María Lionza devotion (Venezuela)

1. Introduction

Version followed: the María Lionza devotion as described in published ethnography (Canals 2012; Ferrándiz 2004, as reviewed by Giobellina Brumana; Barreto 2020, as reviewed by Márquez 2021; Mejías Guiza 2026), Venezuelan state statements (Ministry of Culture, 2024) and press reporting from Sorte. The therapist's own procedures follow the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules, Kleinman's explanatory-model questions and ICD-11. This is not a therapy. It is a living popular religion with its own mediums, centres and sources of authority, and the guide describes the psychotherapist's work alongside it.

What the devotion is. The María Lionza devotion (devotees are often called marialionceros) is a Venezuelan popular religion centred on spirit possession. Scholars describe it as combining Indigenous, African-descended, Catholic, Kardecist Spiritist and other elements, and as formed over a long period and still being recreated by its practitioners [source: https://www.redalyc.org/journal/712/71267820007/71267820007.pdf] [source: https://seer.ufrgs.br/index.php/debatesdoner/article/view/153317]. Devotees hold that spirits, grouped into cortes (courts), are received in the bodies of trained mediums; at the head of the pantheon stand the Tres Potencias (María Lionza, Guaicaipuro and Negro Felipe) [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. The Montaña de Sorte, near Chivacoa in Yaracuy state, is the main pilgrimage centre, with large gatherings around 12 October [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza].

How devotees understand change. Within the tradition, healing (la cura) is described as the central purpose: consultations through mediums address health, money, love, protection and harm attributed to sorcery [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486] [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza]. These are devotees' own accounts, stated here neither as fact nor as error. For the psychotherapist, change comes from understanding the client's illness meanings, distinguishing culturally normative possession from disorder, and coordinating care with the client's chosen sources of help [synthesis].

2. Framework

There is no clinical protocol for this tradition. The framework below has two parts: the structure of the devotion as sources describe it (so the therapist can orient), and a phased sequence for the therapist's own work [synthesis].

2a. The tradition as sources describe it

Pantheon and courts. Spirits of the dead (including national heroes), mythological figures and stock types are grouped into courts such as Indigenous, African, Viking, medical, military and malandro (urban street-tough) courts. The pantheon is not fixed and keeps changing [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486] [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Mejías Guiza links changes in the pantheon to rural-to-urban migration in oil-era Venezuela [source: https://seer.ufrgs.br/index.php/debatesdoner/article/view/153317].
Mediums. Mediums are trained to receive spirits; devotees describe possession as one soul replacing another in the same body, usually with later amnesia, which the community treats as evidence that the possession was genuine. Possession ranges from calm to violent, and violent possession can involve self-injury [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Local terms for mediums (e.g. materias) and for assistants (e.g. bancos) vary [uncertain: not verified]. Devotees may call mediums "hermanos" [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza].
Centres and authority. Practice is organised around local centres, each led by its principal medium, who holds considerable authority within the group [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Ferrándiz's ethnography, as reviewed, describes repeated failed attempts at doctrinal unity and hierarchy, and frequent splits into rival centres [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. There is no single body that speaks for all devotees. Press reports mention a Federación de Espiritismo and self-described "protectors of the goddess" in public disputes; their representative role is [uncertain: not verified] [source: https://www.swissinfo.ch/spa/venezuela-declara-patrimonio-cultural-el-%27baile-en-candela%27-vinculado-deidad-mar%c3%ada-lionza/87717315]. Communities themselves judge authenticity: mediums suspected of faking trance ("plataneros") are looked down on and may be expelled [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272].
Sorte and the October gathering. The Sorte area lies within a protected area, "Cerro de María Lionza" (reported area 118.46 km²) [source: https://protectedplanet.net/307]; the managing authority and decree are [uncertain: not verified]. Devotees say visitors must show respect to the spirit owners of natural features, and that offence may bring retribution [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Thousands attend around 12 October; press reports describe public possession, self-cutting and piercing by possessed mediums, and a dance over burning embers (baile en candela) by mediums possessed by spirits of the Indigenous court [source: https://www.caymancompass.com/?p=11988] [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza]. In October 2024 Venezuela's Ministry of Culture announced the baile en candela would be entered in the national cultural heritage register; participants say the embers purify the body and free them from hatred, evil and curses [source: https://www.swissinfo.ch/spa/venezuela-declara-patrimonio-cultural-el-%27baile-en-candela%27-vinculado-deidad-mar%c3%ada-lionza/87717315]. This guide gives no ceremony procedure.
Social context. The devotion is described as historically subaltern, at times persecuted and at times used for political ends [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]; traditional curing was reportedly prohibited until the 1960s [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza] [uncertain: not verified in legal sources]. Ferrándiz links malandro spirits and trance to urban violence and the body as a site of affliction [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. Participation is reported across social classes, with press estimates of up to a third of Venezuelans taking part in some way [source: https://www.caymancompass.com/?p=11988] [uncertain: estimate not verified]. Devotees also travel to Sorte from Colombia, the Dominican Republic, Curaçao and Aruba [source: https://www.caymancompass.com/?p=11988], and the devotion is likely present among Venezuelan migrants elsewhere [uncertain: not verified].

2b. The therapist's phased work [synthesis]

Phase	Goal	Typical format	Move on when
1. Engagement and cultural assessment	Understand the problem in the client's terms; learn whether and how they take part in the devotion	1–2 sessions; core CFI, selected modules, explanatory model; informant interview with consent	Client's account of the problem, its causes and current help-seeking is clear; trust is adequate to discuss spiritual matters
2. Differential formulation	Separate normative devotion and possession from disorder; screen risk	1–2 sessions, overlapping with phase 1	Working formulation agreed with client; risks identified and planned for
3. Coordinated care	Agree goals that respect the client's devotion; coordinate with medical care and, if the client wishes, with their centre	Ongoing; standard evidence-based therapy for any diagnosed condition	Client's goals progressing; no unresolved safety concerns
4. Integration and review	Help the client make sense of pilgrimage, possession or consultation experiences; review safety around ritual dates	As needed, e.g. before and after October	Client reports coherent meaning and stable functioning

Session counts are not set by any source; adjust to the presenting problem [synthesis]. The CFI can be given 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]. Its duration is [uncertain]; the field trial found later interviews "required less time" [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].

3. Guiding principles

Alongside, not inside. The therapist does not perform, imitate or advise on consultations, possession or ritual; mediums and centre leaders hold that authority. Practical meaning: never offer to "work with the spirits" or to judge a medium's legitimacy [synthesis; scope per sources above].
Attribute, do not adjudicate. Spirits, possession, protection and sorcery are described as devotees hold them, neither confirmed nor dismissed. Practical meaning: say "in your understanding" or "for you", and record the client's words [synthesis].
No single authority. Authority sits with the principal medium of each centre, and centres often split [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272] [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. Practical meaning: ask which centre and person the client trusts; do not assume one leader speaks for all.
The community has its own standards. Devotees distinguish genuine from faked trance [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Practical meaning: ask the client (and, with consent, a trusted community member) what is expected and what is out of the ordinary in their circle.
Normative is not pathological; devotion does not rule out illness. DSM-5-TR and ICD-11 exclude trance or possession that is part of broadly accepted cultural or religious practice, and diagnose only involuntary, unwanted, distressing or impairing states [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html]. Practical meaning: assess context, control, distress and functioning, not the belief itself.
Beware instrument bias. In one study, devotees scored higher on schizotypy than Catholic and Protestant controls but showed no greater general mental-health risk, and among devotees higher religiosity predicted lower depression risk [source: https://link.springer.com/doi/10.1007/s10943-021-01367-7]. Practical meaning: do not read high scores on unusual-experience scales as illness without a cultural formulation [synthesis].
The CFI supports, but does not decide, diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Practical meaning: combine it with standard assessment.
Safety is non-negotiable and culturally informed. Press reports describe self-cutting during trance and walking on embers [source: https://www.caymancompass.com/?p=11988]. Practical meaning: assess burns, wounds and medical follow-up without condemning the practice; act on safeguarding duties where harm or coercion arises [synthesis].
Stigma and history matter. The devotion has been repressed and silenced, and also used in state identity discourses [source: https://www.redalyc.org/journal/712/71267820007/71267820007.pdf]. Practical meaning: expect clients to test whether you will mock or report them; name your respect explicitly [synthesis].
Context of violence and loss. Ethnography links spirit courts to urban violence [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. Practical meaning: screen for trauma, grief and community violence behind spiritual presentations [synthesis].
Medicines and substances stay with the prescriber. Practical meaning: never advise starting, stopping or changing a medicine; route any question to the prescriber [synthesis].
Consent governs collaboration. Practical meaning: contact a medium or centre only on the client's explicit wish and written consent, sharing the minimum needed [synthesis].

4. Intervention inventory

These are the psychotherapist's own interventions. None of them is part of the devotion, and none replaces a medium, centre or pilgrimage. Example language is illustrative unless quoted. [synthesis, built on the CFI, Kleinman and the sources cited]

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with a devotee, to notice your own assumptions about possession, self-injury, sorcery and popular religion (e.g. seeing it as "superstition", or romanticising it) [synthesis].
Steps: (1) Before the first session, write down your beliefs and gut reactions to spirit possession and public self-cutting. (2) Note what you know only from press images; the October ceremonies are heavily photographed and can stand in for everyday devotion. (3) Note class, racial and national assumptions (the devotion is associated with poorer sectors and Indigenous and African-descended imagery) [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza]. (4) Take reactions to supervision. (5) Repeat after striking sessions.
Example language (illustrative): "I'm not part of your tradition, so I'll rely on you to tell me how it works for you, and to correct me if I get something wrong."
Watch for: urges to correct the client's explanation, to ask voyeuristic questions about ceremonies, or to treat devotion as the problem. It is working when the client brings spiritual material without being prompted.

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

Purpose / when: at intake, or when cultural or spiritual themes emerge. The CFI has 16 questions across four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; cultural factors affecting current help-seeking [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. It is designed for "any clinician" in any setting [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Clinicians may reproduce it for use with their patients; translating or modifying it needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: (1) Use the official form; offer it in Spanish only if an authorised translation is available [uncertain: not verified]. (2) Work through the four domains in order, using the client's own words. (3) In the cause and support domain, leave room for spirits, sorcery, envy or protection as possible causes, and for a centre or medium as a support. (4) In the past help-seeking domain, ask specifically about consultations, centres and pilgrimages, alongside doctors and churches. (5) In the current help-seeking domain, ask what the client expects from you and whether they fear judgement or racism. (6) Summarise back and note which supplementary modules to use.
Example language (illustrative): "Some people I see also get help from a centre, a medium or a pilgrimage to Sorte. Has anything like that been part of how you've tried to deal with this?"
Watch for: brief or guarded answers when spiritual help is raised (fear of ridicule); clients presenting a "medical" story first and the spiritual one later. It is working when the client describes the problem in both registers.

4.3 CFI supplementary modules and Informant Version

Purpose / when: for depth on topics the core CFI opens. There are 12 modules, usable as add-ons or standalone, at any point in care [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Most relevant here: Spirituality, Religion and Moral Traditions; Explanatory Model; Cultural Identity; Coping and Help-Seeking; Social Network; Psychosocial Stressors; Immigrants and Refugees; Patient–Clinician Relationship; School-Age Children and Adolescents (with a minor). The Informant Version (17 questions) is for a relative or friend [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Pick modules from the core CFI's cross-references. (2) Spirituality module: map the client's involvement (attendance, whether they are or are training to be a medium, which courts and spirits matter to them, relation to Catholic practice), without asking for ritual details. (3) Immigrants and Refugees module for Venezuelan migrants: loss of access to Sorte and home centres, legal and economic stress. (4) Informant Version, with consent, when the client is in a crisis or possession-like state and cannot give an account.
Example language (illustrative): "You don't need to tell me anything private about ceremonies. I'd like to understand what your faith means to you and how it helps or weighs on you."
Watch for: family members whose religious views differ sharply (e.g. evangelical relatives opposing the devotion); use the Informant Version to hear them but do not let them define the client's experience. It is working when you can describe the client's place in their religious world in their terms.

4.4 Exploring the explanatory model (Kleinman)

Purpose / when: whenever the client attributes the problem to spirits, sorcery, a broken obligation or a spiritual calling. Kleinman, Eisenberg and Good (1978) proposed eight questions; paraphrased: what the client calls 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 it needs; the main problems it causes; what the client fears most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf].
Steps: (1) Ask the eight questions in conversational order. (2) Record the client's terms verbatim (e.g. a spirit's name, "a job done against me"). (3) Ask what a medium or centre has said, and whether the client agrees. (4) Ask what a doctor has said. (5) Identify where models overlap (e.g. both recommend rest, protection, reducing conflict) and where they conflict (e.g. stopping medication). (6) Negotiate goals that fit both where possible.
Example language (illustrative): "In your understanding, what is causing this? And what did the medium at your centre say about it?"
Watch for: fear that naming the cause aloud may worsen it; respect a choice not to name. It is working when the client can hold more than one explanation without feeling one is being taken away.

4.5 Asking about consultations without judgement

Purpose / when: at intake and when symptoms change, because consultations address health, love, money and sorcery-attributed ailments [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza] and are also a livelihood for practitioners [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486].
Steps: (1) Normalise: say many clients use several sources of help. (2) Ask what was recommended and how the client felt about it. (3) Ask about anything that conflicts with medical care, fasting, physical injury or large costs, without listing practices. (4) Ask what the client wants you to do with this information. (5) Document neutrally.
Example language (illustrative): "Is there anything they suggested that you're unsure about, or that you'd want your doctor to know?"
Watch for: reluctance driven by fear that you will report or ridicule them. It is working when the client tells you about consultations as they happen.

4.6 Distinguishing normative possession from disorder

Purpose / when: when trance, possession, amnesia, voices or visions are reported or observed. DSM-5-TR (paraphrased in secondary sources) allows that identity disruption in dissociative identity disorder may appear as possession in some cultures, but excludes disturbance that is part of culturally accepted religious practice [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; exact DSM-5-TR wording [uncertain]. Dissociative trance under other specified dissociative disorder does not apply when it is part of a broadly accepted collective cultural or religious practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. Within the devotion, mediums are trained, possession usually occurs in recognised ritual settings, and amnesia afterwards is expected [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272].
Steps [synthesis]: (1) Establish context: does the state occur in a centre or ceremony, with a recognised role (medium, medium in training), or unpredictably in daily life? (2) Control: can the person begin and end it as the tradition expects, or does it intrude? (3) The client's and community's view: is it welcomed, or do they and their centre see it as unwanted, out of place or a sign of affliction? (4) Distress and functioning: work, relationships, self-care, injuries outside ritual. (5) Look for features outside the tradition's frame: persistent fixed beliefs unrelated to the devotion, disorganisation, mood episodes, substance effects, neurological signs, trauma-linked dissociation. (6) Consult a cultural broker or, with consent, a trusted community member about what is ordinary in that circle. (7) Do not use the expected post-trance amnesia, by itself, as evidence of dissociative disorder. (8) Refer for medical and psychiatric assessment when organic or psychotic illness is possible.
Example language (illustrative): "When the spirits come, is that something you expect and welcome, at the centre? Or does it happen at times you don't choose?"
Watch for: both errors: diagnosing a trained medium's ritual trance as illness, and missing psychosis, mania or trauma-related dissociation because it is framed spiritually. Unusual-experience scales may over-read devotion [source: https://link.springer.com/doi/10.1007/s10943-021-01367-7]. Working looks like a formulation the client and, where involved, their community find accurate.

4.7 Using cultural concepts of distress

Purpose / when: when distress is expressed through idioms such as nervios, ataque de nervios, susto or harm attributed to sorcery. DSM-5-TR treats cultural concepts of distress as idioms, explanations or perceived causes, and syndromes [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]; listed concepts include ataque de nervios, nervios and susto [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] (DSM-5-TR list [uncertain]). No DSM-5-TR concept is specific to the María Lionza devotion [uncertain: not verified].
Steps: (1) Ask what the term means to the client and their family. (2) Treat it as an idiom, explanation or syndrome, not a diagnosis. (3) Map it alongside standard assessment of depression, anxiety, trauma and psychosis. (4) Use the client's term in sessions and the care plan.
Example language (illustrative): "When you say it's your nerves, what happens to you? And what do people around you think causes it?"
Watch for: idioms that mask severe depression or suicidality; and the reverse, over-diagnosing a culturally ordinary expression. It is working when idiom and clinical picture are both captured.

4.8 Risk assessment around trance-related injury and the fire dance

Purpose / when: when the client takes part, or plans to take part, in ceremonies where press reports describe possessed mediums cutting or piercing themselves and dancing over embers [source: https://www.caymancompass.com/?p=11988] [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. The cited sources report no injury data, and participants say the spirits stop them feeling the flames [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza]. Clinical risk of burns, wound infection and blood-borne infection is the therapist's inference [synthesis].
Steps [synthesis]: (1) Ask neutrally about injuries during or after ceremonies and whether they were treated. (2) Separate ritual injury within a recognised role from self-harm outside ritual: ask about timing, intent, emotional state and whether injury happens alone or in daily life. (3) If self-harm or suicidal thoughts occur outside ritual, follow standard risk assessment and safety planning, including lethal-means counselling (safe storage and removal). (4) Encourage medical care for burns and wounds, framed as compatible with devotion. (5) Check health conditions that raise risk (e.g. diabetes, pregnancy, anticoagulant use) and route medical questions to the client's doctor; never advise on medicines. (6) Plan contact before and after October if the client goes to Sorte.
Example language (illustrative): "I'm not asking you to stop anything. I'd like to know whether you were hurt, and whether you got the wound looked at."
Watch for: a client who reports injuring themselves outside ceremonies and calls it a spirit; intoxication at ceremonies; a minor taking part. It is working when the client tells you about injuries and gets treatment.

4.9 Consulting cultural brokers, informants and interpreters

Purpose / when: when you are unsure what is ordinary in the client's circle, or language and regional idiom matter.
Steps [synthesis]: (1) Ask the client whom they would trust to explain (a relative, a fellow devotee, a centre leader). (2) Get written consent stating what will be shared. (3) Use a professional interpreter for Spanish if needed, briefed on the devotion's vocabulary and on neutral translation of spiritual terms; avoid using family members as interpreters for risk topics. (4) Ask the broker about the tradition's expectations, not for ritual details. (5) Remember centres differ and often split [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]: one informant speaks for one circle.
Example language (illustrative): "Is there someone in your community you'd be comfortable with me speaking to, so I understand this better? You decide what I can share."
Watch for: brokers with an interest in the outcome (e.g. a medium who charges the client; a relative hostile to the devotion). It is working when the broker's view helps the client feel understood.

4.10 Collaboration and referral with the client's centre or medium

Purpose / when: only when the client wishes it. No formal referral programme between Venezuelan mental health services and María Lionza centres is documented in the sources cited [uncertain: not verified]. Evidence from other settings: in COSIMPO (Gureje et al., The Lancet 2020), collaborative care between traditional and faith healers and primary care in Nigeria and Ghana reduced psychotic symptoms and harmful practices more than usual care [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]; in a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication 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]. Transfer to this devotion is [synthesis].
Steps [synthesis]: (1) Ask whether the client wants their medium or centre leader involved, and what for (e.g. support, understanding the treatment plan). (2) Obtain written consent; share the minimum. (3) Approach with respect for the medium's role; explain your role and limits; do not ask to attend ceremonies. (4) Look for shared goals: safety, sleep, reduced conflict, continuing medical care. (5) If the medium's advice conflicts with urgent medical or psychiatric care, discuss with the client and the medical team; do not argue doctrine. (6) Document agreements and review them.
Example language (illustrative): "Your faith is important to you, and so is your health. Would it help if I explained to your centre what we are working on, so we're not pulling in different directions?"
Watch for: pressure on the client from either side; costs that strain the client; any suggestion to stop medicines. It is working when the client feels supported by both.

4.11 Integrating pilgrimage, possession and consultation experiences

Purpose / when: after a pilgrimage to Sorte, a first possession, a striking consultation, or a spirit message that unsettles the client.
Steps [synthesis]: (1) Invite the client to describe the experience as they understand it, without asking for ritual content. (2) Explore its meaning for identity, relationships and choices. (3) Distinguish what felt healing from what felt frightening or harmful. (4) Link insights to therapy goals (e.g. a protective spirit as a resource for coping). (5) If the experience triggered persistent distress, dissociation or trauma memories, assess and treat with standard methods, adapted to the client's frame.
Example language (illustrative): "What did that night at Sorte mean for you? Has anything changed since you came back?"
Watch for: experiences that revive trauma, especially where spirits are tied to violent deaths or street violence [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. It is working when the experience becomes part of a coherent personal story.

4.12 Safeguarding

Purpose / when: when there are signs of harm: a minor taking part in self-injury or the ember dance, coercion into mediumship, sexual or financial exploitation, sorcery accusations against a family member, or delay of urgent medical care.
Steps [synthesis]: (1) Know your local reporting duties (in Venezuela, the national child-protection law and bodies [uncertain: not verified]; elsewhere, your jurisdiction's). (2) Separate the practice from abuse: devotion itself is not a safeguarding concern. (3) Assess the specific harm, the child's or adult's wishes and capacity, and who is protective. (4) Consult your safeguarding lead. (5) Explain to the client what you must report and why, in non-stigmatising terms. (6) Never name minors in notes shared outside the service.
Example language (illustrative): "I respect your faith. My concern is only about the burns on your son, because I have a duty to make sure children are safe."
Watch for: misreading devotional practice as abuse, and the reverse: abuse justified as tradition. It is working when safety improves without the family withdrawing from care.

4.13 Family, community, migration and violence

Purpose / when: when distress involves family conflict over the devotion, migration, or community violence.
Steps [synthesis]: (1) Map family religious positions (devotee, Catholic, evangelical, none). (2) Use the Immigrants and Refugees and Social Network modules for migrants. (3) Explore loss of access to home centres and to Sorte. (4) Screen for trauma, grief and exposure to urban violence, which ethnography links to the devotion's spirit courts [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. (5) Help the client find support that fits, including devotional community where they wish.
Example language (illustrative): "Since you came here, how have you kept up your devotion? What has been hardest to lose?"
Watch for: isolation, sorcery attributions within the family, and mourning presented as spirit contact. It is working when the client has reliable support.

4.14 Addressing stigma, racism and historical suppression

Purpose / when: throughout, given reported repression and silencing [source: https://www.redalyc.org/journal/712/71267820007/71267820007.pdf] and reported prohibition of traditional curing until the 1960s [source: https://www.aljazeera.com/features/2011/11/18/the-cult-of-maria-lionza] [uncertain].
Steps [synthesis]: (1) Ask about experiences of ridicule or discrimination in health services (CFI clinician–patient relationship question). (2) Name your respect and your limits openly. (3) Correct stigmatising language in notes and referrals. (4) Avoid exoticising language in documentation.
Example language (illustrative): "Have health workers ever made you feel judged about your beliefs? I'd want to know if I do that."
Watch for: concealment and missed appointments after a clumsy remark. It is working when the client corrects you freely.

5. Handling problems

The sources on the devotion do not address clinical problems; all guidance here is [synthesis] unless a source is cited.

Client will not discuss the devotion (guardedness, fear of ridicule). Do not push. Explain why you ask (to understand all their sources of help), give an example of respectful curiosity, and return to it later. Stigma and repression are documented [source: https://www.redalyc.org/journal/712/71267820007/71267820007.pdf]. [synthesis]
Client asks whether the spirits are real, or whether you believe. Answer honestly about your role: you are not part of the tradition and do not judge it; your job is their wellbeing. Return to what the belief means for them. [synthesis]
Client asks you to judge a medium ("Is she genuine?"). Decline to adjudicate; the community has its own standards [source: https://dra.revistas.csic.es/index.php/dra/article/download/272/272/272]. Explore what makes the client doubt, and whether they feel exploited or unsafe. [synthesis]
A medium has advised stopping medication or delaying medical care. Do not advise on the medicine yourself; route to the prescriber promptly. Explore the client's view, look for shared goals, and with consent offer to explain the treatment plan to the centre. If urgent care is being delayed, act on safety and safeguarding duties. [synthesis]
Possession or trance occurs in session. Keep the space safe and calm; do not attempt to address or dismiss the spirit, and do not imitate ritual. Wait, protect from injury, speak to the client by name when they return, and ask what they need. Afterwards, assess whether this is expected for them and whether it happens outside ritual (4.6). If there is risk to life or signs of medical illness, follow emergency procedures. [synthesis]
Unclear whether it is psychosis or devotion. Hold the question open; use the CFI, an informant interview, cultural brokers and repeated observation; refer for psychiatric and medical assessment when there are features outside the tradition's frame. Avoid a diagnosis based on belief content alone [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. [synthesis]
Self-injury outside ritual, or suicidal thoughts. Follow standard risk assessment and safety planning, with lethal-means counselling (storage and removal). Work with the client's frame: ask whether their spirits or centre would support them staying safe. [synthesis]
Burns or wounds after the October gathering. Encourage medical care without criticism; check for infection; coordinate with primary care. [synthesis]
Rupture after a perceived insult to the devotion. Name it, apologise specifically, ask what felt disrespectful, and adjust. Use the CFI clinician–patient relationship question to check for perceived racism. [synthesis]
Overwhelm after a frightening spirit message or sorcery fear. Ground first; then explore the explanatory model and the client's existing protective resources (including their centre, if they wish). Screen for panic, trauma and depression. [synthesis]
Stuck therapy because the client sees the problem as purely spiritual. Agree goals both frames share (sleep, safety, relationships, work). Offer therapy as complementary to their spiritual help, not a replacement. [synthesis]
Non-attendance around ritual dates or pilgrimages. Plan ahead: schedule around October and other key dates, and agree check-ins before and after. [synthesis]
Family conflict over the devotion (e.g. religious relatives oppose it). Hear all views; do not side on doctrine; focus on safety and the client's wellbeing. [synthesis]
Exploitation or excessive costs. Consultations are also a livelihood for practitioners [source: https://periodicos.ufsc.br/index.php/ilha/article/download/16686/15275/51486]. Explore whether costs are causing hardship or fear; support the client's own decisions; act on safeguarding if there is coercion or abuse. [synthesis]
A minor is involved in self-injury or the ember dance. Follow safeguarding procedures (4.12), with respect for the family's faith. [synthesis]
Therapist's own reactions (fascination, distaste, fear). Take them to supervision; avoid asking for ritual details out of curiosity. [synthesis]
Research instruments flag the client as high risk. Interpret unusual-experience scores in cultural context [source: https://link.springer.com/doi/10.1007/s10943-021-01367-7]. [synthesis]
Client wants you to attend a ceremony or join the devotion. Decline warmly; explain the boundary of your role. Do not encourage clients or colleagues to take part in ceremonies outside the community's own pathways. [synthesis]

Sources

Web sources:

Books and articles cited:

Ferrándiz Martín F (2004). Escenarios del cuerpo. Espiritismo y sociedad en Venezuela. Bilbao: Universidad de Deusto (cited through the review above).
Barreto Ramos D (2020). María Lionza, divinidad sin fronteras. Genealogía del mito y el culto. Universidad de Los Andes / Ediciones Dabánatà (cited through the review above).
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.
Gureje O, et al. (2020). COSIMPO trial. The Lancet.

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