Santería / Lucumí

1. Introduction

Version followed: the Lucumí religion (Regla de Ocha-Ifá, "Ocha") as its houses, community institutions and scholars describe it, with the psychotherapist's own work organised around the DSM-5-TR Cultural Formulation Interview (core CFI, Informant Version and supplementary modules) and the DSM-5-TR and ICD-11 criteria for possession and trance.

What it is. Lucumí is an Afro-Cuban religion that formed in nineteenth-century Cuba among enslaved Yoruba people. Their religion absorbed elements of Roman Catholicism, and devotees honour spirits called orichas (orishas) through the iconography of Catholic saints. The US Supreme Court described the religion's basis as "the nurture of a personal relation with the orishas" [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html]. Many practitioners now reject the older name "Santería" ("way of the saints") because it stresses the Catholic layer and downplays the African roots. They prefer La Regla de Lukumí, La Regla de Ocha-Ifá or Ocha [source: https://pluralism.org/“santería”-the-lucumí-way]. It is a living religion, not a therapy. A psychotherapist does not perform any part of it. Your role is to understand how the client lives it, to assess and treat within your own discipline, and to work alongside the client's religious community when the client wants that.

Elements the client may mention (as practitioners and scholars describe them; no ritual procedure is given here):

Orichas and aché. Orichas are deities of Yoruba origin. Aché is life-energy or power, made manifest through the ancestors (eggun) and the orichas. In Cuba, orichas were paired with saints: for example Changó with St Barbara and Babalú Ayé with St Lazarus [source: https://pluralism.org/“santería”-the-lucumí-way].
Possession by the oricha at drum ceremonies (toque de santo). At religious festivities participants may become possessed [source: https://busqueda.bvsalud.org/portal/resource/pt/mdl-3224955]. A Cuban expression describes it as the saint "climbing into the head" ("el santo se le subió a la cabeza") [source: https://scielo.org.mx/pdf/crca/v31n89/2448-8488-crca-31-89-133.pdf]. At one Miami festival, those present recognised each manifest oricha by its movements [source: https://pluralism.org/“santería”-the-lucumí-way]. Possession is also expected within initiation [source: https://cswr.hds.harvard.edu/news/2026/08/05/babalu-visits-and-shocks]. The term "toque de santo" for these drum ceremonies, and the rules on who may be possessed, are [uncertain: not verified].
Osain (Osaín) and plant knowledge. In a myth quoted by the ethnographer Morton Marks, Osain received the secret of the leaves (ewe) and is "lord of leaves". Each oricha also owns its own plants. Herbalists (osainistas) held knowledge of plant properties, and plants were used "magically and/or medicinally" [source: https://eleda.org/articles/exploring-el-monte-ethnobotany-and-the-afro-cuban-science-of-the-concrete--english]. This is an outsider's scholarly account, based on Lydia Cabrera's El Monte.
Omiero. Clients may mention omiero, which practitioners regard as sacred [uncertain: not verified]. This guide gives nothing on its ingredients, preparation or use.
Babalú Ayé. The Duke University Sacred Arts of the Black Atlantic project describes Babalú Ayé as an oricha of healing and miracles, linked in stories to illness and epidemics (including smallpox), and identified with the Catholic San Lázaro. Those who have suffered are seen as able to help others who suffer [source: https://sacredart.caaar.duke.edu/artifacts/sacred-broom-ja-bracelet-cacha-and-necklace-ileke-elequi-ensemble-for-the-afro-cuban-god-san-lazaro-babalu-aye/].
Animal sacrifice. According to the Supreme Court record, animals are sacrificed at birth, marriage and death rites, for the cure of the sick, for the initiation of new members and priests, and at an annual celebration. The animal is generally cooked and eaten, except after healing and death rituals. In Church of the Lukumi Babalu Aye, Inc. v. City of Hialeah, 508 U.S. 520 (decided 11 June 1993, opinion by Justice Kennedy), the Court struck down Hialeah's ordinances. It held that their object was "the suppression of religion" and that they violated the Free Exercise Clause [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html].

How change happens, for your part of the work. Within the religion, healing and well-being are understood through the person's relationship with the orichas, the ancestors and the godfamily. Describe this as the client's tradition holds it, neither as fact nor as error. For the psychotherapist, change comes from understanding the problem in the client's own terms. That means the cultural definition of the problem, its perceived causes, coping and help-seeking, and what the client expects from care [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. It also means telling culturally normative religious experience apart from disorder, and building a plan that can sit alongside the client's religious life rather than compete with it [synthesis].

2. Framework

This is a framework for culturally responsive psychotherapy with Lucumí practitioners, not a manualised treatment. No source gives a session count for this work. The phases below are [synthesis], built on the CFI's structure and on the published criteria for possession and trance.

Who holds authority in the religion (know this before you start):

Practice is organised in ilés ("houses"): chosen kinship communities of initiates and aspirants, led by an iyalocha (priestess) or babalocha (priest), also called santera or santero. Initiates are the godchildren of their house [source: https://pluralism.org/“santería”-the-lucumí-way].
Babalawos are prestigious diviners, all men, who play a critical role in many initiations [source: https://pluralism.org/“santería”-the-lucumí-way]. The oba oriaté is a senior ritual specialist who appears in accounts of initiation [source: https://cswr.hds.harvard.edu/news/2026/08/05/babalu-visits-and-shocks]. The exact scope of that role is [uncertain: not verified].
Some houses have a council of elders that oversees their religious inheritance. Ilé Oyuma Oloye, which publishes OrishaNet, states that it has a Consejo de Ancianos [source: https://www.orishanet.org/?page_id=25].
There is no central hierarchy. A Cuban journalist describes the religion as working horizontally, with no supra-familial administrative structures. Several bodies issue rival annual pronouncements (the Letra del Año), among them the Asociación Cultural Yoruba de Cuba, founded in 1992 [source: https://oncubanews.com/cuba/en-espera-de-dos-letras-del-ano]. Authority over a client's religious life therefore usually rests with their own godparent and house, not with any outside body.
In the US, the Church of the Lukumi Babalu Aye (Hialeah, Florida), whose priest Ernesto Pichardo brought the 1993 case, is the best-known public institution. One estimate puts US practitioners at 250,000 to one million [source: https://pluralism.org/“santería”-the-lucumí-way] [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html].

Phases of the psychotherapist's work [synthesis]:

Preparation and engagement (before and during session 1). Goal: examine your own reactions (for example to animal sacrifice or possession) and open a safe space for disclosure. Move on when the client is willing to talk about their religious life, or has clearly said they prefer not to.
Cultural assessment (usually sessions 1–3). Goal: the core CFI, then the modules the case needs: Spirituality, Religion, and Moral Traditions; Explanatory Model; Coping and Help-Seeking; Cultural Identity; Immigrants and Refugees; and, with consent, the Informant Version with a relative or godparent. The modules 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]. A time estimate for the core CFI is [uncertain: not verified]. In the DSM-5 field trial, later interviews took less time [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. Move on when you can state the client's explanatory model in their words and they agree with your summary.
Differential assessment (alongside phase 2, whenever possession, trance, voices or visions come up). Goal: decide whether an experience is a normal part of accepted religious practice, a disorder, or both. Move on when you have a working formulation, if needed after consulting a cultural broker or (with consent) the client's godparent.
Shared formulation and plan. Goal: agree on goals, roles and any collaboration with the client's house. Agree on parallel medical care where it is needed. Move on when the client consents to the plan and its information-sharing limits.
Treatment, integration and review (the usual course of the presenting problem's evidence-based treatment). Goal: deliver standard therapy adapted to the client's framework. Integrate religious experiences such as initiation, a possession episode or a reading, and keep safeguarding under review. Repeat CFI modules when the picture changes [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].

3. Guiding principles

You work alongside the tradition, never inside it. Never divine, interpret oracle readings, prescribe offerings, take part in or advise on ceremonies, or claim religious standing [synthesis].
Use the client's names. Ask whether they say Lucumí, Ocha, Regla de Ocha-Ifá or Santería, because the older term is contested [source: https://pluralism.org/“santería”-the-lucumí-way]. In practice: mirror their word and write it in your notes.
Attribute, do not adjudicate. Describe orichas, aché, possession and spiritual causation as the client and tradition hold them, neither as fact nor as dismissal [synthesis]. In practice: write "the client understands X as…".
Authority is local. The godparent and house decide religious matters, and there is no central body [source: https://oncubanews.com/cuba/en-espera-de-dos-letras-del-ano]. In practice: any religious question goes back to the client's own elders, not to a stranger or a website.
Possession is not by itself a symptom. A clinical paper on Santería argues that possession beliefs should not be classed as a culture-bound syndrome. They may appear nonspecifically across many disorders and should be judged within the person's whole belief system and their daily functioning [source: https://busqueda.bvsalud.org/portal/resource/pt/mdl-3224955]. In practice: assess context, control, distress and functioning, not the belief itself.
Avoid both errors. Do not pathologise normative trance, and do not miss psychosis, mania, dissociative disorder, substance or medical causes [synthesis] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. In practice: screen fully even when the religious explanation fits.
Respect secrecy as a historical survival strategy. The religion was practised secretly in Cuba because of persecution [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html], and ilés worked as secret, independent cells [source: https://www.orishanet.org/?page_id=25]. In practice: never press for ritual details. Ask only what you need clinically.
Name racism and religious discrimination. Scholars attribute public hostility, especially to animal sacrifice, to the dominant culture and anti-Blackness [source: https://pluralism.org/“santería”-the-lucumí-way]. In practice: ask about discrimination, and examine your own reactions before they leak into the room.
Religion as resource. A rehabilitation-counselling review frames Santería practice through a strengths lens: coping, well-being, social support [source: https://corescholar.libraries.wright.edu/human_services/24]. In practice: map the godfamily as part of the support network.
Medical care runs in parallel. No religious practice is presented here as a treatment for physical or mental disease. Never advise starting, stopping or changing a medicine. Route such questions to the prescriber [synthesis].
Consent governs every contact with the house. Any contact with the client's godparent or house needs explicit, specific and revocable consent [synthesis].
The CFI supports judgement; it does not replace it. The CFI informs clinical decisions and is not the sole basis for diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].

4. Intervention inventory

Everything below is the psychotherapist's own work. None of it is a Lucumí practice. Example language is illustrative unless quoted.

4.1 Cultural self-examination before and during contact

Purpose / when: before the first session and whenever you notice a strong reaction (fear, disgust, fascination) to possession, animal sacrifice or spirit causation. Unexamined reactions are a source of misdiagnosis and rupture [synthesis].
Steps: (1) Write down what you believe about Afro-Cuban religion and where those beliefs come from: media, religious upbringing, training. (2) Note any images of Lucumí as "dark" or dangerous, which scholars link to anti-Blackness [source: https://pluralism.org/“santería”-the-lucumí-way]. (3) Learn the basics from community and scholarly sources (section 1) so the client does not have to educate you from zero [source: https://corescholar.libraries.wright.edu/human_services/24]. (4) Bring persistent reactions to supervision. (5) Notice the moment in session when curiosity turns into voyeurism, and return to the clinical question [synthesis].
Example language (illustrative, to yourself or a supervisor): "Am I asking this because it matters for the formulation, or because I find it exotic?"
Watch for: questions about ritual detail that have no clinical purpose, discomfort that comes out as over-pathologising, and colleagues using "voodoo" or similar terms. You know it is working when you can hear about sacrifice or possession without your tone changing and keep your questions on the client's experience [synthesis].

4.2 Opening the door: naming and permission

Purpose / when: first session, and any time religious language appears. Many clients hide practice because of the religion's history of persecution [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html].
Steps: (1) Ask generally about religion or spiritual life, with no assumption that a Cuban or Caribbean client practises. (2) If the client mentions Ocha, a santero, a godparent or a reading, ask what they call their religion and use that word [source: https://pluralism.org/“santería”-the-lucumí-way]. (3) Say what you will and will not do: you will not judge it, ask for secrets or try to replace their religious guidance. (4) Ask how open they want to be and whether the topic is private. (5) Agree how it will be written in your records (see 4.17) [synthesis].
Example language (illustrative): "Some people I work with have a religious life that matters a lot to how they understand what's happening. If that's true for you, I'd like to hear about it, in your own words, and only as much as you want to share. You won't need to tell me anything that's meant to stay within your religion."
Watch for: guarded or joking answers ("I'm Catholic") that may be partly true, since many practitioners are both. Watch for relief once the client is given permission. It is working when the client brings in religious meanings without being prompted [synthesis].

4.3 Core Cultural Formulation Interview

Purpose / when: at the initial assessment of every client for whom culture or religion shapes the problem. APA designed the CFI "to be used by any clinician providing services to any individual in any care setting" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: Work through the 16 questions in the APA's four domains, in your own conversational order [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]: (1) Cultural definition of the problem: what the client calls it, and how their family, godfamily and community describe it. (2) Cultural perceptions of cause, context and support: causes, which may include spiritual or oricha-related explanations, stressors, supports (including the ilé), and the role of cultural identity. (3) Self-coping and past help-seeking: including consultations with santeros, babalawos, espiritistas, botanicas, physicians and clergy, and the barriers met. (4) Current help-seeking: preferences, and how the client sees you, including concerns about racism, language or being judged. The form can 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]. Use the official form for item wording; it is not reproduced here.
Example language (illustrative, domain 3): "When this started, who did you turn to? That might include family, a doctor, a priest, your godparent or someone else."
Watch for: answers that change once trust grows. Give the CFI again later if needed. It is working when you can write a short cultural formulation that the client recognises as accurate. In the DSM-5 field trial the CFI was found "feasible, acceptable and useful" [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].

4.4 CFI Informant Version with a relative or godparent

Purpose / when: when the client is too unwell to give a full account (for example acute psychosis), when the family's view matters to the plan, or when the client asks that their godparent be involved. The Informant Version has 17 questions and begins with the informant's relationship to the patient [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Get the client's explicit consent: who, what may be shared, and what may not. (2) Explain to the informant that you are a clinician seeking their understanding, not religious advice or ritual detail. (3) Follow the four domains. (4) Record differences between the client's and the informant's accounts without deciding who is right. (5) Feed back to the client what you will use [synthesis].
Example language (illustrative): "Your goddaughter asked me to speak with you because you know her well. I'm not asking about anything private to your religion. I'd like to understand how you see what she's going through and what you think would help."
Watch for: an informant who speaks for the client or pressures them, which may mean coercion (see 4.15), and conflict between blood family and godfamily. It is working when the informant's view adds to the formulation and the client still feels in control [synthesis].

4.5 Supplementary module: Spirituality, Religion, and Moral Traditions

Purpose / when: when religion is central to identity, coping or the explanation of the problem. It is one of the 12 APA supplementary modules and can be used alone or with the core CFI, and repeated during care [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Ask about religious affiliation, including multiple belonging (Catholic, Lucumí and Espiritismo at once is common [synthesis]). (2) Ask about the client's role: aspirant, initiate (iyawó or later), priest, or with no formal standing [source: https://pluralism.org/“santería”-the-lucumí-way]. (3) Ask how religion helps and how it may add stress, for example obligations, conflicts in the house or costs. (4) Ask which moral teachings shape their choices. (5) Ask whether religion is linked to the current problem in their eyes.
Example language (illustrative): "How does your religion help you get through hard times? And is there anything about it right now that adds pressure?"
Watch for: religious obligations as both support and stressor, guilt over unmet obligations, and spiritual distress. It is working when the client names religious resources they can draw on in treatment [synthesis].

4.6 Explanatory model (Kleinman) and the Explanatory Model module

Purpose / when: whenever the client's view of cause and cure differs from yours, which is the usual case. Use it to negotiate a shared plan. Kleinman, Eisenberg and Good (1978) set out the questions [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]. APA's Explanatory Model module expands the core CFI [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: Cover the eight areas (paraphrased) [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]: the name of the problem; its cause; why it began when it did; what it does and how it works; how severe it is and how long it will last; what treatment the client thinks they should receive; the chief problems it has caused; and what they fear most. Then (1) summarise the model back in the client's words, (2) set out your own view briefly, and (3) look for where the two can work side by side, for example a religious remedy from their house plus therapy and medical review [synthesis].
Example language (illustrative): "So you see the trouble as connected to your relationship with your oricha, and your godmother is helping you with that side. From my side, I see sleep loss and low mood that we can work on together. Could both of those things be true at once?"
Watch for: spiritual explanations offered alongside biomedical ones (they are rarely either/or), and fear that therapy will contradict the religion. It is working when the client agrees to a plan that includes both frames and keeps coming back [synthesis].

4.7 Asking about consultations with religious specialists, without judgement

Purpose / when: at assessment and at every change in the plan. Clients may already be seeing their godparent, a babalawo for a reading, or a botanica, and may act on what they are told. Use APA's Coping and Help-Seeking module for depth [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Ask who they have consulted, and normalise it. (2) Ask what they were told the problem was and what they were advised to do, in general terms only. (3) Ask whether any advice touches health: diet, things taken by mouth, sleep, medicines, attending medical care. (4) Ask how they felt afterwards. (5) Note anything that bears on safety (see 4.12, 4.15) [synthesis].
Example language (illustrative): "Have you talked about this with your godparent or anyone in your religion? I'm not asking what was said in a reading, just whether any of the advice affects your health or your treatment here, so we don't pull in different directions."
Watch for: the client reporting advice selectively to avoid your disapproval, and advice that conflicts with medical care. It is working when the client tells you about religious advice before acting on it [synthesis].

4.8 Cultural concepts of distress

Purpose / when: when the client uses an idiom, a named syndrome or a cultural explanation of distress. DSM-5-TR says cultural concepts of distress "include idioms, explanations or perceived causes, and syndromes" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. A university-hosted DSM-5-TR teaching set lists among them ataque de nervios and nervios (both described for Latin American and Caribbean groups) and maladi dyab [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. The exact DSM-5-TR list is [uncertain: not verified]. DSM-5 (2013) listed nine concepts, including maladi moun [source: https://revistapsiquiatria.pt/index.php/sppsm/article/download/139/69].
Steps: (1) Ask what the term means to the client and to their family. (2) Explore the episode in detail: triggers, what happened, memory of it, aftermath, frequency. (3) Treat the concept as a way of communicating distress and a pointer to further assessment, not as a diagnosis in itself. (4) Screen for the disorders it may overlap with (panic, depression, PTSD, dissociative disorder). (5) Record the concept in the cultural formulation in the client's words [synthesis].
Example language (illustrative): "You said you had an ataque after the phone call. Can you walk me through what that was like, and what your family thought it meant?"
Watch for: spiritual explanations (an oricha's displeasure, the dead, or harm sent by someone) treated as cause rather than symptom. Record them as the client's explanation. It is working when the client feels understood rather than labelled [synthesis].

4.9 Distinguishing religious possession and trance from disorder

Purpose / when: whenever possession by an oricha or the dead, trance, voices or visions appear in the history, or the referrer has labelled them psychotic.
Criteria to apply:
- DSM-5: in dissociative identity disorder, identity disruption "may be described in some cultures as an experience of possession". The disturbance must not be "a normal part of a broadly accepted cultural or religious practice" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. DSM-5-TR keeps both points in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. The exact DSM-5-TR wording is [uncertain: not verified].
- Dissociative trance (other specified dissociative disorder) does not apply when the trance is "a normal part of a broadly accepted collective cultural or religious practice" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574].
- ICD-11 6B63 Possession trance disorder requires that the state "is involuntary and unwanted" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. 6B62 Trance disorder requires a state that is involuntary, unwanted and outside accepted cultural or religious practice, recurrent or lasting several days, with significant distress or impairment [source: https://www.findacode.com/icd-11/code-1807490186.html].
- A DSM-5-TR note that culturally sanctioned beliefs should not be counted as psychotic symptoms is [uncertain: not verified].
Clinical framing from the Santería literature: Alonso and Jeffrey (1988) describe four patients in whom possession beliefs were bound up with mental illness. They argue the beliefs should be assessed within the person's whole belief system and their ability to carry out daily activities [source: https://busqueda.bvsalud.org/portal/resource/pt/mdl-3224955]. The Havana psychologist Dueñas Becerra (2012) argues that possession in Regla de Ocha is a psychological and sociocultural phenomenon, not a neuropsychiatric illness, and quotes Métraux's view of it as "un fenómeno controlado que obedece a normas precisas" (a controlled phenomenon that follows precise norms) [source: https://www.medigraphic.com/pdfs/revhospsihab/hph-2012/hph123h.pdf].
Steps [synthesis, organised around the criteria above]: (1) Context: did it happen in a religious setting where possession is expected, or at work, at home or alone? (2) Recognition: does the client's house recognise it as possession, or are the elders worried too? Ask only with consent. (3) Volition and control: expected, welcomed and time-limited, or intrusive and unwanted? (4) Return to baseline: full recovery between episodes, or continuing symptoms? (5) Other features: hallucinations, delusions, thought disorder, mood elevation or depression, dissociation, trauma history, substance use, seizures or other medical causes outside religious contexts. (6) Distress and impairment as the client and family judge them. (7) Formulate one of three outcomes: normative religious experience, disorder, or a disorder that also draws on religious idiom. Review over time.
Example language (illustrative): "In your religion, when an oricha comes down, how does your house tell that apart from someone who is just unwell? Has anyone there been worried about what's been happening to you?"
Watch for: diagnostic overshadowing in both directions. Treat as red flags: episodes outside religious settings, the client frightened by the experience, no return to baseline, commands to self-harm, new behaviour after sleep loss or substance use, and elders themselves worried. It is working when your formulation holds up over follow-up and the client's community does not see it as an attack on their religion [synthesis].

4.10 Consulting cultural brokers and the client's elders

Purpose / when: when you cannot tell normative from pathological experience, or the plan needs community support. Authority sits with the client's own house, not with any outside body [source: https://oncubanews.com/cuba/en-espera-de-dos-letras-del-ano].
Steps: (1) Ask the client whom they trust to speak about their religious life: godparent, an elder, or a culturally knowledgeable colleague. (2) Get written, specific consent covering what you will ask and share. (3) Ask about the person's state and how it compares with what the house considers normal, never about ritual secrets. (4) Thank them, and tell the client what was said. (5) Without consent, consult only in anonymised form, for example with a colleague familiar with Afro-Cuban religion [synthesis].
Example language (illustrative, to a godparent): "I'm not asking about anything sacred. I'd value your view on whether what she's been going through looks like something your community recognises, or whether you're worried about her health."
Watch for: brokers with their own stake (a rival house, or someone charging for services), and over-reliance on a single voice. It is working when the outside view sharpens your formulation and the client feels respected [synthesis].

4.11 Collaboration and referral with the client's religious house

Purpose / when: when the client wants their godparent or house to be part of their care. No formal health-service programme for collaboration with Lucumí priests is documented in the sources cited here [uncertain: not verified]. Evidence that collaboration with traditional and faith healers can work comes from West Africa, not from Lucumí settings. In the COSIMPO cluster-randomised trial in Nigeria and Ghana (Gureje et al., The Lancet, 2020), collaborative shared care between healers and primary care for psychosis reduced PANSS symptoms more than usual care (adjusted mean difference -15.01) and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]. In a randomised trial in a Ghanaian prayer camp (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication to usual camp care significantly 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]. WHO's traditional medicine strategy 2014–2023 supports integrating traditional practitioners safely into health systems [source: https://www.who.int/activities/implementation-of-the-WHO-traditional-medicine-strategy-2014-2023].
Steps [synthesis]: (1) Confirm the client's wish, and that their participation in the religion is free. (2) Agree the scope of consent: which person, which information, and for how long. (3) Clarify roles: the house holds religious care, you hold psychotherapy, and the prescriber or physician holds medical care. (4) Agree safety points everyone accepts: medical care continues, no restraint, no withholding of food or sleep, and urgent symptoms go to medical services. (5) Agree how you will communicate, for example through the client or in a joint meeting the client attends. (6) Review regularly. Do not attend ceremonies in a professional role, and never send clients to a house or practitioner they have not chosen.
Example language (illustrative): "You'd like your padrino to know what we're working on. Let's decide together what I can tell him and what stays between us. I'll also say clearly that your doctor keeps looking after your medication."
Watch for: clients feeling torn between you and the house, and messages passed on in distorted form. It is working when the client experiences their religious and clinical care as allies [synthesis].

4.12 Parallel medical care, herbs, medicines and environmental exposure

Purpose / when: whenever physical illness, medicines, herbal remedies or items obtained at botanicas come up. Babalú Ayé is honoured as an oricha of healing [source: https://sacredart.caaar.duke.edu/artifacts/sacred-broom-ja-bracelet-cacha-and-necklace-ileke-elequi-ensemble-for-the-afro-cuban-god-san-lazaro-babalu-aye/], and plants are used "magically and/or medicinally" [source: https://eleda.org/articles/exploring-el-monte-ethnobotany-and-the-afro-cuban-science-of-the-concrete--english]. None of this is presented here as a treatment for physical or mental disease. Accounts that circulate in communities, such as a reported reversal of a cancer diagnosis after initiation, are recorded as "it is said" lore, not as medical fact [source: https://cswr.hds.harvard.edu/news/2026/08/05/babalu-visits-and-shocks].
Steps: (1) Ask whether anything is being taken by mouth, bathed in or used at home as part of religious or folk care. Ask in general terms; you need neither recipe nor ritual. (2) Encourage the client to tell their prescriber and physician about everything they take. Never advise on starting, stopping or changing any medicine or remedy; route such questions to the prescriber [synthesis]. (3) Ask about elemental mercury (azogue) in the home. A US state health department guide for clinicians names Espiritismo, Santería and Voodoo as practices in which azogue, sold in botanicas, is sometimes used, and notes that not all followers use it. Mercury vapour can cause tremor, irritability, nervousness, insomnia, memory loss, headaches and mood swings. Children and pregnancy are at particular risk [source: https://ldh.la.gov/assets/oph/Center-EH/envepi/Mercury_for_Health_Providers_Hg_Final.pdf]. (4) If exposure is possible, refer for medical assessment and testing, and follow local reporting rules [source: https://ldh.la.gov/assets/oph/Center-EH/envepi/Mercury_for_Health_Providers_Hg_Final.pdf].
Example language (illustrative): "Some people use things from a botanica at home or take remedies their house recommends. Is there anything like that? I'm not going to judge it. I just want your doctor to have the full picture, especially because some substances can affect mood and sleep."
Watch for: new tremor, insomnia, irritability or memory problems (consider mercury before reading them as purely psychiatric), a religious instruction to stop medical treatment, and delay of urgent care. It is working when the client's physician knows about their religious remedies and the client is not hiding either kind of care [synthesis].

4.13 Integrating initiation, possession and readings into therapy

Purpose / when: when a client is considering, undergoing or recovering from initiation, has been possessed or seen someone possessed, or has had a reading that affects their decisions. Initiation as iyawó is described as a lifelong commitment to a central oricha, followed by a period of ritual seclusion [source: https://pluralism.org/“santería”-the-lucumí-way]. It can carry heavy costs and lifelong obligations, "a great deal to put at the feet of an areligious person" [source: https://cswr.hds.harvard.edu/news/2026/08/05/babalu-visits-and-shocks].
Steps [synthesis]: (1) Ask what the experience meant to the client, not what was done. (2) Help them make meaning in their own frame: what changed, and what they feel is now asked of them. (3) Explore practical effects (money, time, relationships, work) and any ambivalence. (4) If they are deciding about initiation under pressure, support a free decision without taking a religious position. (5) Plan around periods when the client may be unavailable, for example seclusion or religious anniversaries. (6) Watch for distress that outlasts the experience.
Example language (illustrative): "You said becoming iyawó changed how you see yourself. What feels different now, and is there anything about it you're still carrying?"
Watch for: a decision driven by fear ("I'll die if I don't"), financial strain, family conflict over conversion, and lasting fear or dissociation after an intense possession experience. It is working when the client can hold the experience as meaningful and still use therapy [synthesis].

4.14 Working with families and the godfamily

Purpose / when: when blood family and religious family both matter. Ilés are chosen kinship communities; members are godchildren and the house works as a surrogate family [source: https://pluralism.org/“santería”-the-lucumí-way] [source: https://www.orishanet.org/?page_id=25]. Use APA's Social Network module for mapping [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps [synthesis]: (1) Draw a genogram that includes the godfamily. (2) Identify supports and conflicts in each. (3) Note disagreements about the religion within the blood family: different denominations, generations or converts. (4) With consent, include family members in sessions about the plan, not about the religion's merits. (5) Keep the client's own view at the centre.
Example language (illustrative): "Let's map who's around you: family by blood and family through your religion. Who do you lean on, and where's the friction?"
Watch for: the therapist being recruited into a family argument over religion, and isolation if the client leaves a house. It is working when the client uses both networks deliberately [synthesis].

4.15 Safeguarding

Purpose / when: at every assessment and whenever risk appears. Lucumí practice, including animal sacrifice, is a lawful religious practice in the US under the 1993 ruling [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html], and is not a safeguarding concern in itself. The concern is harm to a person, whatever its setting [synthesis].
Steps [synthesis unless cited]: (1) Screen as you would for anyone: suicide and self-harm risk, abuse, exploitation, neglect and delay of urgent medical care. (2) Ask specifically about financial exploitation or coercion into costly obligations, given the costs described for initiation [source: https://cswr.hds.harvard.edu/news/2026/08/05/babalu-visits-and-shocks]. (3) Ask about mercury exposure where children or pregnancy are involved [source: https://ldh.la.gov/assets/oph/Center-EH/envepi/Mercury_for_Health_Providers_Hg_Final.pdf]. (4) For minors, check the young person's own assent and understanding of any religious commitment, and follow child-protection procedures for any harm. Do not treat a child's religious participation itself as abuse. (5) If abuse, including sexual abuse, is disclosed in a religious setting, follow your mandatory reporting duties, document factually and do not investigate religious practice yourself. (6) Make clear that a religious explanation does not remove the reporting duty, and that a lawful practice is not abuse.
Example language (illustrative): "Sometimes people feel pushed to pay for or take part in things they're not sure about, in any religion. Has anything like that happened to you?"
Watch for: a client isolated by a single authority figure, sudden large payments, and fear of leaving. In a minor, watch for withdrawal from school or a sudden change in caregivers. It is working when the client can talk about risks without feeling their religion is on trial [synthesis].

4.16 Identity, migration, racism and religious discrimination

Purpose / when: when the client is an immigrant or refugee (for example Cuban, Puerto Rican or Dominican), a convert from another background, or has met hostility to the religion. Use APA's Cultural Identity and Immigrants and Refugees modules [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. The core CFI's last domain covers the clinician–patient relationship, including perceived racism [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: (1) Explore migration history and losses, including separation from a house in Cuba. (2) Ask about discrimination, including hostility rooted in anti-Blackness [source: https://pluralism.org/“santería”-the-lucumí-way] and the legal history of suppression [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html]. (3) Ask how the client expects to be seen by you and by services. (4) Address these experiences directly in the work [synthesis].
Example language (illustrative): "Has your religion ever been mocked or treated as something dangerous, by people around you or by services like this one? How has that affected what you feel safe telling me?"
Watch for: concealment learned from past discrimination, and internalised shame. It is working when the client corrects you, or brings religious material more freely [synthesis].

4.17 Documentation and confidentiality

Purpose / when: throughout. Records outlast the therapy, and the religion has a history of secrecy for protection [source: https://www.orishanet.org/?page_id=25].
Steps [synthesis]: (1) Record what you need clinically, such as the client's explanatory model, religious supports, any health-relevant advice and risk, not ritual details. (2) Use the client's own terms and attribute beliefs ("client describes…"). (3) Note consent for each contact with family or the house. (4) Avoid diagnostic labels for normative experiences. (5) Let the client know what is recorded.
Example language (illustrative): "In my notes I'll write that your religion is an important support and that your godmother is involved with your consent. I won't write down anything about your ceremonies."
Watch for: notes that would read as stigmatising to a future clinician. It is working when you would be comfortable for the client to read the record [synthesis].

5. Handling problems

All guidance in this section is [synthesis] unless a source is cited.

The client will not talk about their religion. Respect it. Historical persecution and secrecy are good reasons [source: https://www.law.cornell.edu/supct/html/91-948.ZO.html]. Say the door stays open, ask only what bears on safety and health, and offer the CFI's help-seeking questions in general terms. Revisit after trust builds.
Stuck: the client sees the problem as wholly spiritual and therapy as irrelevant. Go back to the explanatory model (4.6). Find a goal that fits both frames, such as sleep, conflict in the family or grief. Frame therapy as support alongside the religious care, not a substitute.
A reading or a religious instruction conflicts with treatment (for example, advice to stop medication). Do not argue theology. Name the safety issue, involve the prescriber promptly, and, with consent, ask whether the client's godparent would support medical care continuing alongside religious care. Never advise the client on the medicine yourself.
The client asks you to attend a ceremony, endorse a practice or say whether an oricha is real. Decline warmly and explain your role. Say that their elders hold that authority, and that your job is their well-being as they live their religion.
Possession-like behaviour occurs in session, or outside any religious setting. Keep the client safe, speak calmly and orient them to time and place, and avoid restraint unless there is an emergency. Afterwards, assess using 4.9, including medical and substance causes, and consider an urgent psychiatric or medical review if the episode is unwanted, prolonged or dangerous. Ask the client (and, with consent, their house) how the episode is understood.
Risk of mislabelling. If a referrer has called normative possession psychosis, or a religious frame is masking psychosis or mania, document your reasoning against the DSM and ICD criteria (4.9), seek a second opinion, and review over time [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://busqueda.bvsalud.org/portal/resource/pt/mdl-3224955].
Overwhelm after an intense religious experience. Use standard stabilisation (grounding, sleep, routine), and help the client find meaning in their own frame (4.13). Watch for trauma symptoms and treat them in the usual way.
Suicide risk expressed in religious terms (for example, wanting to join the dead or saying an oricha demands it). Carry out a standard, full risk assessment and safety plan as for any client. Do not let the religious framing lower your vigilance or replace the assessment. Include religious supports in the plan if the client wishes.
Rupture over your reactions (to animal sacrifice, possession or spirits). Name it, own it and repair: "I think my question came across as judgement. That wasn't fair to you." Take it to supervision (4.1).
Non-adherence to sessions around religious obligations. Plan around anniversaries, seclusion periods or feast days [source: https://pluralism.org/“santería”-the-lucumí-way], and agree in advance how contact will work.
Conflict within or between houses. Houses differ, and there is no central arbiter [source: https://oncubanews.com/cuba/en-espera-de-dos-letras-del-ano]. Do not take sides or suggest another house. Help the client weigh options using their own values.
Converts and newcomers. Clients from outside Afro-Cuban communities may face family disapproval or misunderstand obligations. Explore motivation and supports without judgement, and avoid becoming their guide to the religion.
Interpreters. Use a trained interpreter, not a family member, and brief them on confidentiality and neutrality about religion. Check that religious terms are kept as the client says them, not translated into stigmatising words.
Unexplained neuropsychiatric symptoms (tremor, irritability, insomnia, memory loss). Consider environmental mercury and refer for medical assessment [source: https://ldh.la.gov/assets/oph/Center-EH/envepi/Mercury_for_Health_Providers_Hg_Final.pdf].
Signs of exploitation or abuse in any religious setting. Follow 4.15 and your local reporting duties. Separate the harm from the religion when talking with the client.

Sources

Lucumí religion: community, legal and scholarly sources

Clinical literature on Santería and possession

Cultural assessment and diagnostic criteria

Collaboration with traditional and faith healers

WHO, Implementation of the WHO Traditional Medicine Strategy 2014-2023
Gureje O, Appiah-Poku J, et al. (2020) COSIMPO trial, The Lancet: PubMed 32861306 abstract; Centre for Global Mental Health summary
Ofori-Atta A, Attafuah J, Jack H, Baning F, Rosenheck R, et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. Br J Psychiatry 212(1), doi 10.1192/bjp.2017.12. The publication year is [uncertain]: the repository gives 2019, while volume 212 is the 2018 volume.

Books and papers cited

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.
Cabrera L. El Monte, cited as discussed by Marks (above). Edition and year [uncertain: not verified].

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