The Role of an Espiritista in the Treatment of a Homeless, Mentally Ill Hispanic Man

When evaluating persons who are mentally ill and living on the streets, the primary objective of an emergency psychiatric outreach team is to determine survival status—that is, do these persons present an immediate danger to themselves or to others? The outcome of the team's evaluation determines the client's disposition, which may range from support in seeking appropriate services to immediate transport to a psychiatric emergency room.

Among the factors that influence the outcome of such evaluations are the referral source, the client's mental and physical status, environmental factors, and the range of interventions available at the moment (1). The determination of survival status takes precedence over other important factors, such as the client's values or religious beliefs. Under section 9.37 of New York State's mental hygiene law, individuals who lack the capacity to protect themselves from obvious danger or who pose a risk of physical harm to themselves or others in the immediate future may be taken, with or without their consent, to a psychiatric emergency room for evaluation.

The case presented here is from the annals of the Homeless Emergency Liaison Project (Project HELP), an outreach program that conducts emergency psychiatric assessments among New York City's street-dwelling, mentally ill population (2). A Project HELP team, which consists of a psychiatrist, a social worker, and a nurse, functions as a mobile psychiatric emergency room on the streets, conducting several thousand assessments each year. The case of Mr. V elucidates the team's assessment process, its rationale for involuntary hospitalization, and its resourcefulness in providing culturally oriented services.

In response to a referral from another outreach worker, a Project HELP team began observing Mr. V, a 68-year-old single Hispanic male, in early January 1997 (identifying data have been altered to ensure confidentiality). During the next two weeks, Mr. V remained seated in the alcove of a Salvation Army building next to a wall that had a cross engraved on it. He was surrounded by bags, clothing, and blankets. His lower right leg was covered with bloodstained bandages and oozed a purulent discharge.

The team tried to persuade Mr. V to go to a hospital to have his leg treated, but he refused repeatedly, saying that his leg was okay and that the hand of God would take care of it. His condition continued to worsen, and the team believed that his leg was at risk of osteomyelitis or sepsis.

A mental status examination found Mr. V alert and oriented. Deficit symptoms observed by the Project HELP psychiatrist included depression and apathy. Mr. V's continuous mutterings about God were of a type that constituted positive symptoms of religious delusions and auditory hallucinations. His judgment and insight were considered to be extremely poor, as evidenced by his disregard for his leg and his lack of self-care and understanding of his disabilities. Mr. V was given a diagnosis of psychotic disorder not otherwise specified, but schizophrenia was ruled out. After the two weeks of observation, the team determined that Mr. V had reached the threshold for involuntary hospitalization on the grounds that he presented a danger to himself.

This case more accurately meets the criteria of the standard of "gravely disabled," a legal definition that is less stringent than "dangerousness" and allows involuntary hospitalization for a wider range of less severe clinical emergencies (3).

The hospital records indicate that on admission, Mr. V was experiencing occasional auditory hallucinations and that his affect was constricted and his mood depressed. He was given a diagnosis of unspecified psychotic disorder, with schizophrenia and organic brain syndrome ruled out. He was judged to be a danger to himself by virtue of his poor insight, and 10 mg of haloperidol per day was prescribed. Because of the pressing medical concerns, the possibility that Mr. V was suffering from a culture-bound syndrome or a trance or possession disorder was not addressed during the course of this hospital stay.

After five months in the hospital, Mr. V's leg had healed, and he was discharged to a men's shelter with a prescription for 20 mg of haloperidol per day. Immediately after discharge, however, he returned to the same alcove where he was initially observed.

Mr. V's condition gradually deteriorated. By December 1997 he was sitting in a wheelchair, surrounded by his belongings and an odor of feces and infected flesh. A physical examination indicated cellulitis and ulcer of the foot. Mr. V's thought content included positive delusions that spirits inhabited his body and that they were connected with his current health status. The team psychiatrist diagnosed Mr. V with delusional disorder, ruling out schizophrenia, organic-induced delusions, and alcohol and other drugs.

The condition of Mr. V's leg and his refusal to seek shelter despite the cold temperatures appeared to be life-threatening, but even with his severe debilitations, Mr. V again refused hospitalization, stating that the hospital didn't treat him well and that he would be better if the spirit that was in him were removed.

The Project HELP team determined that Mr. V had again reached the legal threshold for involuntary hospitalization. As Mr. V was being escorted to the transport van, a man sitting next to him advised the team that taking Mr. V to the hospital would be useless because "he believes he's possessed." This remark, in conjunction with Mr. V's own statements, his resigned state, the failure of the previous hospitalization, and the tenacity with which he remained fixed on his mutterings about God, prompted the first author to explore the possibility of employing spiritual healing in Mr. V's treatment.

Espiritismo, or spiritism, is an element of Puerto Rican culture that accepts the duality of matter and spirit and the existence of an invisible world inhabited by good and evil spirits who attach themselves to human beings and influence their affairs (4,5). Many Puerto Ricans believe that a person's physical suffering is often an indication of spiritual troubles (6); therefore, physical and psychiatric ailments are seen as requiring spiritual rather than medical intervention.

Spirit possession has a long history in psychiatry (7). It has been reported that 30 to 60 percent of Puerto Ricans from all socioeconomic groups have consulted spiritist mediums at some point in their lives. Given that there are an estimated 3.1 million Puerto Ricans living in the United States, the treatment of possession is particularly relevant (8,9). Csordas and Lewton have reviewed the literature on ritual healing and espiritismo (10).

In light of Mr. V's psychiatric evaluation and his belief that he was possessed by demonic spirits, an espiritista, or spiritist, was sought to complement the treatment provided during his second hospitalization. Locating an espiritista on the Lower East Side of New York City proved remarkably easy. A middle manager at the hospital where Project HELP is housed kept the appointment book of an espiritista, alias Julia, a 72-year-old Hispanic woman who spoke only Spanish. Julia was well known to the hospital's Puerto Rican staff and clients. For several years her average weekly caseload at the hospital had been three inpatient and five outpatient visits per week. Julia was living on her Social Security income, and she refused payment—even tips—for her services. The manager recommended Julia, explained her procedures, and arranged an appointment.

Mr. V had been hospitalized for one month at the time of Julia's visit. He had been diagnosed with dementia and his prescribed medication was 1 mg of haloperidol per day. His chart indicated that he had refused the recommended medical treatment over the course of his stay.

Julia introduced herself to Mr. V and began her trabajo, or work, while Project HELP staff observed. She began by telling Mr. V that in this life people are born rich or poor, but it is what is in their soul that determines their real value. She said that she, like him, was born poor but believed that she, like him, was a good person. She revealed that she had found solace and comfort in her belief in God.

Julia then questioned Mr. V about his beliefs and his religious practices. Mr. V was immediately engaged and answered that he had been a devout believer since childhood and had continued to attend religious services every Sunday at the hospital. He said his life had taken a turn for the worse when the trucking company he worked for closed and, being unemployed, he began drinking heavily. His wife and children left him, and he was evicted from his home.

Mr. V was convinced that his misfortunes and suffering were due to his being possessed by an evil spirit. His homelessness, his bleeding feet, and his drinking were irrelevant compared to what he considered the irreparable damage to his soul. He told Julia that he did not like the hospital, that the staff did nothing for him, and that he had not participated in any treatment, to the extent of refusing to change the bandages on his foot.

Julia then began to distinguish between Mr. V's actions and his soul. She told him that although his unemployment, poverty, and family troubles were hardships that he had endured in his life, they did not make him evil. She said she could remove the spirit that possessed him and asked for his permission to perform certain rituals. Mr. V consented, and Julia began to read from the Bible, occasionally touching Mr. V's forehead, hands, and feet with water from a small bottle. At the end of the reading and blessing ritual, she told Mr. V that he was no longer possessed. Furthermore, she instructed him to participate in his treatment, cooperate with the nurse and doctors, and begin changing his own bandages.

Julia informed the Project HELP staff that there was no need for a follow-up session, but she agreed to come back if it would comfort the team. Indeed, after Julia's visit, Mr. V became an active participant in his treatment regimen and continued taking his medication. He was discharged to a supervised residence five months later with a prescription for 1 mg of haloperidol per day. Three years later he had not returned to living on the streets.