Spiritist views of mental disorders in Brazil

transcultural psychiatry December 2005 ARTICLE Spiritist Views of Mental Disorders in Brazil ALEXANDER MOREIRA-ALMEIDA & FRANCISCO LOTUFO NETO University of São Paulo Abstract The Spiritist perspective on mental disorders exerts a great influence in Brazil. Spiritist theory supports the survival of the spirit after death with an exchange of knowledge between the incarnated and disincarnated spirits. This article reviews the texts on mental disorders and Spiritism written by four leading Spiritist authors: Allan Kardec, Bezerra de Menezes, Inácio Ferreira and Joanna de Ângelis. These authors advocated a model of spiritual etiology without rejecting the biological, psychological, and social causes of mental disorders. The Spiritist etiologic model for mental disorders includes the negative influences of discarnated spirits (termed ‘obsession’) or trauma experienced in previous lives. In addition to conventional medical and psychological therapeutics, spiritist séances for disobsession are recommended, as well as ‘passes’, prayers and efforts to live according to ethical principles. The importance of Spiritist views in Brazil indicates the need for more academic research on this tradition. Key words channeling • etiology • medium/mediumship • mental disorders • Spiritism • spiritualism • treatment Introduction Spiritism originated in the mid-19th century in France when an intellectual, Hippolyte-Léon Denizard Rivail, under the pseudonym of Allan Kardec, proposed scientific investigations into alleged manifestations of the spirits. Convincing himself of the authenticity of spirit-related Vol 42(4): 570–595 DOI: 10.1177/1363461505058916 www.sagepublications.com Copyright © 2005 McGill University 570 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders phenomena, he developed a method to collect information based on the communication of spirits. In 1857, after comparing and analyzing the answers obtained through mediums in several different countries, Kardec compiled the resulting information in a theoretical framework. He named the resulting theory ‘Spiritism’ or ‘Spiritist Doctrine’ (Kardec, 1996), which was defined as ‘a science that deals with the nature, origin and destiny of the spirits, as well as its manifestations with the corporeal world’ (Kardec, 1995, p. 50). Reincarnation distinguishes Spiritism from its Anglo-Saxon sibling, Spiritualism, for which reincarnation is a controversial tenet (Hess, 1991). Kardec believed that Spiritism was essentially a science as well as a philosophy rich with moral concerns, and not a religion, according to the literal meaning of the word.1 According to Hess (1991, pp. 45–46), Spiritism implies a ‘reification’ of the spiritual world in the sense that spirits are scientifically real and this reification in turn comprises two consequences: it desacralizes the spirit world into an object of scientific analysis and presents an alternative interpretation of orthodox scientific thinking. However, traditional scientists usually view the spiritist thesis as ‘pseudoscientific’. In the history of dynamic psychiatry and psychology, Spiritism was ‘an event of major importance as a source of unexplainable phenomena’ (Janet, 1889, pp. 357–8; Ellenberger, 1970, p. 115). Spiritism produced psychological phenomena to be investigated by the medical sciences. In the late 19th century, dynamic theories of the unconscious were in part a result of the translation of the doctrine of communication of the spirit into orthodox medical rhetoric (Ellenberger, 1970). Hess (1991) identifies more objective signs of this translation in Myers’ ‘subliminal self ’ and in the writings of Pierre Janet, William James and Jung. Koss-Chioino (2003) recently showed several parallels between Jungian and Spiritist views in the structure and content of human consciousness. Investigations dealing with mediumship and telepathy were frequent during the transition from the 19th to the 20th century, involving several renowned authors in the international scientific milieu (Murphy & Ballou, 1960; Stevenson, 1977; Ross & Joshi, 1992; Myers, 2001). Spiritism was introduced in Brazil in the late 19th century. It soon gained prominence, essentially in its religious domain. Nowadays, the Brazilian Spiritist followers belong mainly to the urban middle class. The numbers as well the social class of newcomers are increasing, and there is a clear trend for a higher educational background among Brazilian Spiritism followers. On the other hand, the influence of Spiritism goes far beyond the reported number of followers. Spiritism has more followers in Brazil than anywhere else in the world, despite the fact that the country presently has the world’s largest Roman Catholic population (Aubrée & Laplantine, 571 Transcultural Psychiatry 42(4) 1990; Machado, 1993; Damazio, 1994; Santos, 1997). The main type of Spiritist practice in Brazil nowadays is a charitable enterprise, which is in keeping with the principle of justification by good will rather than by faith alone. Spiritist charities include a wide array of social services that are offered to the impoverished (Hess, 1991).2 Spiritist organizations always provide their treatments and mediumistic activities free of charge. In respect to mental health in contemporary Brazil, Spiritism plays an important and yet largely under-recognized role. In addition to providing a rational spiritual etiology for several mental disturbances, nearly 50 psychiatric Spiritist hospitals were built throughout the country from the early 1930s until the late 1970s (Souza & Deitos, 1980). The majority of the philanthropic mental health institutions located in the state of São Paulo (the most populous state in Brazil) complied with Spiritist principles as documented in a study performed by Figueiredo and Ferraz in 1998. A large section of the general Brazilian population embraces the views and practices of Spiritism, including health-care professionals who endorse these practices openly. Currently, institutions that study and endorse Spiritist professional practice principles include ABRAPE (Associação Brasileira de Psicólogos Espíritas/Brazilian Association of Spiritist Psychologists) and AME (Associação Médico Espírita/Medical Spiritist Association). Given the importance that the Spiritist view of mental disorders has attained in Brazil, the authors have undertaken a review of the main Spiritist authors in this subject.3 Despite the fact that the Afro-Brazilian traditions and their strong syncretism with Catholic institutions and Spiritism (namely, Umbanda and Camdomble) hold an important role in Brazilian society, they are not the main objectives of this article. Instead, this text presents the Spiritist theory for mental disorders originally introduced by Allan Kardec and its subsequent elaboration in Brazil. Allan Kardec During the formulation of his Spiritist philosophy, Allan Kardec dealt several times with behavioural disorders, suicide attempts and changes of sensorial perception. The 15-year-long experience Kardec accumulated with Spiritism led him to found the Spiritist Journal – Journal of Psychological Studies; he was editor-in-chief of this journal for 12 years. The objectives of the Spiritist Journal were to find facts and test hypotheses about different spiritual phenomena. Kardec attempted to give rise to a new science and to avoid ‘the exaggerations of credulity and skepticism’. Kardec used the subtitle ‘Journal of Psychological Studies’ as he believed that ‘to study the nature of the spirits is to study mankind’ (Kardec, 1858, p. 6). 572 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders Figure 1 Allan Kardec – a pseudonym of Hippolyte Leon Denizard Rivail (3 October 1804–31 March 1869), founder of Spiritism (courtesy of France-Spiritualités). Causes Allan Kardec discussed the causes for mental disorders in his first publication. He stated that the basic etiology is essentially organic and that a mental illness might be triggered by excessive worries: Intense mental application of any kind may induce a cerebral disorder; sciences, arts, even religion have all supplied their quota of madness. The predisposing cause for madness resides within a brain predisposition. A tendency that renders the brain more vulnerable to certain impressions; and, where the predisposition to insanity exists, its manifestation takes on the character of the pursuit to which the mind is most addicted, and it then assumes the form of a fixed idea. (Kardec, 1996, p. 41) 573 Transcultural Psychiatry 42(4) Mediumship itself might be a triggering factor in individuals predisposed to madness. Therefore, people ‘who show the slightest symptoms of mental eccentricity or weakness should be dissuaded from its exercise by every possible means; for there is, in such persons, an evident predisposition to insanity, which any and every species of excitement would tend to develop’ (Kardec, 1986, item 221–222). Kardec’s assertion differs from the practice that was subsequently adopted in most of the Spiritist centres in Brazil to develop the mediumship for the relief of various physical and mental imbalances because these symptoms could be the signs of a dormant mediumship potential. As far as the relationship between body and mind is concerned, Spiritism operates on a dualist interactionist model. Namely, the origin of the mind is spiritually independent of the body, but in order to manifest itself, while incarnated, the spirit needs to make use of the body. The body and the soul exercise a mutual influence on each other. Likewise, the corporeal humors are altered according to the tendencies of the spirit: a man is not choleric because he is bilious, but the man is bilious because he is choleric. Similarly, with all the instinctive dispositions . . . if he is active and energetic, his blood, his nerves will have very different qualities. . . . What triggering factor could alter the blood other than the moral dispositions of the Spirit? (Kardec, 1869, p. 66) It is recognized, however, that someone’s temperament may in part derive from organic imbalances. These imbalances might affect the spirit itself. As the incarnated spirit uses the body to manifest itself, the spirit might have difficulties if the body is disordered. This is the case in mental illness due to an organic origin. A spirit . . . when incarnated . . . is . . . compelled to act only through the instrumentality of special organs. If some or all of those organs are injured, his actions or his impressions, as far as those organs are concerned, are interrupted. . . . Suppose that the organ which presides over the manifestations of intelligence and of will is partially or entirely weakened or modified in its action, and you will easily understand that the spirit, having at his service only organs that are incomplete or diverted from their proper action, must experience a functional perturbation of which he is perfectly conscious, but is not able to arrest the course. (Kardec, 1996, p. 375) Spiritism does not disavow the social and biological causes of mental disturbances, but it adds one more origin: the obsessions, that is, ‘the persistent action that an evil spirit exerts over an individual’ (Kardec, 1992, p. 45): One day the obsession is going to be recognized as one of the main causes of mental disorders, as is today the action of microscopic living creatures 574 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders whose existence nobody even suspected . . . before the invention of the light microscope. (Kardec, 1863b, p. 34) In analyzing the types of obsession, Kardec distinguished three levels of severity: 1. 2. 3. Simple obsession: the influence via thoughts and pernicious intuitions but without altering the individual’s judgment or free will. Fascination: ‘an illusion which is produced by the direct action of a spirit on the medium’s thought, and which paralyzes his judgement . . . to make him regard with admiration the most ridiculous nonsense.’ Subjugation or Possession: a constraint which paralyzes the will of its victim and makes him act in spite of himself. . . . Subjugation may be moral or corporeal in nature. In the first case, the subjugated victim is often drawn on to do things that are foolish or reprehensible. . . . In the second case, the spirit acts on the material organs of the victim, provoking involuntary movements . . . (Kardec, 1986, item 237–240). Obsession is caused by the moral imperfections believed to exist in all individuals. The moral imperfections render them susceptible to receiving and accepting the obsessing spirit’s harmful influences, progressively aggravating the patient’s condition. The obsessing spirit is motivated most of the time by a vengeful feeling against the victim. Kardec characterized the difference between madness of organic origin from madness resulting from an obsession: Let us not confuse pathological madness with obsession. The latter does not derive from any brain damage but it derives from the subjugation that malevolent spirits exert over certain individuals and the obsession often has the appearance of madness itself. This change is very frequently independent of any belief in Spiritism and it has always existed. (Kardec, 1995, p. 113; emphasis in original) However, the difference between these two types of conditions may be complex. Obsessions may aggravate pre-existing organic affections or even cause them (Kardec, 1992, chp. 15, p. 32). Organic phenomena may be mistaken for obsessions: ‘Men have often mistaken for cases of possession what were really cases of epilepsy or madness, demanding the help of the physician rather than of the exorciser’ (Kardec, 1996, Q. 474, p. 250). Finally, obsession might have a role in hysterical phenomena (Kardec, 1863b). When several evil spirits cast themselves upon a community, possession epidemics will ensue (Kardec, 1992, chp. 14, item 49). Kardec gave special attention to a well-known event that took place during his lifetime. This event concerned the possession epidemics that took place in the village of Morzine located in the French Alps over several years. In 1861, the French 575 Transcultural Psychiatry 42(4) government assigned a physician named Constans (1991 [1862]) to pursue an epidemiological investigation on local epidemics. Dr Constans concluded that there was a contagious ‘hysteric-demonopathy’ triggered by the region’s unhealthy conditions and the villagers’ malnutrition, lack of culture and superstitions. All the exorcisms and medical treatments had failed to eliminate the epidemics except for the reduction of new cases when the possessed villagers were relocated to neighboring towns (Kardec, 1863b). For an entire year after the Morzine epidemics, Kardec developed a detailed argument about the ‘Morzine’s possessed individuals’, often quoting and critiquing Dr Constans’ medical records (Kardec, 1862a, 1862b, 1863a, 1863b, 1863c, 1863d) for attributing the Morzine epidemic’s etiology to physical causes alone. Based on his personal observations as well as other physicians’ records, Kardec challenged the alleged existence of malnutrition and poor health among the villagers. Kardec argued that if these physical factors were the cause for the epidemics in question, similar epidemics would have occurred in surrounding regions under identical conditions of poverty and the problems would have been endemic (Kardec, 1863b). Kardec collected evidence indicating a spiritual cause for the Morzine possessions: the expression of previously non-acquired skills (speaking fluent French and answering questions in different languages, such as German and Latin), the knowledge of distant events (clairvoyance), reading other people’s thoughts (telepathy), transfiguration, referring to oneself in the third person (‘she’, ‘the daughter’, etc.), a current manifesting personality claiming to be the Devil, the patient mentioning an external power controlling him, normal behaviour during the intervals between episodes, normal heart rate despite the intense agitation, intense dislike of religion and amnesia about the episodes (Kardec, 1863c, 1863d). Manifestations Between the second half of the 19th century and the first half of the 20th century, Spiritism was considered by a large part of the Brazilian and European psychiatric community to be a major cause of madness. These critics presented the mystic and spiritual content of many psychoses as evidence that Spiritism caused madness (Moreira-Almeida et al., 2005). To defend Spiritism, Kardec emphasized the cultural pathoplasty of obsessions in several different psychiatric conditions. In cases of possession, the obsessing spirit ultimately determines the type of behavior the patient will display. The obsessing spirit momentarily takes over the incarnated body, acting as if it is also incarnated. Whoever had known him in life, would have recognized his language, his voice, his gestures and even his features . . . blasphemes, insults as the 576 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders obsessing spirit harms those around him; the obsessing spirit surrenders to eccentricities and characteristically acts with furious madness. (Kardec, 1992, chp. 14, item 47–48) As for the content of delusions, his hypothesis was that the delusions might be due in part to vague recollections from past lives. In the specific case of mental disorders, these recollections might not be so clearly due to an ongoing organic derangement. Recollections from past lives become mixed up with recollections of the present life (Kardec, 1861b, 1866a). Kardec (1861a) designed a detailed study of changes of perception and identified three types: (1) imagination: this is now called illusion, involving distortions of a real external stimulus, often caused by fatigue or by a low illumination level and suggestion; (2) hallucination: a sensorial perception of internal origin – ‘it is the retrospective vision, by the soul, of an image that has been recorded in the brain, often created during an illness’; (3) apparitions or true visions: these result from a real spiritual perception. Apparitions occur in two ways: ‘it is either the spirit coming upon the person who sees him, or it is the person’s spirit that is transported and goes to meet the other incarnated spirit.’ The main difference between an apparition and perceptions produced by the imagination or a hallucination is that apparitions convey unknown information to the individual, information that is later confirmed. Kardec presented numerous examples of apparitions. Apparitions are far more frequent near the time of death. For instance, a situation involving someone who was previously healthy is witnessed, stating he or she has died in an accident with a detailed description of the event, and the accident was subsequently confirmed. In the differentiation between hallucinations and apparitions, Kardec (1861a, p. 212) gives the benefit of the doubt to the hallucination: ‘Every apparition that does not give any intelligent warning signal may definitely be listed as an illusion.’ Treatment In Kardec’s work, the commitment to consider the spiritual etiology of mental disorders is emphasized without rejecting all possible organic causes. However, the recognition of spiritual causes is fundamental given that it is not ‘with cold shower baths, cauteries or bleedings that the cases of spiritual causes may be treated’ (Kardec, 1861b, p. 242). The essential element for the treatment of the obsessions is a change in the patient’s behavior, essentially aiming at moral growth. This attitude is meant to prevent the patient from becoming attuned to the evil thoughts of the obsessing spirit. Additionally, ‘passes’ (laying-on of hands) and prayers would be quite beneficial because passes aim to balance the spirit of the obsessed subject. 577 Transcultural Psychiatry 42(4) As for the obsessing spirit, one should try to dissuade the spirit of his evil purpose by means of dialogue in meetings with mediums when the obsessing spirit is evoked (Kardec, 1992, chp. 14, item 46). Kardec wrote several case studies describing cures that were achieved by means of these evocations (Kardec, 1864, 1865a). He denied that they were spontaneous cures, because there were numerous similar cases. These cures were the evidence of the existence of ‘obsessional insanity’ (Kardec, 1866b). The proof of the participation of a concealed intelligence, in those cases, derives from chief facts: the multiple and radical cures that were obtained, in some Spiritist centres, induced only by the evocation and indoctrination of the obsessing spirits, without magnetization or medications, and often, in the absence of the patient and at a great physical distance from the patient. (Kardec, 1992, chp. 15, item 33) Prophylaxis Kardec contended that the Spiritist point of view helps people cope with adversities of life as Spiritism acts as a buffer against life’s stressful events: Spiritism . . . when correctly understood, is a preservative against insanity. Among the most common causes of cerebral disturbance must be reckoned the disappointments, misfortunes, blighted affections, and other troubles of human life, which are also the most frequent causes of suicide. But the enlightened Spiritist looks upon the things of this life from so elevated a point of view, they seem to him so petty, so worthless, in comparison with the future he sees before him. Life appears so short, so fleeting, that its tribulations are, in his eyes, merely the disagreeable incidents of a journey. . . . His convictions, therefore, give him a resignation that preserves him from despair, and consequently from a frequent cause of madness and suicide. (Kardec, 1996, pp. 52–53) By clearly demonstrating the objectives of the subject’s life and motivating the human being to improve himself further and further, Spiritism prevents the ‘tedium vitae’, that is, the negative aversion to life’s misfortunes, and thus melancholy, despite thoroughly recognizing an organic predisposition to melancholy as a real disorder (Kardec, 1862c). Spiritism also decreases the number of cases of insanity by preventing the abusive use of alcohol (Kardec, 1865b). The spiritist philosophy could be an effective prophylaxis method against suicide. In addition to the point of view that Spiritism would give greater ‘moral courage’, the spiritist has several other reasons to refrain from suicide: the certainty of a future life . . . the certainty that the abbreviation of life results in something completely opposite to what is originally expected; that 578 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders he is freed from one evil to endure something that is much more severe, . . . that in the other world he will not be able to see the objects of his preference that he wished to become united with. Thus, suicide is totally against his own interests. (Kardec, 1862c, p. 201, emphasis in original) Kardec emphasized several times that the admission of a ‘spiritual reality’ would be a great advance to the sciences, especially medicine: Opening new horizons to every science, Spiritism also clarifies the very obscure question of mental disorders signaling a cause that has not yet been fully considered: real cause, evident, established by experience whose veracity will be subsequently recognized . . . the part of action of the invisible world over the natural phenomena. Once we get on this road, science will possess the key to the mysteries and shall overcome the most formidable hindrances detaining progress: materialism, that restrains the circle of observation, rather than amplifying it. (Kardec, 1862a, p. 110) Bezerra de Menezes Adolfo Bezerra de Menezes Cavalcanti is considered one of the most important personalities in the history of Spiritism in Brazil. He was born in the state of Ceará and became a physician in 1856. He was elected four times as a member of the City Council in Rio de Janeiro (the country’s capital at that time). He was also elected three times as a Rio de Janeiro State Legislative Assembly deputy. Bezerra was an abolitionist and a member of the local Liberal Party. He publicly admitted in 1886 his unrestricted adherence to Spiritism, devoting himself to it intensively until his death in 1900. He presided over the Brazilian Spiritist Federation for six years (two terms) from 1894 to 1900 and wrote for ten years, under the pseudonym of Max, a weekly column about Spiritism for the main newspapers of Rio de Janeiro (O Paiz and Jornal do Brasil) (Nobre, 1986; Wantuil, 1990; Abreu, 1991). Bezerra also published a book that has greatly influenced the Spiritist view of mental disturbances in Brazil. The book was titled Insanity through a New Prism (1988 [1897]). Despite basically reaffirming Kardec’s positions, Bezerra’s work is generally considered a major landmark in the ‘Spiritist view of madness’, being far more renowned and quoted than Kardec’s texts on this matter. The book can be divided into three parts: first, a philosophical and scientific criticism of materialism; secondly, a discussion of some Spiritist principles; and lastly, an attempt to demonstrate that obsessions can be a cause of madness. We will discuss only the last topic, that is, obsessions and madness. Bezerra’s book was well-timed with the emergence of categorical organicism in psychiatry. Medical psychiatric publications from the last quarter of the 19th century largely dealt with general paresis of the insane, tumors 579 Transcultural Psychiatry 42(4) and traumatic injuries of the central nervous system, in addition to the assorted clinical syndromes deriving from nutritional deficiencies. Citing Esquirol, Bezerra was concerned with the fact that several cases of madness became clinically manifested without a clearly identifiable brain injury. Psychiatry was only able to account for madness due to a brain injury. Bezerra defines thus the objectives of his propositions: . . . I will try to solve . . . the problem of madness with its most recent features, that is, madness free from a brain injury. It is well understood how important it is in clinical practice to differentiate these two classes of madness. In order to avoid grouping them together under the same treatment modality, being as they are of different etiologic natures. My plan is to determine the special nature of madness without a brain injury to establish the basis for a differential diagnosis for both causes and to offer the healing means for this unknown kind of madness. (1988 [1897], p. 13) The physical body being just a tool of the soul, madness could be caused by problems in the body (madness with injury) or outside the body (madness without injury). The final part of Bezerra’s book is entirely dedicated to obsessions. He acknowledges ‘the persecution exerted by discarnated spirits upon the incarnate spirits is one of the most difficult points to accept in the new [Spiritist] cosmogony.’ Nevertheless, he asserts the possibility of irrefutable evidence of their existence through ‘strictly scientific’ methods. Bezerra mentions several cases treated by him with a fairly positive outcome that might enable one to affirm ‘a sure conviction in spirits free of systematic prejudice and fanaticism’ (p. 141). One of his patients was a medical student who had dropped out of medical school for two years because ‘he was suddenly assaulted by madness, with a fixed idea of suicide, and therefore his family kept him in a safely locked room taking every precaution’. Several weeks after séances were introduced as part of his treatment, Bezerra persuaded the obsessing spirit to quit persecuting the student’s body. He reports this: On Friday, about the time the enemy spirit unequivocally gave up the persecution, Raul, at his home at a distance . . . of perhaps about some 10 miles from the Spiritist center, woke up as if it was from a long nightmare; he called his mother and other relatives to whom he had become indifferent; he left his isolation, and he found himself so well that in the following week he resumed attending medical school. . . . The coincidence of the renunciation of the persecutor spirit with the timely resumption of the mental faculties is a remarkable fact worthy of due attention, and we assert that, sooner or later, quicker or slower, we have always observed this phenomena, given that the persecutor is converted. (1988 [1897], pp. 141–143) Bezerra followed the patient for three years after the cure. The patient was free of any relapses and graduated from medical school some time later. 580 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders The author mentions several witnesses who followed the progress of this particular case as well as other victims of obsessing spirits. As mentioned previously, Bezerra reiterates, to a great extent, the ideas discussed by Alan Kardec. However, Bezerra advances the theory that the obsessing spirit is able to subjugate the patient’s will and harm the transmission of thoughts from the patient’s soul to the body. It is as if there were ‘interfering noises’ in the message transmitted to the body, and thus the symptoms manifested by the victims, making it difficult to differentiate the obsessive madness symptoms from those caused by organic madness. Severe obsessions are a type of madness: It is madness because there is definitely a disturbance of the mental senses, but it is not madness as it is currently known, because the madness depends on an organic brain injury and presently, this is not the case. It is the madness that for instance Esquirol has not been able to record a cause related to a brain injury, it is the psychic madness. The double cause of the illness presents the same symptoms, although it has very distinct origins. (1988 [1897], p. 162) Bezerra asserts that brain injuries may prompt the onset of the obsessive process (pp. 173, 178–9), and that long-lasting obsessions may lead to brain injuries and, therefore, the need for a combined treatment modality, that is, physical and spiritual treatments. The descriptions of what might be the residual changes resulting from brain injury secondary to the obsessions are very similar to the negative symptoms of schizophrenia: ‘. . . instead of the excitement, the subdued obsession leaves the brain in a state of depression’ (p. 182) ‘that leads the individual to a despairing indifference’ (p. 184). The differential diagnosis of the two classes of madness is very difficult to establish. This is especially true because the clinical symptoms are quite similar (pp. 162, 171–172). One has to resort to Spiritist resources to achieve a correct diagnosis. There are three possibilities: 1. 2. 3. Hypnotize the patient so that his spirit can manifest itself more freely. Bezerra reports several experiments where the patient can lucidly express himself and the patient is also able to describe the cause for his insanity. This method, however, carries two clear uncertainties: not everyone can become hypnotized, and the spirit of the sick person may not know the origin of his illness. Evoke the obsessing spirit in a mediumistic séance. If it is an obsession, the obsessor spirit will manifest itself in a medium, otherwise nothing will take place. Consult a spirit-protector via a medium about the nature of the mental alienation. As soon as it has been defined as an obsession, the obsessing spirit is evoked in order to be dealt with morally. This was the author’s preferred method (pp. 176–178). 581 Transcultural Psychiatry 42(4) In the case of a diagnosis of obsession, the best evidence of an accurate diagnosis was prompted by ‘the cure by moral means’. As there is a twofold cause for insanity, the treatment modalities should also be differentiated. However, quite frequently, combined treatment was advised, since organic injuries may prompt the obsessions, and these may trigger further physical damage: ‘it is imperative to eliminate the injury in any diseased organ of the victims taken by obsessing spirits. Simultaneously with this effort, all the means to moralize the spirit of the obsessed must be employed’ (p. 179). Despite pioneering in the Spiritist view on madness in Brazil, Bezerra was neither an alienist nor did he claim this title for himself. Bezerra was not a practitioner of Spiritist psychiatry, a method employed to evaluate and treat physical and spiritual aspects of the mental disorders, but was concerned primarily with curing obsessions (Menezes, 1988 [1897], pp. 9, 178). Inácio Ferreira Although Ferreira is not as well known as Bezerra, he was probably the first physician to take into account Bezerra’s ideas about carrying out Spiritist treatments (Hess, 1991, pp. 187–188). Inácio Ferreira was appointed as the director of the Sanatório Espírita de Uberaba in southeastern Brazil in 1934. From 1934 to 1988 he headed that institution, where he applied conventional psychiatric treatments combined with the Spiritist therapy of passes, prayers and disobsession séances. During his time working at the sanatorium in Uberaba, Ferreira (1996) stated that the spirit of Pierre Janet communicated with him in French through a medium named Maria Modesto Cravo. Ferreira endorsed the view that conventional medicine substantially limited the possibilities of novel investigations about the origin of mental disorders and consequently limited therapeutic interventions. The refusal to investigate spiritual factors playing a role in the determination of mental disorders was due to materialistic dogmatism and the authoritarian features of the academic milieu restricted to the magister dixit. Despite the fact that Ferreira praised psychiatrists’ efforts in the development of psychiatry, he emphasized his personal frustration in the search for the etiology of mental disorders and the lack of treatment efficacy (Ferreira, 1993, 1995). Ferreira developed a series of epistemological criticisms of psychiatry. He pointedly remarked that psychiatric classifications were essentially catalogues or lists of descriptive diagnostic entries with fairly limited use for prognosis and therapeutics. At that time, psychiatric theory was periodically plagued by fragile, inconsistent and unverified evidence (Ferreira, 582 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders 1993, pp. 22–44, 126). Suppositions based on a restricted number of observations, exclusion of evidence, contradiction of the main hypothesis and a non-critical acceptance of the ‘masters of psychiatry’ accounted for the unreliability of the mainstream psychiatric theory in Ferreira’s time. These limitations led to ineffective therapeutic interventions. Ferreira compared Spiritism to microbiology. Microorganisms, although invisible to the naked eye and unknown to the scientific world, had afflicted humanity for thousands of years. Yet it was only with the advent of the light microscope that it became possible to identify and treat disorders of previously unknown causes. Spiritism, let it be known to canonical science, shall be the powerful lens of this new microscope, through which it will be possible to unveil this invisible world to our materialized eyes. (Ferreira, 1993, p. 105) Ferreira’s main theory was based on Bezerra’s hypothesis, but Ferreira reported on several cases of patients treated by means of Spiritist treatment alone. Ferreira’s books were not written in technical language but seemed to be directed to the lay public. Ferreira’s writing style is often emotional and grandiloquent, announcing the advent of a new era for medicine. His books carried plentiful case reports and, notwithstanding the fact that psychopathological features were not described in minute detail, provide a good representation of the way Ferreira attempted to apply Spiritist theory to mental disorders. The case reports contain descriptions of several types of delusions, hallucinations, psychomotor disturbance, stupor, nonepileptic seizures, suicide attempts and pathological gambling, all of which showed improvement after the Spiritist therapeutics. The high cure rate obtained with very scarce resources is presented in his books as strong evidence in favor of Spiritist therapy. Ferreira’s statistics from his sanitorium (1934 to 1944) give an account of 1352 admitted patients: 554 (41%) were cured, 210 (16%) improved, 163 (12%) were referred to another facility, 241 (25%) were removed and 51 (4%) died. In this same time period, the 423 cases that were classified as obsession had a nearly 100% rate of cure. There were several kinds of psychosis (infectious, auto-toxic, hetero-toxic, manic-depressive, degenerative and brain affections), schizophrenias, paraphrenias, paranoias, neurosyphilis, general paralysis, epilepsies, psychoneuroses, oligophrenic and psychopathic personality disorders (Ferreira, 1993, pp. 200–208). He did not absolutely discard physical causes of mental disorders. To the contrary, he wrote that ‘more than half of the patients referred to the sanitorium as victims of obsessing spirits were not anything other than carriers of organic or functional diseases of the medical domain’ (Ferreira, 1996, pp. 8–9). Although Ferreira directed the sanitorium until 1988, his case 583 Transcultural Psychiatry 42(4) reports date from the early 1940s, before modern psychopharmacology had been developed. An important theoretical change concerning the different Spiritist authors relates to the role of mediumship in triggering obsessive conditions. Whereas Kardec advised individuals with signs of a mental disorder to withdraw from mediumistic activity, Ferreira recommended that his patients should participate in séances as mediums during the convalescent period. Ferreira asserted that mediums would act as a magnet attracting the influences of the spirits. If the person’s mediumistic abilities were not adequately developed and put to use in a proper fashion, the person would be very vulnerable to additional noxious influences of the spirits, and therefore vulnerable to the recurrence of the original symptoms. The regular practice with mediums in an adequate Spiritist center could promote education about mediums and reconciliation with superior spirits, ‘the only resource that will prevent the patient being subject to these obnoxious disturbances that will take him to the insane asylum’ (Ferreira, 1993, pp. 189–190). This continues to be the prevailing belief in the current Brazilian Spiritist milieu. Interestingly, a book psychographed by Inácio Ferreira’s spirit (Baccelli, 2001) reports on several other cases he treated while incarnated. Joanna de Ângelis Divaldo Pereira Franco is a male medium born in Bahia (northeastern Brazil) with more than 150 published psychographed books (6 million copies translated into 15 languages). He has also been a Spiritist public speaker, with numerous talks given in Brazil and in 56 foreign countries. He proclaimed that his spiritual mentor was a female spirit named Joanna de Ângelis. She wrote, with his help, 55 books by means of automatic writing. Joanna de Ângelis has also written several papers on mental health since 1990. These papers became acclaimed as the ‘psychological series’ (Franco, 2002). Joanna’s writings are a fairly good model of the current Brazilian psychological Spiritist mainstream. The books were printed in large numbers, with considerable repercussion in the Brazilian Spiritist milieu. A complementary approach to Kardec, Bezerra and Ferreira’s theories is described in these books, dealing mainly with ‘neurotic’ imbalances and links with transpersonal and Jungian psychology. The introduction to the first work in the Joanna series reads: Spiritism, amalgamating several streams of the psychological thought and studying humankind under the unique circumstance of an eternal spirit, proposes an idealistic, immortal philosophical behaviour, helping 584 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders humankind to equate uncertainties free from violence and based on the principles of reincarnation, pointing to humankind the fortunate paths to be followed. (Franco, 1990, p. 9) The spirit of each person is the totality of the conscience, the Self. The Self is composed of a conscious part and by an extended unconsciousness, and it includes the experiences of current and past lives. The Self is not just a mere standard-archetype, but the Spirit with his initial and deep experiences of previous processes. . . . It is therefore predicted that the spirit possesses heritages, atavistic elements, reminiscences, a personal and collective unconsciousness, in the context of his evolutionary process throughout the millenniums. An heir of himself, the Self is more than an archetype, being the spiritual being that predates the cradle and survives the sepulcher. (Franco, 2002, p. 70) This unconsciousness carries a deep influence in our thoughts, acts and conscious behavior. The unconsciousness contents might be partly approached in dreams, during meditation, prayers and trances. These phenomena were often taken in error as mediumistic. The trance state where the individual’s unconsciousness, not another spirit, becomes manifested is called ‘animism’ (Franco, 1997, p. 86). In theory, the spirit regulates the functioning of the neuro-endocrine and immune systems and the central nervous system. This regulation is presumably the tool used by the spirit to act upon the body. An imbalance in these systems is clearly present in several mental disorders. The imbalance of the spirit is the germane cause for these specific body disharmonies (Franco, 1997, p. 24; 1999, pp. 35, 42; 2000b, p. 101). The intense relationship of body and mind is emphasized by Joanna de Angelis; the influences of the spirit over the body generate either a harmonious or unhealthy functioning of the body, leading to mutations and physiologic changes. Apart from organic and social factors, experiences from previous lives play an important role in the determination of psychic maladjustments. Phobias may result from traumatic events, as well as depression resulting from a guilty conscience over unfortunate past actions (Franco, 1997, p. 32). The guilt sentiments derived from acts of either this or past lives, often acting unconsciously, could be significant factors in psychic maladjustment (Franco, 2000c, p. 31). That is why ethical behaviour is highly regarded, and instead of continuously disturbing guilt feelings the concept of responsibility is emphasized as ‘the crop derives from ploughing without any fatalistic expression of suffering’ (2000b, p. 43). Obsessions are also included among the etiologies as well as the results of mental disorders. the depressive condition that brings about pessimistic and nefarious thoughts . . . opens breaches for the settlement of harmful obsessions, or any 585 Transcultural Psychiatry 42(4) other phenomena that deteriorate the cell machinery, favoring the settling of different disorders. (Franco, 1999, p. 59) In search of an effective rebalancing endeavor, a great deal of emphasis is given to ethical behaviour and introspection as generators of a healthy strength of the spirit over the body (Franco, 1999, pp. 57–62). However, this search for virtue could be brought about by a real desire for growth or development and not by the repression mechanisms that could be driven into ‘dissimulation and indignity disguised as virtue’ (Franco, 2000d, p. 7). The real and ultimate healing could come about by the intellectual and moral improvement of the spirit during several incarnations (Franco, 1999, pp. 65–69). Mental health is only possible with the Self well thought-out on noble and ethical values. The Self ultimately recognizes the manifest goal of human existence, directing its feelings and knowledge in favor of order, progress and the well-being of the entire society. (Franco, 2002, p. 113) The development of existential and transcendental values and a life free of anxiety is the most valued pursuit. ‘Life itself would remain meaningless without a spiritual view of the physical existence’ (Franco, 1995, p. 9). Religion liberates one from fear and anxiety and ‘generates natural courage for facing oneself, thus becoming therapeutic and health generating’. On the other hand, religion should not serve as a ‘psychological departure for the individual to spare oneself from confronting life’s conflicts, the processes of liberation from the suffering’ (Franco, 2002, p. 178). The foremost model of the ‘integral man’ is Jesus Christ, who is an ‘example of the perfect identification of the anima and animus, having developed all the skilfulness inherited from the Almighty God’ (Franco, 1990, p. 8; 2000a, pp. 9–10). Despite the fact that there are paradigmatic models, every human being should engage in the quest for the inner self in a process of individuation. This is the pilgrimage to become a ‘total, individual and unique being, disengaging the consciousness from the strongest constrictions of the dominating unconsciousness . . . integrating the unconscious into the current consciousness’ (Franco, 1997, pp. 92–94). No one would be found reincarnated on Earth had not their physical existence possessed a superior purpose. . . . Step by step, progress is contrived and it grows permanent through the habits that are incorporated in the individuality. . . . Mistakes and rightful achievements are resources to the unfolding of consciousness to greater achievements. (Franco, 1997, p. 27) The healthy man is not the overjoyed one, apparently triumphing over situations he daily faces, but nonetheless, he is the one who perseveres struggling, always willing to advance with his perceptions that are ultimately set on the future to where he advances. (Franco, 1999, p. 38) 586 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders The search for self-knowledge is the fundamental step for the total unfolding of the spirit. In order for the self-discovery process to be accomplished, illuminating the shadows, some qualifying contingencies are absolutely necessary: Dissatisfaction with oneself, a sincere will for change, persistence in the endeavor; a disposition to accept oneself and triumph; strength to grow emotionally. (Franco, 1995, pp. 9–13) The conquest of oneself is possible only following several consecutive incarnations and it could allow the overcoming of the breakout mechanisms, the transfer of responsibilities, the rejection and facing oneself free of accusations. (Franco, 1993, pp. 151–152) A psychologically mature man lives in the greatness of the aspirations of the good, the beautiful and the true, and, freed from the ego, reaches the self, becoming an integral, ideal man, on the way to infinity. (Franco, 1993, p. 28) Discussion The four authors and their respective theories described above yield a reasonably comprehensive overview of a Spiritist perspective on mental disorders. There are various other theories by other authors dealing with the same subject (Mundin, 1984; Santos, 1991; Balduíno, 1994; Facure, 1996; Oliveira, 1996; Diversos, 1997; Palhano Jr & Oliveira, 1997; Claro, 2000). However, these authors are far less well accepted, and their contributions do not add any further understanding to the field of mental disorders and Spiritism. There are only a few studies on Brazilian Spiritist physicians. The most investigated author is Bezerra de Menezes, whose work was analyzed by two different American researchers who have reached quite different conclusions. The historian Donald Warren (1984) produced a rather negative view about Bezerra’s book Insanity through a New Prism. Warren considered the book a ‘mediocre record of what a physician thinks that he is doing’ and believed that Bezerra was unconsciously influenced by his northeastern origin (the poorest region in Brazil): ‘Bezerra has given a poor scientific rationale for indigenous and African rituals of the “traditional Brazilian art of healing”’ (1984, pp. 62–3). On the other hand, anthropologist David Hess (1991, pp. 94–98) compares Bezerra’s theory for the understanding of mental disorders without brain damage to the ideas brought forward by Freud and Janet in the early 20th century. Bezerra, Freud and Janet attempted to fill the current medical knowledge gap. They earnestly believed that they had discovered a new type of mental illness. Nevertheless, Bezerra was not well 587 Transcultural Psychiatry 42(4) accepted among his peers in his attempt to bring scientific legitimacy to what was seen and understood then as popular religion and sorcery. David Hess asserts that, as with dynamic psychiatry, Spiritism tried to connect exorcism and neurology. Like Freud’s psychoanalytic method, which borrowed the therapeutical method from the Catholic confessional chamber and even used a biomedical idiom, Menezes’ disobsession therapy borrowed from Catholic exorcism but on the contrary used the spirit idiom. Like Freud, Menezes challenged the accepted dogmas of both the Catholic church and biomedicine. Yet, instead of mapping out an unconscious, Menezes mapped out a spirit world – one that was as real to most Brazilians as the world of repressions, automatisms, and psychic energies was to the psychological reformers of Europe. Menezes’ disobsession therapy was similar to the new dynamic psychiatry in a second way: the triad of spirit of light/client/errant spirit is in many ways similar to that of superego/ego/id . . . the passive figure of medium plays a role similar to that of the silence of the analyst: both are empty stages on which the drama of unconscious conflict plays itself out. (1991, pp. 97–98) The similarities between the rhetoric of spiritist therapy and psychoanalysis have also been noted by Bastide (1967) and Garrison (1977) and led Hess to call Bezerra the ‘Brazilian Freud’. A key difference in regard to psychoanalysis was that the patient did not have to be present in person at the séance. That is one of the Spiritist arguments to deny that the therapeutic effect takes place just by means of catharsis or suggestion. Independent of the issue of dualism versus monism in analyzing Bezerra’s work, in the view of a 21st-century psychiatrist, the most fragile point in Bezerra’s theory seems to be his concept of ‘insanity without brain damage’. Despite not having affirmed this idea explicitly, Bezerra apparently assumed that if there was no evident macroscopic brain damage, this condition would be consistent with a brain ‘free of minimal damage’ or a brain in the ‘most perfect physiologic condition’ (Menezes, 1988, pp. 11–12). Ferreira tried to integrate Bezerra’s theory into the conventional psychiatric practice. The major importance of Ferreira’s ideas resides in his pioneering attempt to unite the two different approaches more than half a century ago. It is important to emphasize that Kardec, Bezerra and Ferreira developed their theories in a period when there were no antipsychotic or antidepressant agents, and psychiatry basically dealt with severe mental disorders, its clinical practice being mainly confined to the sanatoriums for the mad. The mental illnesses that currently are the focus of everyday psychiatric practice (anxiety and mood disorders) were often under the care of general physicians and neurologists, or they were not even considered mental disorders (Marx, 1992). Anxiety and mood 588 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders disorders have become the central focus of attention in the Spiritist literature and in society as a whole only over the past few decades. The failure of alienists to obtain major positive outcomes in the treatment of the majority of cases combined with the fact that none of the current psychiatric medications were available then seemed an important factor allowing for the development of the Spiritist treatment approach. An investigation into the impact of modern psychopharmacology on the therapeutic practices performed at the Uberaba Mental Hospital/Sanatorium would be very valuable to clarify these issues. The authors mentioned have discussed several cases of ‘spectacular cures’ obtained by means of Spiritist therapy. Unfortunately, the methodological rigor of contemporary clinical trials was not available at that time. The major limitations regarding the methodology of the Spiritist investigations include: lack of randomization, lack of a treatment control group, and lack of objective outcome measures (Guyatt, Sackett, Taylor, Chong, Roberts, & Pugsley, 1986; Sackett, Haynes, & Tugwell, 1985). Despite the methodological limitations of published cases, they are nonetheless useful for the formulation of a hypothesis to be tested in studies with more elaborate designs. The Center for the Study of Religious and Spiritual Problems (NEPER; Núcleo de Estudos de Problemas Espirituais e Religiosos) is developing different research lines. Historical (Moreira-Almeida, Almeida, & Lotufo Neto, 2005) and anthropological (Puttini, 2004) studies have been conducted on the relationship of Spiritism and the psychiatric community, as well as a clinical trial investigating the efficacy of ‘Spiritist therapies’ (Leão, 2004). Despite the fact that ‘spiritual therapies’ such as laying-on of hands and prayers are ubiquitous worldwide, the treatment by means of sessions with mediums for disobsession performed by medical doctors seems unique to Brazil in the last 100 years. Puttini (2004) recently reported the results of his investigation with 26 Spiritist psychiatric hospitals in São Paulo state, the wealthiest and most populous state in Brazil. There were 4300 health-related professionals in his data base working within these institutions, and many of these workers were not Spiritists. All 26 institutions employed traditional medical and psychological care, and Spiritist therapies were also employed. Puttini’s investigation also demonstrated that there was a significant difference in the importance attributed by the mental institutions regarding the role and the importance of the Spiritist therapies. The setting ranged from a Spiritist activity separated from and almost undesired by the local clinical staff to a thorough integration where the spiritual evaluations and interventions were recorded in the subject’s charts. Leão’s (2004) double-blind investigation recorded the impact of mediumistic therapies in the clinical and behavioral progress of subjects admitted with mental retardation to a Spiritist hospital. All subjects were 589 Transcultural Psychiatry 42(4) submitted to conventional psychiatric therapeutic approaches, and the experimental group was also given simultaneous mediumistic sessions for six months as a complement. The experimental group showed statistically significant clinical and behavioral improvement. This investigation needs to be replicated in other patient populations and with more rigorous methods. A more recent Spiritist view on mental disorders has been supplied by Joanna de Ângelis, who adopts the assumptions of the previous authors and complements them with a more psychological approach, mostly directed to ‘neurotic’ disorders and existential problems. Despite some focal resistance, her work has received greater acceptance in the Spiritist milieu among laymen and mental health professionals. It is worth stressing that the psychological themes are also a growing topic in the recent North American medium literature (Hastings, 1991, p. 196; Klimo, 1998). Several books with significant impact became available in the 1970s, namely, A Course in Miracles (Schuman, 1975) and the essays of an entity called ‘Seth’ (Roberts, 1970, 1972, 1974) that sold millions of copies (Hastings, 1991; Klimo, 1998). There are several similarities between the contents of these North American publications and the Brazilian publications. All of them have generated local and non-local study groups, seminars and conferences, besides being a self-help source for millions worldwide. These books also deserve a share of academic study so that an interested party may better understand the content and impact of these psychological theories on the general population (A Course in Miracles has received some academic attention; Hastings, 1991, pp. 111–113). The religious and spiritual dimensions of culture are among the most important factors that structure beliefs, values, behaviors and patterns of human ailments, that is, the human experience (Lukoff, Lu, & Turner, 1992). Kardec’s theory of how Spiritism could play a role in preventing mental disorders (helping people deal with life’s difficulties and acting as a buffer against stressful life events) is in line with the cognitive-behavioral approach used by Koenig, Larson, and Larson (2001) to explain how religion helps patients to cope. The majority of psychiatrists and psychologists in clinical practice have met some resistance from religious groups (including Spiritist ones). It is important to consider that the Spiritists themselves recognize fairly well that this specific issue is frequently abused. A prominent Brazilian medium called Teixeira (1990, pp. 86–87) has stated that psychiatric conditions are commonly misinterpreted as mediumship. Ferreira (1996, pp. 8–9) and Kardec (1996, question 474) shared the same opinion. While some Spiritists consider that all mental disorders result from mediumship or obsessions, thus dismissing the conventional psychiatric or psychological treatment modalities, this is not the opinion of the main Spiritist authors. The fact that they have often acknowledged the concomitant use of the two 590 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders treatment approaches may be an important argument in helping patients and families accept psychiatric treatment. The recommendation found in the Brazilian Spiritist milieu to ‘develop the mediumship’ as a therapy for psychiatric problems does not find any basis in the writings of the two most significant Spiritist authors, Kardec and Bezerra. Conclusions Spiritism has developed a complex theory about mental disorders that has influenced patients and health-care professionals, most notably in Latin America, and particularly in Brazil. A complementary etiology to the social, biological and psychological factor is proposed, the spiritual cause. This spiritual cause has its origins in previous incarnations and spiritual influences, the so-called obsessions. The Spiritists argue that acceptance of this complementary factor could have an enormous heuristic power, tremendously facilitating the development of medicine and psychology, but they maintain that materialistic dogmatism and academic authoritarianism prevent the acceptance of their beliefs. It is important to stress, however, that the Spiritist milieu itself has little awareness of this theory and has developed practices that conflict with the practices suggested by their own authors. Academic study of this subject is of great importance due to the significance it has attained in Brazilian culture and its practical implications. Two fields open up for this investigation: the examination of the objective reality and efficacy of Spiritist practices, and the cultural impact of such views on the population. This essay sets out several possible lines of investigation, some of them already in progress. Hopefully, this article will help to attract the attention of the scientific community to the significance of this theme. Notes 1. 2. 3. Information on Spiritism and Kardec’s works may be found at: www.spiritist. org and http://spiritsonline.net Spiritism also plays an important social role related to mental health in both Puerto Rico and in the Puerto Rican community in the United States (Harwood, 1977; Hohmann et al., 1990). However, compared to Brazil, Spiritism among Puerto Ricans has shown a greater degree of syncretism with Afro-American traditions. It is important to point out that we have attempted to present the ideas in a descriptive way, without any judgement as to their ontological or therapeutic validity. To avoid the excessive and tiresome use of the conditional tense and expressions such as ‘supposedly’, ‘hypothetical’ and ‘assumed’ when describing the Spiritist theories, the present tense was mostly used, but this does not imply the acceptance of those hypothesis by the authors of this article. 591 Transcultural Psychiatry 42(4) References Abreu, C. (1991). Bezerra de Menezes. São Paulo: Edições FEESP. Aubrée, M., & Laplantine, F. (1990). La table, le livre et les espirits. Paris: Éditions Jean-Claude Làttes. Baccelli, C. A. (2001). Sob as cinzas do tempo/pelo espírito Inácio Ferreira. Votuporanga, Brazil: Editora Pierre Paul Didier. Balduíno, L. (1994). Psiquiatria e mediunismo. Rio de Janeiro: FEB. Bastide, R. (1967). Le spiritisme au Brésil. Archives de Sociologie des Religions, 24, 3–16. Claro, I. (2000). Depressão: Causas, conseqüências e tratamento (8th ed.). Matão, Brazil: Casa Editora O Clarim. Constans, A. (1991 [1862]). Relation sur une épidémie d’hystéro-démonopathie en 1861. Paris: Thunot. Damazio, S. F. (1994). Da elite ao povo: Advento e expansão do espiritismo no Rio de Janeiro. Rio de Janeiro: Bertrand Brasil. Diversos. (1997). Desafios em saúde mental: Contribuições da terapêutica espírita. (Anais do IV ENESAM-Encontro Nacional Espírita de Saúde Mental). Belo Horizonte, Brazil: Editora Espírita Cristã Fonte Viva. Ellenberger, H. (1970). The discovery of the unconscious. New York: Basic Books. Facure, N. O. (1996). Repercussão dos paradigmas espíritas numa clínica de neurologia. In: Associação Médico-Espírita de São Paulo – Boletim Médico Espírita no. 10 Mednesp 95, 7–25. Ferreira, I. (1993 [1945]). Novos rumos à medicina, Vol. I. São Paulo: Edições FEESP. Ferreira, I. (1995 [1948]). Novos rumos à medicina, Vol. II. São Paulo: Edições FEESP. Ferreira, I. (1996). Psiquiatria em face da reencarnação. São Paulo: Edições FEESP. Figueiredo, G. R., & Ferraz, M. P. T. (1998). Hospício, caridade e psiquiatria. Revista ABP-APAL, 20, 1–8. Franco, D. (1990). O homem integral/pelo espírito Joanna de Ângelis. Salvador, Brazil: Livraria Espírita Alvorada. Franco, D. (1993). O ser consciente/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (1995). Autodescobrimento: uma busca interior/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (1997). Vida: desafios e soluções/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (1999). Dias gloriosos/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (2000a). Jesus e o evangelho – À luz da psicologia profunda/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (2000b). O despertar do espírito/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. Franco, D. (2000c). Jesus e atualidade/pelo espírito Joanna de Ângelis. São Paulo: Pensamento. Franco, D. (2000d). Desperte e seja feliz/pelo espírito Joanna de Ângelis. Salvador: Livraria Espírita Alvorada. 592 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders Franco, D. (2002). Elucidações psicológicas à luz do espiritismo/pelo espírito Joanna de Ângelis (organização de G. Campetti Sobrinho & P. R. A. Pedrosa). Salvador: Livraria Espírita Alvorada. Garrison, V. (1977). The Puerto Rican syndrome in psychiatry and espiritismo. In V. Crapanzano & V. Garrison (Eds.), Case studies in spirit possession (pp. 383–449). New York: John Wiley & Sons. Guyatt, G., Sackett, D., Taylor, D. W., Chong, J., Roberts, R., & Pugsley, S. (1986). Determining optimal therapy: Randomised trials in individual patients. New England Journal of Medicine, 314, 889–892. Harwood, A. (1977). Puerto Rican spiritism. Culture, Medicine and Psychiatry, 1, 69–95, 135–153. Hastings, A. (1991). With the tongues of men and angels: A study of channelling. Fort Worth, TX: Holt, Rinehart and Winston Inc. Hess, D. (1991). Spirits and scientists: Ideology, spiritism and Brazilian culture. University Park, PA: Pennsylvania State University Press. Hohmann, A. A., Richeport, M., Marriott, B. M., Canino, G. J., Rubio-Stipic, M., & Bird, H. (1990). Spiritism in Puerto Rico. British Journal of Psychiatry, 156, 328–335. Janet, P. (1889). L’automatisme psychologique. Paris: Félix Alcan. Kardec, A. (1858). Introdução. Revista Espírita, 1(1), 1–6. Kardec, A. (1861a). Ensaio sobre a teoria da alucinação. Revista Espírita, 4(7), 208–215. Kardec, A. (1861b). Fenômenos psico fisiológicos:Das pessoas que falam de si mesmas na terceira pessoa. Revista Espírita, 4(8), 239–243. Kardec, A. (1862a). Epidemia demoníaca na sabóia. Revista Espírita, 5(4), 107–111. Kardec, A. (1862b). Estudo sobre os possessos de morzine. Revista Espírita, 5(12), 355–365. Kardec, A. (1862c). Estatística de suicídios. Revista Espírita, 5(7), 196–202. Kardec, A. (1863a). Estudo sobre os possessos de morzine (II artigo). Revista Espírita, 6(1), 1–8. Kardec, A. (1863b). Estudo sobre os possessos de morzine (III artigo). Revista Espírita, 6(2), 33–40. Kardec, A. (1863c). Estudo sobre os possessos de morzine (IV artigo). Revista Espírita, 6(4), 99–110. Kardec, A. (1863d). Estudo sobre os possessos de morzine (V artigo). Revista Espírita, 6(5), 130–140. Kardec, A. (1864). Cura de uma obsessão. Revista Espírita, 7(2), 45–46. Kardec, A. (1865a). Nova cura de uma jovem obsedada de marmande. Revista Espírita, 8(1), 4–19. Kardec, A. (1865b). O fumo e a loucura. Revista Espírita, 8(5), 142–144. Kardec, A. (1866a). Monomania incendiária precoce. Revista Espírita, 9(6), 171–177. Kardec, A. (1866b). Curas de obsessões. Revista Espírita, 9(2): 44–48. Kardec, A. (1869). A carne é fraca – Estudo fisiológico e moral. Revista Espírita, 12(3), 63–67. 593 Transcultural Psychiatry 42(4) Kardec, A. (1986 [1861]). The mediums’ book (trans. Anna Blackwell). Rio de Janeiro: FEB. Kardec, A. (1992[1868]). A gênese, os milagres e as predições segundo o espiritismo. Rio de Janeiro: FEB. Kardec, A. (1995 [1859]). O que é o espiritismo? Rio de Janeiro: FEB. Kardec, A. (1996 [1857]). The spirits’ book (trans. Anna Blackwell). Rio de Janeiro: FEB. Klimo, J. (1998). Channelling: Investigations on receiving information from paranormal sources. Berkeley, CA: North Atlantic Books. Koenig, H., Larson, D., & Larson, S. S. (2001). Religion and coping with serious medical illness. Annals of Pharmacotherapy, 35, 352–359. Koss-Chioino, J. D. (2003). Jung, spirits and madness: Lessons for cultural psychiatry. Transcultural Psychiatry, 40(2), 164–180. Leão, F. C. (2004). ‘Práticas espirituais no tratamento de portadores de deficiência mental.’ Dissertação de Mestrado. Dept Psiquiatria da Faculdade de Medicina da Universidade de São Paulo. Lukoff, D., Lu, F., & Tuner, R. (1992). Toward a more culturally sensitive DSM-IV: Psychoreligious and psychospiritual problems. Journal of Nervous and Mental Disease, 180, 673–682. Machado, U. (1993). Os intelectuais e o espiritismo. De Castro Alves a Machado de Assis. Rio de Janeiro: Antares. Marx, O. M. (1992). What is the history of psychiatry? History of Psychiatry, 3, 279–292. Menezes, A. (1988 [1897]). A loucura sob novo prisma. Rio de Janeiro: FEB. Moreira-Almeida, A., Almeida, A. A. S., & Lotufo Neto, F. (2005). History of spiritist madness in Brazil. History of Psychiatry, 16(1): 5–25. Mundin, P. O. (1984). A posição doutrinária espírita na psiquiatria. In Associação Médico-Espírita de São Paulo, Boletim Médico Espírita, 1, 57–71. Murphy, G., & Ballou, R. O. (1960). William James on psychical research. New York: Viking Press. Myers, F. W. H. (2001 [1903]). Human personality and its survival of bodily death. Charlottesville, VA: Hampton Roads Publishing Company Inc. Nobre, F. (1986). Introdução. In B. Menezes, Perfis Parlamentares 33 / Bezerra de Menezes. Brasília: Câmara dos Deputados. Oliveira, S. F. (1996). As funções verticais do cérebro. In Associação MédicoEspírita de São Paulo, Boletim Médico Espírita, 10, 187–95. Palhano Jr, L., & Oliveira, J. A. S. (1997). Laudos espíritas da loucura. Niterói, Brazil: Lachatre. Puttini, R. F. (2004). Medicina e religião num espaço hospitalar espírita. Tese de Doutorado. Departamento de Saúde Coletiva da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp). Roberts, J. (1970). The Seth material. Englewood Cliffs, NJ: Prentice-Hall. Roberts, J. (1972). Seth speaks: The eternal validity of the soul. Englewood Cliffs, NJ: Prentice-Hall. Roberts, J. (1974). The nature of personal reality: A Seth book. Englewood Cliffs, NJ: Prentice-Hall. 594 Moreira-Almeida & Lotufo Neto: Spiritist Views of Mental Disorders Ross, C. A., & Joshi, S. (1992). Paranormal experiences in the general population. Journal of Nervous and Mental Disease, 180, 357–361. Sackett, D., Haynes, R. B., & Tugwell, P. (1985). Clinical epidemiology: A basic science for clinical medicine. Boston: Little, Brown. Santos, J. A. (1991). Visão espírita das distonias mentais (2nd edn). Rio de Janeiro: FEB. Santos, J. L. (1997). Espiritismo. Uma religião brasileira. São Paulo: Moderna. Schuman, H. (1975). A course in miracles (3 vols: text, workbook for students and manual for teachers). Tiburon, CA: Foundation for Inner Peace. Souza, D. S., & Deitos, T. F. H. (1980). Terapia espírita em hospitais psiquiátricos (Brasil). Revista Asociación Brasilera de Psiquiatría, 2, 190–194. Stevenson, I. (1977). The explanatory value of the idea of reincarnation. Journal of Nervous and Mental Disease, 164, 305–326. Teixeira, J. R. (1990). Diretrizes de segurança. Rio de Janeiro: Editora Fráter. Vandermeersch, P. (1991). The victory of psychiatry over demonology: The origin of the nineteenth-century myth. History of Psychiatry, 2, 251–263. Wantuil, Z. (1990 [1969]). Grandes espíritas do Brasil. Rio de Janeiro: FEB. Warren, D. (1984). A terapia espírita no Rio de Janeiro por volta de 1900. Religião e Sociedade, Dec., 56–83. Alexander Moreira-Almeida, MD, PhD, is a Clinical Psychiatrist, Founder and Director of NEPER (Center for the Study of Religious and Spiritual Problems) at the Institute of Psychiatry, University of São Paulo, Brazil. He is a post-doctoral fellow at the Center for Spirituality, Theology and Medicine at Duke University Medical Center and Clinical Director of a psychiatric hospital (HOJE – Hospital João Evangelista). His research interests include mediumistic trances and the relation of religiosity/spirituality and health. Address: Rua Caetés 737/205 Perdizes 05016–081 São Paulo – SP, Brazil. [E-mail: alexma@usp.br] Francisco Lotufo Neto, MD, PhD, is a Clinical Psychiatrist, Co-Founder of NEPER (Center for the Study of Religious and Spiritual Problems) at the Institute of Psychiatry, University of São Paulo, Brazil. He is Associate Professor of Psychiatry at the University of São Paulo and his research interests include mental health of immigrants and the relation of religiosity/spirituality and health. 595