leader before concluding.
• Example language (illustrative): "In your community, how would people understand what you saw? Does it feel the same as other experiences in services, or different?" / "Has this carried on at home, at work, when you're trying to sleep?"
• Watch for: Two errors: labelling ordinary religious experience as psychosis, and missing emerging psychosis or mania because it has religious content. Working: a formulation that explains the experience, the community's view and any clinical features separately.

4.10 Integrating experiences from services

• Purpose / when: When a client wants help making sense of, or living out, experiences from services, or is unsettled by them. ICEERS describes integration support as reducing the risk of lasting after-effects [source: https://www.iceers.org/en/ayahuasca-safety-profile/]. General psychedelic-integration methods are in Domain VII.
• Steps: (1) Ask the client to describe the experience and what it meant within their faith; do not supply interpretations of doctrine or symbols. (2) Ask whether they have taken it to their own leaders and what was said. (3) Help translate meanings into concrete, client-chosen changes (relationships, habits, values), using ordinary therapy skills. (4) Track distress; if experiences are intrusive or frightening, treat as in 4.11 [synthesis].
• Example language (illustrative): "What did that experience mean to you, in the language of your faith? And what would living that out look like this week?"
• Watch for: Your own interpretations replacing the client's or the church's; spiritual bypassing of practical problems. Working: the client links the experience to valued action and reports less rumination.

4.11 Challenging after-effects and crisis response

• Purpose / when: When fear, anguish, dissociation, sleep loss, psychotic features or suicidal thinking follow a service. ICEERS says difficult reactions are usually temporary but lasting effects are more likely after very challenging experiences or without support [source: https://www.iceers.org/en/ayahuasca-safety-profile/]; prolonged psychotic reactions are rare [source: https://revistas.usp.br/acp/en/article/view/144864].
• Steps: (1) Assess safety: suicidal ideation, psychotic symptoms, mania, intoxication with other substances, medical symptoms. (2) If physical symptoms suggest a drug interaction or medical emergency, direct to emergency medical care at once [synthesis]. (3) Use standard crisis and suicide-risk practice; involve psychiatry for psychotic or manic features. (4) Offer grounding and stabilisation; postpone meaning-making until stable. (5) With consent, involve trusted church members or leaders as supports. (6) Afterwards, review the crisis plan and the vulnerability conversation (4.8).
• Example language (illustrative): "Let's first make sure you're safe tonight. We can come back to what it means once you're feeling steadier."
• Watch for: Symptoms persisting beyond the immediate aftermath; the client or community treating clear illness only as spiritual work. Working: sleep, orientation and functioning recover; the client can tell the story without being flooded.

4.12 Collaboration with church leadership (client-led)

• Purpose / when: When the client asks for coordination with their leaders, e.g. on returning to services after a crisis, or on support within the community. The church decides participation; you contribute clinical information the client agrees to share [synthesis].
• Steps: (1) Obtain written consent that names the person, purpose and exact information to share. (2) Identify the right person through the client (4.5). (3) Explain your role and limits; do not ask about or comment on ritual matters. (4) Share only what is needed (e.g. that the client is under psychiatric care and has a crisis plan). (5) Agree how the client will be supported and who contacts whom. (6) Review with the client. Evidence from collaboration between mental health services and faith and traditional healers in West Africa (a different setting) supports structured cooperation: in the COSIMPO cluster trial in Nigeria and Ghana (Gureje et al., The Lancet, 2020), collaborative shared care reduced psychotic symptoms more than usual care [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]; in a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric care reduced symptoms but days in chains were not significantly reduced [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. Whether any trial of collaboration with ayahuasca churches exists is [uncertain].
• Example language (illustrative, to a leader): "Your member has asked me to contact you. I'm their therapist; I don't advise on your practices. With their permission, I can tell you they're under psychiatric care and what helps them when they're struggling."
• Watch for: Disclosures beyond consent; pressure on the client from either side. Working: the client feels supported by both and reports no conflict of loyalty.

4.13 Family and informant perspectives

• Purpose / when: When family members disagree about membership, are worried, or can help clarify whether an experience is normative. Use the CFI Informant Version (with a family member or friend) [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
• Steps: (1) With consent, invite the informant. (2) Cover their relationship to the client, then the four CFI domains from their viewpoint. (3) Map agreements and disagreements about the church. (4) Use family sessions to reduce conflict and agree safety plans, not to settle religious questions [synthesis].
• Example language (illustrative): "You see things differently about the church. Can we find what you both want for [client] right now?"
• Watch for: Coercion to join or to leave; family members who are also members using religious authority in family conflict. Working: shared safety goals despite religious differences.

4.14 Joining, leaving and religious conflict

• Purpose / when: When the client is deciding whether to join, stay in or leave a church, or is in conflict with leaders or members [synthesis].
• Steps: (1) Stay neutral on the choice; explore values, relationships and losses on each side. (2) Separate religious questions (for the client and their tradition) from clinical ones (risk, medicines, mental state). (3) For leavers, attend to grief, loss of community and identity; for new joiners, review 4.7 and 4.8. (4) If the conflict involves misconduct or coercion, move to 4.16.
• Example language (illustrative): "This is your decision. What would you be gaining and losing either way?"
• Watch for: Your own preferences steering the client. Working: the client owns the decision and copes with its consequences.

4.15 Distinguishing churches from commercial or tourist ceremonies

• Purpose / when: When a client describes participation that may be outside a recognised church, or asks you to recommend ayahuasca for treatment [synthesis].
• Steps: (1) Clarify the setting (church centre, retreat, private ceremony, abroad). (2) Note that Brazilian regulation prohibits commercialisation, tourism and therapeutic use [source: https://www.redalyc.org/pdf/5521/552156375008.pdf], and that adverse reactions are reported as more frequent outside controlled settings [source: https://revistas.usp.br/acp/en/article/view/144864] and risks rise when contents are unknown [source: https://www.iceers.org/en/ayahuasca-safety-profile/]. (3) Do not recommend or broker any ceremony (Amazonian ayahuasca ceremony is covered in guide 107); for interest in psychedelic-assisted therapy, refer to Domain VII and to lawful research or clinical routes. (4) Address medicines and vulnerability as in 4.7–4.8.
• Example language (illustrative): "I can't recommend ayahuasca or any ceremony. I can help you think through what you're hoping for and the safest lawful options."
• Watch for: Retreats marketed as "church" or "therapy"; clients travelling abroad without medical review. Working: the client makes decisions with full information and medical input.

4.16 Safeguarding

• Purpose / when: Whenever a child, a pregnant client or any vulnerable person may be at risk, or the client reports coercion, abuse or exploitation by anyone in a religious setting [synthesis].
• Steps: (1) Ask directly and neutrally about safety. (2) Note that Brazilian rules on minors have changed over time and that use in pregnancy has been debated [source: https://www.redalyc.org/pdf/5521/552156375008.pdf]; current church policies on minors are [uncertain]. (3) Follow local child-protection and adult-safeguarding law; consult supervisors. (4) Report where required, regardless of religious context. (5) Do not treat a whole church as abusive on the basis of one person's conduct; do not treat abuse as acceptable because it occurred in a religious setting.
• Example language (illustrative): "Has anyone in any group you belong to pressured you or touched you in a way you didn't want?"
• Watch for: Reluctance to report a respected leader; children's exposure decided without regard to law. Working: risk reduced and duties documented.

4.17 Confidentiality and documentation

• Purpose / when: Always; legal status differs by country and church, and records may be read by others [synthesis].
• Steps: (1) Explain what you record and who may see it. (2) Record religious membership and clinically relevant facts; avoid detail of practices, sourcing or other members' identities. (3) Share with the prescriber only with consent, except where law or imminent risk requires otherwise.
• Example language (illustrative): "I'll note that you're a member of a religious community and that we've discussed medicine safety. I won't write down anything about other members."
• Watch for: The client withholding information because of legal fear. Working: disclosure increases over time.

5. Handling problems

The sources address clinical risk and legal status, not therapy process; all guidance in this section is [synthesis] unless a source is given.

• Client will not disclose membership. Ask about religion and medicines together at intake and again later; explain confidentiality limits plainly (4.6, 4.17). Do not press; revisit when medicines change.
• Client wants you to endorse or condemn the church. Decline both; return to the client's goals and to the clinical questions you can answer (risk, medicines, symptoms).
• Client asks you to interpret visions, hymns or doctrine. Say this belongs to them and their tradition's leaders; offer to help with what the experience means for their life and choices (4.10).
• Client plans to stop an antidepressant or other medicine to take part. Do not advise on the medicine; state the interaction concern [source: https://www.iceers.org/en/ayahuasca-safety-profile/], urge contact with the prescriber before any change, offer to make that contact with consent, and document.
• Personal or family history of psychosis, and the client wants to continue. Give the published risk information [source: https://revistas.usp.br/acp/en/article/view/144864]; encourage discussion with the prescriber and church leaders; agree warning signs and a crisis plan; respect the client's autonomy unless capacity or acute risk is in question.
• Emerging psychosis or mania framed as spiritual development. Assess as in 4.9 and 4.11; involve psychiatry; with consent, involve trusted members; avoid arguing about meaning while the client is acutely unwell.
• Overwhelm after a service. Stabilise first (sleep, grounding, safety), then process. If medical symptoms suggest an interaction, send to emergency care.
• Rupture: client feels judged as a "drug user". Acknowledge it directly, separate religious practice from substance misuse in your language, and repair before continuing assessment.
• Family conflict over membership. Use the Informant Version and family sessions focused on shared safety goals (4.13); avoid taking sides on religion.
• Client is attending commercial ceremonies or travelling abroad. Distinguish these from church practice and review risks (4.15); refer to Domain VII for psychedelic-assisted therapy questions.
• Disclosure of misconduct by a leader or member. Assess safety, follow safeguarding and reporting duties (4.16), and support the client through any loss of community.
• Legal fear blocks treatment. Clarify that legal status varies by country and church and that you are not a legal adviser; suggest legal advice where needed; keep records factual and minimal.
• Therapist discomfort or over-enthusiasm. Take it to supervision; return to cultural humility (4.1).
• Stuck therapy because two explanations compete. Hold both explanatory models side by side (4.4) and set goals both frames can support.

Sources

• GONZALES v. O CENTRO ESPIRITA BENEFICENTE UNIAO DO VEGETAL (No. 04-1084), syllabus
• Church of the Holy Light of the Queen v. Mukasey
• Labate BC, Feeney K. O processo de regulamentação da ayahuasca no Brasil e na esfera internacional: desafios e implicações. Periferia 3(2), 2011
• UDV USA: Our History
• UDV: The Origin
• ICEFLU: Centro de Documentação e Memória (English home page)
• Barnard GW. Santo Daime timeline, World Religions and Spirituality Project
• ICEERS: Ayahuasca Safety Profile
• Santos RG, Bouso JC, Hallak JEC. Ayahuasca: what mental health professionals need to know. Arch Clin Psychiatry 44(4):103–109, 2017
• APA. DSM-5-TR Cultural Formulation Interview
• APA. DSM-5-TR Section III
• APA. Cultural Formulation Interview, Informant Version
• APA. Cultural Formulation Interview, Supplementary Modules
• Lewis-Fernández R et al. Feasibility, acceptability and clinical utility of the Cultural Formulation Interview. Br J Psychiatry 2017
• Tanenbaum. Explanatory Models of Illness (handout on Kleinman's questions)
• PMC9199574 (DSM-5 dissociative disorders and possession; ICD-11 possession trance disorder)
• Lewis 2023, DSM-5-TR study guide (University of Missouri System Pressbooks)
• ICD-11 6B62 Trance disorder (third-party mirror of WHO text)
• Gureje O et al. COSIMPO trial, The Lancet 2020 (PubMed 32861306 record)
• Centre for Global Mental Health: COSIMPO
• Ofori-Atta A et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. Br J Psychiatry 212(1)
• Labate B, Meyer M. Understanding the Santo Daime case – correction (blog post on the Oregon injunction terms, posted 31 March; Bia Labate's site)
• Callaway JC, Grob CS (1998). Ayahuasca preparations and serotonin reuptake inhibitors: a potential combination for severe adverse interactions. pp. 367–369 (PubMed 9924842); abstract also in a HEIG-VD catalogue record
• UDV: Hoasca Tea is harmless to the health
• Irigaray T (2017). Hoasca as a theme of research and publications: the role of the UDV (UDV blog)
• Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.
• American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).