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Temas em Psicologia
ISSN 1413-389X
Temas psicol. vol.27 no.2 Ribeirão Preto abr./jun. 2019
https://doi.org/10.9788/TP2019.2-10
ARTICLE
Religiosity/Spirituality (R/S) in the clinical context: professional experiences of psychotherapists
Religiosidade/Espiritualidade (R/E) no contexto clínico: experiências profissionais de psicoterapeutas
Religiosidad/Espiritualidad (R/E) en el contexto clínico: experiencias profesionales de psicoterapeutas
Vivian Fukumasu da CunhaI; Fabio Scorsolini-CominII
IOrcid.org/0000-0002-0963-956X. Universidade de São Paulo, Ribeirão Preto, SP, Brasil
IIOrcid.org/0000-0001-6281-3371. Universidade de São Paulo, Ribeirão Preto, SP, Brasil
ABSTRACT
Although the scientific production on religiosity/spirituality (R/S) is increasing, notably from their connection with the health dimension, this theme is practically absent in Psychology training. The objective of this study was to learn the professional reality of psychotherapists regarding their clinical experiences and the R/S dimension. Twenty-four professionals from two cities in the states of São Paulo and Minas Gerais, Brazil, with an average psychotherapy experience of 10.54 years, were interviewed individually. The interviews were transcribed in full and analyzed from the R/S literature. Such a dimension is evoked as relevant for all psychotherapists, although it has not been sufficiently addressed in their training. The exploration of R/S stems from client demands and presents at times as an important resource for intervention, while in other times hinders the development of many conditions. The recent proposals of the Psychology Councils regarding R/S are unknown by the professionals, suggesting the need for greater dialog and also the presence of such discussions in Psychology training.
Keywords: Spirituality, Psychotherapy, Clinical Psychology, Religion.
RESUMO
Embora a produção científica sobre religiosidade/espiritualidade (R/E) esteja aumentando, notadamente a partir de sua vinculação com a dimensão da saúde, tal temática revela-se praticamente ausente na formação em Psicologia. O objetivo deste estudo foi conhecer a realidade profissional de psicoterapeutas no que tange às suas experiências clínicas e a dimensão da R/E. Foram entrevistados individualmente 24 profissionais de duas cidades do interior dos Estados de São Paulo e Minas Gerais, com tempo médio de experiência em psicoterapia de 10,54 anos. As entrevistas foram transcritas na íntegra e analisadas a partir da literatura sobre a R/E. Tal dimensão é evocada como importante para todos os psicoterapeutas, embora não tenha sido suficientemente abordada em suas formações. A exploração da R/E parte das demandas dos clientes, apresentando-se ora como um importante recurso para intervenção, ora impedindo o desenvolvimento de muitas condições. As recentes proposições dos Conselhos de Psicologia referentes à R/E são desconhecidas pelos profissionais, sugerindo a necessidade de maior diálogo e também da presença dessas discussões na graduação em Psicologia.
Palavras-chave: Espiritualidade, Psicoterapia, Psicologia Clínica, Religião.
RESUMEN
Aunque la producción científica sobre religiosidad/espiritualidad (R/E) esté aumentando, notadamente a partir de su vinculación con la dimensión de la salud, tal temática se revela prácticamente ausente en la formación en Psicología. El objetivo del estudio fue conocer la realidad profesional de psicoterapeutas en lo que se refiere a sus experiencias clínicas y la dimensión de la R/E. Se entrevistaron individualmente 24 profesionales de las ciudades del interior de los Estados de São Paulo y Minas Gerais, con tiempo promedio de experiencia en psicoterapia de 10 años alrededor. Las entrevistas fueron transcritas en su totalidad y analizadas a partir de la literatura sobre la R/E. Tal dimensión es evocada como importante para todos los psicoterapeutas, aunque no ha sido suficientemente abordada en sus formaciones. La explotación de la R/E parte de las demandas de los clientes, presentándose ahora como un importante recurso para intervención, o impidiendo el desarrollo de muchas condiciones. Las recientes proposiciones de los Consejos de Psicología referentes a la R/E son desconocidas por los profesionales, sugiriendo la necesidad de mayor diálogo y también de la presencia de esas discusiones en la graduación en Psicología.
Palavras clave: Espiritualidad, Psicoterapia, Psicología Clínica, Religión.
The scientific production on the themes of religiosity and spirituality has increased significantly in recent years. Spirituality is often reported as a broad concept, a mental state, universally accessible, in which there is a quest for the sacred, linked to the cultivation of values, transcendence, and faith, and is found in all cultures (Koenig, McCullough, & Larson, 2001; Marques, 2010; Snyder & Lopez, 2009). Religiosity involves human dispositions that lead people to the ability of experiencing religious phenomena, the frequency of participation in religious cults, to the repetition of rituals and beliefs in rites, and is a term more related to specific religions and social practices (Freitas, 2014; Marques, 2010).
This distinction, although important, is also questionable, because both concepts refer to very similar experiences, feelings, and inclinations (Marques, 2010), experienced subjectively and difficult to distinguish (Lucchetti, Koenig, Pinsky, Laranjeira, & Vallada, 2015), in which both spirituality and religion are complex and multidimensional phenomena, and where any definition would limit the perspective of interest (Hill et al., 2000). In this way, based on each person's subjective experience and without the intention of discussing the specificities of these phenomena, the combined term religiosity/spirituality (R/S) will be adopted in this study, in line with the international scientific literature, especially in the field of health (Moreira-Almeida, Sharma, Van Rensburg, Verhagen, & Cook, 2016).
In a review article, Koenig (2012) points out that many studies have been confirming a positive relationship of R/S with physical and mental health, for providing aspects such as coping resources, increase in positive emotions, promoting human virtues, and encouraging social support in the face of difficulties. On the other hand, the author does not deny that this dimension may also have a negative relationship which may be used to justify hatred and aggression, control of vulnerable subjects, produce tension when it fails conforming to religious standards, and even interfere negatively in medical treatments, according to the religion. This suggests to psychologists a watchful eye on the influence that R/S may present in the lives of their patients/clients, considering that only 8% of Brazilians declare not having a religion (Instituto Brasileiro de Geografia e Estatística, 2010) and that the World Health Organization (WHO) has already included the spiritual dimension in the multidimensional concept of health (WHO, 1998).
In addition, reports show that patients/clients would like to be approached about their R/S (Lucchetti, Granero, Bassi, Latorraca, & Nacif, 2010), thus indicating a perception of care regarding their quality of health (Moreira-Almeida, Koenig, & Lucchetti, 2014). It is believed that R/S is an inseparable part of culture and permeates several aspects of social life, so much so that the Brazilian Federal Council of Psychology (FCP), in 2013, presented the Technical Notes on the Position of the System Council of Psychology to the issue of "Psychology, religion, and spirituality", in which are clarified the condition of secularity, the importance of religion, and the possible interfaces of Psychology with religion and spirituality, based not only on the professional's clinical performance, but on their insertion in the most diverse scenarios.
Having clinical performance as a guide, with it still being considered the most traditional activity of the Psychology professional, themes linked to R/S might present themselves in this context. Supported by the mentioned literature, which also prioritizes clinical performance, it is thought that considering these issues in psychotherapy is a way of respecting the patient/client's need for expression before their social and cultural context, which requires from the professional specific skills regarding attitudes, knowledge, and therapeutic management (Vieten et al., 2013). In 2016, the Regional Council of Psychology of São Paulo (RCP-SP) published a collection committed to discussing many aspects related to R/S, entitled "Psychology, Secularism, and their Relationship with Religion and Spirituality", pointing out, once again, the importance of the topic within Psychology. The emphasis to these documents disseminated by the FCP and RCP-SP is due to the fact that these are results of current discussions on the subject in forums composed of professionals from different approaches, providing important guidelines for the professional practice, in a movement swifter than the notes available in academic materials on the theme and their management on the work in Psychology. Thus, it is considered that these documents in question provide significant considerations for the practice, supporting a psychological assistance that is, in fact, secular and respects the broad pantheon of religious and spiritual listening spaces promoted by Psychology.
According to Freitas (2014), for many newly trained psychologists, issues related to R/S introduce insecurity because they feel unprepared to deal with the matter, showing fear of incurring in ethical problems. On the other hand, experienced professionals, precisely because they have encountered these issues often, seem to develop a mode of action from studies developed by their own account, or from a kind of conciliation between what they learned and their own religious/spiritual education.
The literature refers to a gap in Psychology training regarding the R/S issue, at both the national and international scopes (Freitas, 2012), almost as if the subject could not be mentioned, or considering only the psychopathological issues. That is, Psychology training seems to not prepare the professional for approaching the subject, be it to integrate it into the health condition or to acquire skills to handle the multicultural context (Vieten et al., 2013). In the specific domain of psychotherapy, prioritized in this study, the scientific literature is still scarce in the Brazilian scenario (Neubern, 2010; Scorsolini-Comin, 2015), in contrast with the international literature (Pargament, Lomax, McGee, & Fang, 2014). This fact may be explained by both specific R/S issues as well as by the difficulty in maintaining a psychotherapy research tradition in our country, given the emergence of other areas more related to measurements, such as psychological assessment and psychometry.
A difficulty in the clinical field is reported by Peres, Simão, and Nasello (2007). These authors understand that psychotherapy has guidelines and settings that are characteristic of the process, but that the different employed and available approaches provide biases that may or may not favor the adjustment of the R/S theme in its interventions. According to a review by these authors, some evidence suggest that psychotherapy is effective whether or not it includes the religious/spiritual content, and that the inclusion of R/S also favors positive results, so patients/clients who regard the spiritual life as relevant to the understanding of the problems demonstrate a preference for therapists who feel comfortable in discussing these issues in the therapeutic space.
Although the practice of Psychology is secular, this does not imply not studying the relationship that R/S has with health and its expression in human behavior (FCP, 2013; Marques, 2017). From the panorama exposed, the objective of this study was to get to know the professional reality of psychotherapists regarding their clinical experiences and the R/S dimension. From this central objective, we seek to identify situations in which R/S may be present in psychotherapy, possible interventions, and therapeutic management, as well as the importance that these psychotherapists attribute to this dimension and their knowledge concerning ethical issues related to the theme. The goal of the study is to contribute to the research on R/S, with an emphasis on psychotherapeutic activity as a field of expression of these issues that compose the current notion of health.
Method
Type of Study
This is an empirical and exploratory study supported by the qualitative research approach and approved by the Research Ethics Committee of the Federal University of Triângulo Mineiro.
Participants
Twenty-four clinical psychologists with at least three years of experience in psychotherapeutic practice participated in this study. This criterion was employed to broaden the access to different professional repertoires and also due to the possibility of the emergence of the R/S theme in clinical practice. We did not delimit inclusion criteria regarding gender, age, income, time since graduation, or clinical approach. The participants were recruited in two medium-sized cities, one in the State of São Paulo and the other in the State of Minas Gerais, Brazil. The number of interviewed participants followed the recommendations of sampling by saturation, which recommends ending the interviews after reaching the objective of the study or until exhaustive repetitions in the answers of different participants are verified (Turato, 2013). Table 1 presents the main characteristics of the sample regarding gender, age, marital status, average time as a psychotherapist, theoretical approaches to the care, and religious or spiritual belief, as reported by the participants.
Instruments
We employed semi-structured interviews, applied face-to-face and individually with each of the participants, and containing questions about their experience as psychotherapists, as well as personal and professional experiences related to the theme.
Procedures
Data Collection. The participants were initially recruited through the contact of the researchers in their social media as well as from interviews carried out, using the "snowball" technique (Turato, 2013), where the psychologists themselves indicated other professionals for participation. The data collection took place after the approval and signature of the Free and Informed Consent Form, with the individual application of the semi-structured interview script. All interviews had ethical consideration in order to preserve the comfort and convenience so the professionals could express themselves freely. The audio of the interviews was recorded and later transcribed in full and literally, constituting the analytical corpus of the research. The participants of the survey were identified in this study by letter S and, subsequently, by numbers from 1 to 24, thus preserving their identities.
Data Analysis. The data analysis was performed following the content analysis procedures proposed by Bardin (1977/2011). To build the analytical categories, the three phases proposed by the author were applied: pre-analysis, exploration of the material, and treatment and interpretation of the results. In a first moment, a vertical analysis was performed, which entails an individual exploration of the material, one interview at a time. In a second moment, we proceeded to the horizontal analysis, using the entire corpus, listing the points of similarity and differences among the statements of the participants, allowing a picture of the visions shared or not among them, in order to enable a more comprehensive panorama of the set of interviews. After the exploration of the entire corpus (set of interviews), we constructed the categories a posteriori, that is, the categories were produced based on the contents of the statements, their recurrence and importance, in addition to the frequency in which they were mentioned. We chose not to emphasize only the frequency of mentioning, as traditionally occurs in content analyses, but the importance attributed by the group to the aspects that composed the analytical categories. The interpretation of the data available in the different categories was based on works on the topic of R/S at its interface with psychotherapy (e.g., Dal-Farra & Geremia, 2010; Daniels & Fitzpatrick, 2013; Dein, 2013; Freitas, 2014; Freitas & Piasson, 2016; Henning-Geronasso & Moré, 2015; Koenig, 2007; Marques, 2017; Neubern, 2010; Scorsolini-Comin, 2015; Vandenberghe, Prado, & Camargo, 2012).
Results and Discussion
Given the responses of the participants, it was possible to identify that R/S is important in people's lives and permeates the psychotherapeutic relationship, albeit indirectly. In this sense, there are also demands which require religious/spiritual issues to be discussed, as well as psychotherapeutic focus, which does not inhibit the professionals from working on the subject, even though, in most cases, their training has been deemed deficient regarding this matter. From the analytical process, we produced four categories which are detailed and discussed next: (a) The importance of R/S for psychotherapists; (b) Demands and contexts presented by the patients/clients; (c) Clinical interventions related to R/S; and (d) Knowledge in training and ethical issues.
The Importance of R/S for Psychotherapists
Unlike in the past, when mental health pro-fessionals denied the religious/spiritual aspects, considering R/S old-fashioned and pathological (Moreira-Almeida, Lotufo, & Koenig, 2006), nowadays, for the professionals interviewed, it constitutes an important dimension in people's lives, which does not necessarily condition it as being important in their own lives. For them, R/S may make itself present because it is a constituting aspect of the human being, often employing an argument of authority for its recognition from the scientific viewpoint, as expressed in the following excerpt: "... the World Health Organization regards it as a variable to be considered along with the classical others, to understand the individual as healthy" (S24). In this condition, the professional view that respects the human being from the comprehensive perspective recognizes the importance of R/S as relevant to people's health (Dal-Farra & Geremia, 2010), positively implicating the patients/clients' clinical care (Koenig, 2007).
For psychotherapists, this dimension "gives greater strength in times of tension" (S2), "is important because it helps us, helps people to give meaning" (S5), "organizes the lives of most people" (S7), "help following-up in psychotherapy" (S19), so that it is not present in the same way and intensity: "some people need religion more than others" (S9), "one seeks religion in deprivation" (S13). Such views are shared in the literature when we recognize R/S as a favorable condition, which provides the promotion of resources to human development such as, for example, conditions of coping and resilience (Vandenberghe et al., 2012).
For Daniels and Fitzpatrick (2013), R/S is essential for healing, growth, and for creating a world perspective. Upon talking about the subject, the message that patients give to psychologists is significant: that to disregard the importance of this dimension is also to reflect the position of a relationship specialist who cannot relate with those who think differently, which significantly impacts the profession since it begins to feed a distrust and discredit about the psychologist (Neubern, 2013). In this way, we consider that the unanimous recognition of the importance of R/S among the interviewees transmits a message that psychotherapy is a space to talk about everything, enabling these professionals to handle religious/spiritual feelings and behaviors, which does not necessarily mean having skills and knowledge for this handling.
It is also emphasized the importance of psychologists themselves paying attention to the role that R/S has in their own lives (Scorsolini-Comin, 2015), as this would influence the way that the professional recognizes and integrates the other's R/S in psychotherapy, given that personal values reflect on the professionals (Peteet, 2014). Although R/S introduces positive and constructive aspects in the lives of the subjects, there is evidence that religious/spiritual doubts are common among individuals or religious/spiritual groups, and that questionings may be common in the structuring of faith (Dein, 2013).
R/S does not always emerge as a category that promotes health and well-being. An example of this is the concept of religious/spiritual coping (Panzini & Bandeira, 2007). In the search for a cure, the elements of R/S that compose the coping may produce positionings in which people subjugate from the data of the reality, attempting a change according to their own will. This posture may lead to detrimental/negative consequences for the individual such as questioning God's existence, love, or acts, delegating to God the solving of problems, feeling dissatisfaction/discontentment in relation to God or the frequenters/members of a religious institution, or redefining the stressor as divine punishment or forces of evil. Given the positive or negative use that R/S may have, it is expected that such questionings involving R/S emerge in the clinic, which is installed as a privileged space for promoting senses (Oliveira & Junges, 2012). With the intention to get to know and better discuss the manifestations of R/S in the context of psychotherapy, we characterize the next category.
Demands and Contexts Presented by the Patients/Clients
Indeed, themes involving R/S permeate the context of psychotherapy. Even if superficial and trivially, all the interviewees perceive this discourse as being present, which is pertinent to the condition found in Brazil, a country composed of a mosaic of different ethnicities, cultures, and religions which has a population with strong religious/spiritual ties (Dal-Farra & Geremia, 2010). For the majority of the participants (n = 19), the subject has arisen in a deeper context and is substantially present in the lives of patients: "I have had patients who regard this religious institution as a prescription of life, they support theirs, really frequent, they bring this language" (S17). According to Freitas (2014), this seems to be a common reality, because both newly trained psychologists and more experienced professionals report that the religious/spiritual issues are frequent in the discourse and experience of their patients. However, for the interviewees in question, some situations were more frequent, such as the presence of conflicts involving the R/S and the discourses and demands associated with the mediumistic phenomenon.
Among the conflicts involving religious/spiritual aspects commonly observed by the participants (n = 9), there was diversification in forms and contexts, such as, for example, sexuality: "she came because of issues with sexuality, and there was a big confusion in her mind about what religion brings regarding sexuality" (S5). The moral conduct in the face of the prescriptive reading that religion does also raises questionings by the patients:
He felt much anguish in wanting to separate from his wife or wanting to get more tattoos, of wanting to go to parties and not being able to: oh, so have I made a wrong choice in entering this religion? (S19)
Abandonment, questionings, and change of religion were also manifested: "I remember us working hard on the issue of how much she really wanted to be in that religion, of how much that religion was good for her, how much it was a desire of hers" (S18). These conflicts directly reflect forms of influence that religion has on the psyche, preventing a range of behaviors and choices of the patients. However, Oliveira (2012) notes that behind religions there is a "basic ethics" which all people seem to need, but this does imply experiencing it absolutely. The author also underscores that the use that religious groups make of their prescriptions progresses in a movement that goes according to the needs of the believers and that they may present practices that are different than their propositions. In this way, R/S shows to be a dimension tangled with so many other parts that compose the individual, and, in some cases, of important attention in the psychotherapeutic scenario. Dein (2013) confirms that conflicts are common and pertinent when it comes to this subject, possibly raising negative feelings such as anger, confusion, tension, guilt, and leading to emotional distress, anxiety, and depression.
Discourses and demands including the mediumistic field such as visions, embodiments, influence of spirits, and contact with spiritual entities are also part of this context experienced by the interviewees (n = 5):
Patients that arrive, that you realize there is a condition of depression, even psychotic, but they arrive with the idea that it is the influence of an evil spirit, right? And it isn't the case, you realize there is an issue of psychopathology. (S16)
Or "cases emerge of people who have visions, mainly that, visions, sensations, they have dreams, they bring situations of actual experiences" (S10). Bairrão (2016) highlights that the role of Psychology and the psychologist is not to validate, refute, or question the veracity of the religious/spiritual phenomenon or experience itself, but the way it reverberates in the lives of the subjects. To Moreira-Almeida et al. (2014), it is important to be careful to avoid assumptions based on social affiliation or origin, because the same religion may have different groups, practices, interpretations, and behaviors, especially regarding a possible mental disorder. In this way, the psychotherapeutic focus remains ethical in taking into consideration the subjective experience and maintains the relationship's respect when considering and going into such issues with patients.
However, psychologists must be aware of and attentive to some important criteria and considerations upon differentiating a religious experience from a mental disorder (Menezes & Moreira-Almeida, 2009). For Vergilio and Holanda (2010), it is important to also get to know more about mediumistic practice and its relations with the psychotherapeutic treatment, for example, because they may offer resources that enable the psychologist to explore and recognize symbols integrated to the patient's life, revisiting, many times, the individual trajectory itself. This recommendation extends to other religious phenomena, of other religions, since knowing such practices and/or rituals ends up approximating the understanding and, consequently, the patient. This does not mean that psychotherapists must have training and master all the religions that exist, but they can exercise this knowledge through contact with their patients.
Faced with the demands and contexts presented by the patients, some negative experiences of R/S are illustrated by statements such as the following: "preventedthe subject from other things that he can do" (S1), "the use she made of it was very repressive," (S2), "there are situations, which I believe are the most serious, of spiritual leaders who do not agree with psychological treatment" (S6),
I've had a lot of patients extremely destructible, of sometimes transforming the religiosity, the spirituality, revert in the sense of bringing a notion of more destructiveness, a more narcissistic aspect, of saying: Look, my world is better than yours. (S12)
This negative view is also observed in the literature by Murakami and Campos (2012), according to whom, sometimes, certain religions may become rigid and inflexible, being asso-ciated with magic and resistance thinking, which may hamper the patient's treatment in psychotherapy or the use of medication, for example, are prohibited. Although R/S may be associated with psychopathology, studies indicate that this relationship is weaker compared to the positive associations between R/S and mental health (Koenig, 2007).
Whilst a positive experience, a very important aspect presented was how R/S promotes a better health condition, which the psychotherapists reveal: "religion is a great support, depending on the beliefs the patient has" (S20), and that "people who have religiosity, who have spirituality, and the way they engage with the treatment, the way they respond, how this is different" (S10), where "I see that patients who have this faith have a prognosis many times better" (S19). This relationship is seen as R/S being a protection factor that contributes to preventive or moderate behaviors such as the non-use of alcohol or drugs, compliance with medical recommendations, and the incentive for regularly practicing physical activities (Murakami & Campos, 2012). In the face of the contexts and demands that present themselves to these professionals, the next category identifies ways that such psychotherapists interact therapeutically with these issues.
Clinical Interventions Related to R/S
According to the study by Elkonin, Brown, and Naicker (2014), psychologists should not introduce subjects regarding R/S in therapy, because it may imply the imposition of their perspectives on the patient/client. However, other studies in health literature indicate that patients/clients feel considered as a whole when questioned about their R/S and would the theme to be approached (Lucchetti et al., 2010). For this, instruments are already available that can help to inquire about this issue, such as the FICA and the Royal College of Psychiatrists Assessment (Moreira-Almeida et al., 2014). The DSM-5 itself (American Psychological Association [APA], 2014) already contains references on how to do this investigation.
For the interviewees in question, it is frequent to ask the patients' religion (n = 11), be it in the medical history itself "I ask about the religion in an initial interview, for example" (S11) or at some moment during the process: "it is not a question I normally ask in the initial interview, because sometimes I think that we have to be careful, even as clinical professionals, not to induce a religious necessity in the treatment". For other professionals (n = 6), this is an issue that is not present nor important for the patient's treatment, unless it is brought up by them: "it is not a practice of mine, this is why I say, unless this emerges as something relevant in the therapeutic context or something that information about religiosity may complement something that I'm thinking" (S24). For the other professionals (n = 7), this is a piece of information that eventually comes up spontaneously, so much so they learn it without asking about it: "they say, I think in the first or second encounter, inevitably, something ends up coming up" (S6).
More important than whether or not they ask about the patient's religion, this action denotes a relevant and useful piece of information for the professional. For those who ask about the presence of religion, the intention of inquiring about this issue offers a notion of the beliefs, values, and world perspective that circumscribe the patient: "it can provide me with data about that person, about the way they see the world, see themselves, see others, and how they relate to this" (S4). Also, it also allows a language that is more intimate, taking into consideration the patient's cultural issues: "it helps me in how I'm going to address something, some subject, even in terms of respect" (S14).
This posture is sustained and shown to be relevant since it allows getting to know the importance and view of the patients regarding religious/spiritual beliefs, which is being encouraged when considering R/S part of the subject's multicultural condition (Crook-Lyon et al., 2012). This does not mean that the professionals who do not ask about their patients' religion disregard this dimension. We do not prescribe here a single practice, even because it is known that different psychological approaches lead to different psychotherapeutic interactions. However, international studies in the literature already consider a form of psychotherapy oriented towards R/S stemming from various well-known psychological approaches (Sperry & Shafranske, 2005), which indicates its scientific feasibility and the integration of this dimension in clinical practice, even if it is still a little-present reality, often explored and/or presented in academic curricula.
Seeing that R/S may be present in the clinical context, be it due to the professional's inquiry or spontaneously from the patients, some professionals use R/S as a resource or therapeutic strategy to guide interventions, when necessary. The primary strategy used by them was the encouragement of religious/spiritual practices (n = 6) as a resource that may stimulate the development of positive aspects, also known as behavioral activation:
For example, a fairly depressed patient, when she came to me, she was no longer leaving the house, she had a lot of difficulties, she had lost her job, and she had a depression that had been there for a long time. One of the things that she really liked to do and had stopped doing was to frequent the church near her house. So great, this week, this is part of the cognitive therapy, right? So great, this week we will attempt that you go to church once. You may sit all the way to the back, you may sit near the door, but you go once to church. This was something she used to do, that she liked to do, that she had pleasure doing, that was important, and that she had stopped doing. (S23)
Through this report, one may observe that the patient's own R/S serves as a resource connected with the promotion of health, which obviously must be tied to how each approach may handle the event, be it as an aspect linked to a behavior of active search for well-being, such as the one reported in the previous excerpt, or even as a way of assigning meaning to life, in a more individual and intimate perspective. For religious patients, this type of request may be much more attractive and executable (Vandenberghe et al., 2012). Henning-Geronasso and Moré (2015) also identify that this is a possibility to work with the patient's religious/spiritual content. Also, the authors identify that the discursive pathway, through the use of metaphors and parables and of subjects that circulate the theme, may deepen the comprehension and understanding and even soften conducts or positionings, while always respecting the patient's choice and belief. In this sense, the participants (n = 5) also mention similar interventions:
I have some patients who are very Catholic, devout, active, and sometimes the use of a parable from the Bible helps me to work some themes, right? Like, you know, using the story of Job, I will talk about the ability to adapt and resilience, right? About resignation, understanding, so I often approach it in the sense of favoring a theme, about a specific experience. Sometimes what I ask the person, regardless of their religion, is to bring an excerpt from a book from their religion that represents their current life experience, this is a great thematic trigger in my work... (S16)
The discourses with religious/spiritual contents point to the presence of a system of beliefs and behaviors in which the patients' R/S may be used to access their universe, given that the subjective sense in the religious/spiritual experience also aggregates, in a complex manner, the personalization of social, historical, cultural, and institutional processes that exceed the experience (Neubern, 2010). However, it is important to pay attention to the use of this symbolic language from religious/spiritual contents so not to conduct an immoral posture, considering that professionals themselves suffer interference of their values in their patients/clients' process of growth (Pinto, 2013), and that the use of this language may lead to the professional's personal interpretation and not necessarily to that of their patient/client. According to Neubern (2010), one must seek an attitude of acceptance and sensitivity when integrating these experiences into psychotherapy, aiming at a pragmatic attitude in which the psychological theory works in the articulation of the processes that originate from the experience of the sacred.
Although meditation and relaxation are practices associated with some religions, especially those of oriental origin, mindfulness meditation aims to develop a deeper insight of the mental processes, which implies in paying attention, without judgment, to all the stimuli in the internal and external environments (Germer, 2016; Snyder & Lopez, 2009). It has been considered in studies that the effects and use of this type of meditation or relaxations exert significant effects on cerebral physiology, influencing and constituting a potential to establish physical and mental health (Dal-Farra & Geremia, 2010). In the clinic, some psychotherapists (n = 5) are already aware of these contributions and make use of this resource, but in a manner detached from the R/S dimension:
I'm talking about meditation as a technique for you to be able to empty your mind. Many times meditation is associated with Buddhism and other religions, that is not what I'm talking about here. So I highlight in yellow, as yellow as my t-shirt, just to make it clear for the other person that the dimension of meditation, when I bring it, I bring it disassociated from religion. Then I bring it because it makes sense in that person's life. (S5)
One may observe, from this excerpt, the attempt to present meditation as a technique validated by science (Germer, 2016) and to distance it from the religious field, perhaps signaling fears in ethical terms when this approximation occurs. This concern also becomes clear when some interviewees (n = 4) narrate that this dimension has never been used as a resource or therapeutic strategy due to their professional unpreparedness to conduct such a discussion or intervention, which is corroborated by the literature (Henning-Geronasso & Moré, 2015; Plante, 2007) and will be further developed in the following category.
Knowledge in the Training and Ethical Issues
The field of study involving R/S is not present in most undergraduate courses in Psychology in Brazil, nor in other disciplines in health. Such a reality may be identified when only one of the interviewees reported that R/S was addressed in their Psychology training:
Introduction to theological thinking, which is a wonderful discipline, was very, very good. We usually think that it seems more like, how do you say it? Like a requirement, that discipline that will be, but no, it was one of the best disciplines that I had, which questioned many religiosities, which questioned a lot the way of seeing spirituality, in a good way, you know? (S15)
Under this condition, it is important to emphasize that this professional's training institution has, at its base and foundation, a religious tradition, which may have favored so this theme was put into discussion as a component of the curriculum. The other professionals reported a total absence of the theme or superficiality when it was addressed within other issues: "yes, there were some disciplines that mentioned those issues, but, like, very superficially" (S22). They also speak more radically regarding the presence of the subject: "We did not have many reflections about it, nothing close to that, it is even seen as kind of a forbidden subject, you know?" (S19), "at the college I went to it was almost like I had one, a contradiction, right? As if religion were something that had to be combated by the psychologist" (S14), "the whole dialogue on religiosity was very much in the sense that we respect it, we understand, we know it's important, but it is not a focus of the work" (S23).
Similar situations were also identified in the study by Henning-Geronasso and Moré (2015). Internationally, R/S has also been kept out of the curricula, and the ethical difficulties and boundaries related to the theme are often considered (Elkonin et al., 2014; Plante, 2007). In Brazil, the FCP and the RCPs are responsible for regulating and discussing issues related to the role of the psychologist. In recent years, there has been an effort to publish and edit newsletters, documents, and manifests, among other media instruments, regarding R/S (Freitas & Piasson, 2016), but it still seems not to be enough to reach the professionals. In the case of the interviewees, only two reported having some knowledge about the ethical issues involving the relationship with R/S.
Other psychotherapists (n = 18) know the basic issues laid out in the Code of Professional Ethics of the Psychologist (FCP, 2005), emphasizing that: "the issue of not mingling too much, not influencing, not indicating to the other person" (S13), "There has to be impartiality, respect, and at the same time a non-involvement of a religion in the treatment, in psychotherapy" (S12), "not impose a belief of yours to the patient, I remember there is something written more or less about this" (S19), and "neutrality, non-interference, the respect of the other person's belief, just as I need to respect their skin color, sexual orientation, any type of culture, because religiosity is part of the culture" (S24). On the other hand, they do not indicate any awareness about the Technical Notes of the Position of the System Council of Psychology (FCP, 2013) or the publication of the "Psychology, Secularism, and their Relationship with Religion and Spirituality collection by the RCP-SP (2016), for example. The reference to the code of professional ethics as a model of conduct regarding R/S, although it is an advisable posture, may also hinder a real approximation with the theme and the concerning their incorporation into professional practice.
This reality reflects how much there is a distance between the advice and practice of psychologists. This is confirmed by the fact that none of the participants had formally consulted the councils regarding the theme: "I didn't feel the need. I felt that I was able to handle the ones I had, I didn't have to make any consultation" (S7), and also due to bad experiences with the council when there was a search for more information or even formal consultations about procedures to be adopted.
Even though university education has disregarded R/S as a more indepth subject, failing to present the multiple positive and negative influences in which this dimension may be present in people's lives (Koenig et al., 2014), the professional experiences of psychotherapists signal the importance of this inclusion in the training, even for a better performance of the professional with regard to the subject, also covering the current and recent ethical issues that are postulated by the FCP and RCPs. The APA and the World Psychiatric Association (WPA) also recommend the need to incorporate the R/S dimension into comprehensive health care, a movement consistent with the proposal of the WHO.
It is worth emphasizing that the Position of the System Council of Psychology is relatively new, dating from 2013, so are the "Recommendations for the professional performance of psychologists" upon dealing with the theme, a product of the Synthesis Report of the Discussions of the State Seminars in Psychology, Secularism, and their Relationship with Religion and Spirituality, promoted by the RCP-SP in 2015. In this manner, for the practicing professionals, it is recommended a closer follow-up of what guides the ethical performance on the subject and has been promoted by the councils, which ensures even more possibilities for action in the practical experience with their patients. That said, we recall the condition that the Brazilian culture has a wide religious/spiritual diversity, where R/S is very present (Marques, 2017), and that the integration of this dimension requires ethical professionalism and high quality of knowledge and skills to align the information collected about the beliefs and values with therapeutic effectiveness (Peres et al., 2007).
Final Considerations
In the face of the reality investigated, it is possible to perceive the importance of R/S in people's lives and how the theme ends up permeating the therapeutic relationship, sometimes presenting itself as a significant source of resources and interventions, and sometimes preventing the development of many conditions in patients. R/S has been gaining ever more space in the scientific field due to its positive relationship with physical and mental health (Koenig, 2012) and for integrating the concept of health proposed by the WHO (1998) as well as part of the multicultural condition of the subjects (Crook-Lyon et al., 2012).
However, the contact of health professionals with the subject in their university training, including psychologists, is still flawed (Freitas & Piasson, 2016). This gap raises questionings about the practical work of psychotherapists regarding the subject, presenting as an important aspect mentioned by the interviewees. Even though in practice psychotherapists demonstrate relating to the theme from a general condition provided by their training, presenting a welcoming posture and consideration for the patient's subjectivity (Neubern, 2010), they would very likely benefit from the knowledge that has been developing in this area. This inclusion of the theme in training also allows discussions that end up being considered as "taboos", thus contributing to minimizing radicalisms and prejudice.
Among the limitations of this study, we mention the fact that the access to the professionals occurred only in two cities. Although the cities are in different states, their regions are geographically and economically close so, consequently, the participants may have certain aspects of professional training somewhat coincidental, both regarding the universities of origin of the interviewees and the socioeconomic and cultural characteristics of their patients. The investigation of professionals from other regions of the country may add relevant data, notably when we incorporate areas in which there is a strong appeal of religion for cultural and touristic reasons, for example.
From this study, there opens the possibility that other investigations are conducted, possibly with the addition of other instruments or even studying the patients/clients who come to clinics seeking guidance, thus understanding the real demand for the R/S approach o in the psychotherapeutic space. The investigation of other contexts of activity, in addition to the clinic, may bring significant results and contribute to the incorporation of the theme in other forms of listening and care promoted in health, educational, and organizational equipment, for example. Still in the clinical scenario, one must consider the possible specificities of the approaches employed, establishing parallels and comparisons, given that the majority of studies on R/S and Psychology delimit epistemological positionings clearly. In all these possibilities, acknowledging our cultural context of reference, of a strong influence of the R/S dimension in our cultural life, seems to be a condition for conducting such studies at the national level. Promoting a dialog with the universities and the councils seems to be a compelling recommendation.
We emphasize, at last, that it is not about overvaluing the R/S dimension in clinical practice (Scorsolini-Comin, 2015), but recognizing the importance of the impact of religiosity and/or spirituality on the mental health of patients/clients, observing the potential for promoting well-being and physical and mental health, as well as conflicts and psychopathology. In this process, it is of utmost importance to respect the interests and wishes of the patients/clients. For this to happen, discussions and knowledge about the subject are essential, be it in professional training or by means of advances made in studies that allow to better get to know the reality, suggesting possible practices that do not breach the ethical condition of the relationship and that, fundamentally, may be accessed by the professionals and incorporated into their practices in a continuous, reflexive, and respectful manner.
References
American Psychological Association. (2014). Manual diagnóstico e estatístico de transtornos mentais - DSM 5 (5th ed., M. I. C. Nascimento, P. H. Machado, R. M. Garcez, R. Pizzato, & S. M. M. da Rosa, Trans.). Porto Alegre, RS: Artmed. [ Links ]
Bairrão, J. F. M. H. (2016). Psicologia e práticas espirituais: Diálogos e fronteiras. In Conselho Regional de Psicologia de São Paulo, Na fronteira da Psicologia com os saberes tradicionais: práticas e técnicas: Vol. 2. Psicologia, laicidade e as relações com a religião e a espiritualidade (pp. 21-28). São Paulo, SP: Conselho Regional de Psicologia de São Paulo. [ Links ]
Bardin, L. (2011). Análise de conteúdo (L. A. Reto & A. Pinheiro, Trans.). São Paulo, SP: Edições 70. (Original work published 1977) [ Links ]
Crook-Lyon, R. E., O'Grady, K. A., Smith, T. B., Jensen, D. R., Golightly, T., & Potka, K. A. (2012). Addressing religious and spiritual diversity in graduate training and multicultural education for professional psychologists. Psychology of Religion and Spirituality, 4(3),169-181. doi: 10.1037/a0026403 [ Links ]
Dal-Farra, R. A., & Geremia, C. (2010). Educação em saúde e espiritualidade: Proposições metodológicas. Revista Brasileira de Educação Médica, 34(4),587-597. doi: 10.1590/S0100-55022010000400015 [ Links ]
Daniels, C., & Fitzpatrick, M. (2013). Integrating Spirituality into Counselling and Psychotherapy: Theoretical and Clinical Perspectives. Canadian Journal of Counselling and Psychotherapy, 47(3),315-341. Retrieved from http://cjc-rcc.ucalgary.ca/cjc/index.php/rcc/article/view/2501 [ Links ]
Dein, S. (2013). Religious doubts: Implications for psychopathology and psychotherapy. Bulletin of the Menninger Clinic, 77(3),201-221. doi: 10.1521/bumc.2013.77.3.201 [ Links ]
Elkonin, D., Brown O., & Naicker, S. (2014). Religion, Spirituality and Therapy: Implications for training. Journal of Religion and Health, 53,119-134. doi: 10.1007/s10943-012-9607-8 [ Links ]
Federal Council of Psychology. (2005). Código de Ética Profissional do Psicólogo. Brasília, DF: Author. [ Links ]
Federal Council of Psychology. (2013). Posicionamento do Sistema de Conselhos de Psicologia para a questão da Psicologia, Religião e Espiritualidade. GT Nacional Laicidade e Psicologia. Brasília, DF: Author. [ Links ]
Freitas, M. H. (2012). Religiosidade na experiência de atuação psi: sintoma ou saúde? In M. H. Freitas & G. J. Paiva (Eds.), Religiosidade e cultura contemporânea: Desafios para a Psicologia (pp. 191-229). Brasília, DF: Universa. [ Links ]
Freitas, M. H. (2014). Religiosidade e saúde: Experiências dos pacientes e percepções dos profissionais. Revista Pistis e Práxis: Teologia e Pastoral, 6(1),89-105. doi: 10.7213/revistapistispraxis.06.001.DS05 [ Links ]
Freitas, M. H., & Piasson, D. L. (2016). Religião, religiosidade e espiritualidade: Repercussão na mídia e formação profissional em Psicologia. Esferas, 5(8),103-112. doi: 10.19174/esf.v1i8.7909 [ Links ]
Germer, C. K. (2016). Mindfulness: O que é? Qual sua importância? In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness e psicoterapia (2nd ed., pp. 2-36). Porto Alegre, RS: Artmed. [ Links ]
Henning-Geronasso, M. C., & Moré, C. L. O. O. (2015). Influência da religiosidade/espiritualidade no contexto psicoterapêutico. Psicologia: Ciência e Profissão, 35(3),711-725. doi: 10.1590/1982-3703000942014 [ Links ]
Hill, P. C., Pargament, K. I, Hood, R. W., Jr., McCullough, M. E., Swyers, J. P., Larson, D. B., & Zinnbauer, B.J. (2000). Conceptualizing religion and spirituality: Points of commonality, points of departure. Journal for the Theory of Social Behaviour, 30, 51-77. doi: 10.1111/1468-5914.00119 [ Links ]
Instituto Brasileiro de Geografia e Estatística. (2010). Censo Demográfico - 2010. Rio de Janeiro, RJ: Author. [ Links ]
Koenig, H. G. (2007). Religião, espiritualidade e psiquiatria: Uma nova era na atenção à saúde mental. Revista de Psiquiatria Clínica, 34(Suppl. 1), 5-7. doi: 10.1590/S0101-60832007000700002 [ Links ]
Koenig, H. G. (2012). Religion, spirituality, and health: The research and clinical implications. ISRN Psychiatry, 2012. doi: 10.5402/2012/278730 [ Links ]
Koenig, H. G., Berk, L. S., Daher, N. S., Pearce, M. J., Bellinger, D. L., Robins, C. J., ...King, M. B. (2014). Religious involvement is associated with greater purpose, optimism, generosity and gratitude in persons with major depression and chronic medical illness. Journal of Psychosomatic Research, 77, 135-143. doi: 10.1016/j.jpsychores.2014.05.002 [ Links ]
Koenig H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York: Oxford University Press. [ Links ]
Lucchetti, G., Granero, A. L., Bassi, R. M., Latorraca, R., & Nacif, S. A. P. (2010). Espiritualidade na prática clínica: O que o clínico deve saber? Revista Brasileira de Clínica Médica, 8(2),154-158. Retrieved from http://files.bvs.br/upload/S/1679-1010/2010/v8n2/a012.pdf [ Links ]
Lucchetti, G., Koenig, H. G., Pinsky, I., Laranjeira, R., & Vallada, H. (2015). Spirituality or religiosity: Is there any difference? Revista Brasileira de Psiquiatria, 37(1),83. doi: 10.1590/1516-4446-2014-3610 [ Links ]
Marques, L. F. (2010). O conceito de espiritualidade e sua interface com a religiosidade e a Psicologia Positiva. Revista Psicodebate Psicología, Cultura y Sociedad, 10, 135-151. Retrieved from https://dspace.palermo.edu/ojs/index.php/psicodebate/article/view/393 [ Links ]
Marques, L. F. (2017). Religiosidade/espiritualidade na educação e na saúde: Ensino e extensão. Revista Pistis & Praxis: Teologia e Pastoral, 9(1),189-203. doi: 10.7213/2175-1838.09.001.DS09 [ Links ]
Menezes, A., Jr., & Moreira-Almeida, A. (2009). O diagnóstico diferencial entre experiências espirituais e transtornos mentais de conteúdo religioso. Archives of Clinical Psychiatry (São Paulo), 36(2),75-82. doi: 10.1590/S0101-60832009000200006 [ Links ]
Moreira-Almeida, A., Koenig, H. G., & Lucchetti, G. (2014). Clinical implications of spirituality to mental health: Review of evidence and practical guidelines. Revista Brasileira de Psiquiatria, 36(2),176-182. doi: 10.1590/1516-4446-2013-1255 [ Links ]
Moreira-Almeida, A., Lotufo, F., Neto, & Koenig, H. G. (2006). Religiousness and mental health: A review. Revista Brasileira de Psiquiatria, 28(3),242-250. doi: 10.1590/S1516-44462006000300018 [ Links ]
Moreira-Almeida, A., Sharma, A., van Rensburg, B. J., Verhagen, P. J., & Cook, C. C. H. (2016). WPA Position Statement on Spirituality and Religion in Psychiatry. World Psychiatry, 15(1),87-88. doi: 10.1002/wps.20304 [ Links ]
Murakami, R., & Campos, C. J. G. (2012). Religião e saúde mental: Desafio de integrar a religiosidade ao cuidado com o paciente. Revista Brasileira de Enfermagem, 65(2),361-367. doi: 10.1590/S0034-71672012000200024 [ Links ]
Neubern, M. S. (2010). Psicoterapia e religião: Construção de sentido e experiência do sagrado. Interação em Psicologia, 14(2),263-273. doi: 10.5380/psi.v14i2.14937 [ Links ]
Neubern, M. S. (2013). O que significa acolher a espiritualidade do outro? Considerações de uma clínica Ethnopsy. In M. H. Freitas, G. J. Paiva, & C. Moraes (Eds.), Psicologia da religião no mundo contemporâneo: Desafios da interdisciplinaridade: Vol. 2 (pp. 145-183). Brasília, DF: Editora da Universidade Católica de Brasília. [ Links ]
Oliveira, J. L. M. (2012). Diálogo entre religião, ciência e ética: Desafios e contribuições da Psicologia. In M. H. Freitas & G. J. Paiva (Eds.), Religiosidade e cultura contemporânea: Desafios para a Psicologia (pp. 191-229). Brasília, DF: Universa. [ Links ]
Oliveira, M. R., & Junges, J. R. (2012). Saúde mental e espiritualidade/religiosidade: A visão de psicólogos. Estudos de Psicologia (Natal), 17(3),469-476. doi: 10.1590/S1413-294X2012000300016 [ Links ]
Panzini, R. G., & Bandeira, D. R. (2007). Coping (enfrentamento) religioso/espiritual. Archives of Clinical Psychiatry (São Paulo), 34(Suppl. 1), 126-135. doi: 10.1590/S0101-60832007000700016 [ Links ]
Pargament, K. I., Lomax, J. W., McGee, J. S., & Fang, Q. (2014). With one foot in the water and one on shore: The challenge of research on spirituality and psychotherapy. Spirituality in Clinical Practice, 1(4),266-268. doi: 10.1037/scp0000046 [ Links ]
Peres, J. F. P., Simão, M. J. P., & Nasello, A. G. (2007). Espiritualidade, religiosidade e psicoterapia. Revista de Psiquiatria Clínica, 34(Suppl. 1), 136-145. doi: 10.1590/S0101-60832007000700017 [ Links ]
Peteet, J. R. (2014). What is the Place of Clinicians' Religious or Spiritual Commitments in Psychotherapy? A Virtues-Based Perspective. Journal of Religion and Health, 54, 1190-1198. doi: 10.1007/s10943-013-9816-9 [ Links ]
Pinto, E. B. (2013). A ciência da religião aplicada à psicoterapia. In J. D. Passos & F. Usarski (Eds.), Compêndio de ciências da religião (pp. 677-690). São Paulo, SP: Paulinas. [ Links ]
Plante, T. G. (2007). Integrating spirituality and psychotherapy: Ethical issues and principles to consider. Journal of Clinical Psychology, 63(9),891-902. doi: 10.1002/jclp.20383 [ Links ]
Regional Council of Psychology of São Paulo. (2015). Relatório Síntese das Discussões dos Seminários Estaduais Psicologia, Laicidade e as relações com a Religião e a Espiritualidade. Retrieved from http://www.crpsp.org.br/diverpsi/arquivos/Recomendacoes_Diverpsi.pdf [ Links ]
Regional Council of Psychology of São Paulo. (2016). Psicologia, Laicidade e as relações com a religião e a espiritualidade. São Paulo, SP: Author. [ Links ]
Scorsolini-Comin, F. (2015). Um toco e um divã: Reflexões sobre a espiritualidade na clínica etnopsicológica. Contextos Clínicos, 8(2),114-127. doi: 10.4013/ctc.2015.82.01 [ Links ]
Sperry, L., & Shafranske, E. P. (Eds.). (2005). Spiritually oriented psychotherapy. Washington, DC: American Psychological Association. [ Links ]
Snyder, C. R., & Lopez, S. J. (2009). Psicologia Positiva: Uma abordagem científica e prática das qualidades humanas (R. C. Costa, Trans.). Porto Alegre, RS: Artmed. [ Links ]
Turato, E. R. (2013). Tratado da metodologia da pesquisa clínico-qualitativa: Construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas (6th ed.). Petrópolis, RJ: Vozes. [ Links ]
Vandenberghe, L., Prado, F. C., & Camargo, E. A. (2012). Spirituality and Religion in Psychotherapy: Views of Brazilian Psychotherapists. International Perspectives in Psychology: Research, Practice, Consultation, 1(2),79-93. doi: 10.1037/a0028656 [ Links ]
Vergilio, S. R., & Holanda, A. F. (2010). Analogias e diferenças entre reuniões mediúnicas espíritas e o atendimento em psicologia clínica. Revista da Abordagem Gestáltica, 16(2),173-182. Retrieved from http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1809-68672010000200007 [ Links ]
Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and Religious Competencies for Psychologists. Psychology of Religion and Spirituality, 5(3),129-144. doi: 10.1037/a0032699 [ Links ]
World Health Organization. (1998). Division of mental health and prevention of substance abuse. WHOQOL and spirituality, religiousness and personal beliefs (SRPB). Genève: Author. [ Links ]
Mailing address:
Fabio Scorsolini-Comin
Departamento de Enfermagem Psiquiátrica e Ciências Humanas da Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo
Av. dos Bandeirantes, 3900, Monte Alegre
Ribeirão Preto - SP, Brasil 14040-902
Phone: (16) 3315-3439
E-mail: fabio.scorsolini@usp.com
Received: 04/04/2018
1st revision: 31/05/2018
Accepted: 24/06/2018
Acknowledgements: The first author of this paper is a doctoral scholarship holder from the Coordination for the Improvement of Higher Education Personnel (CAPES) and the second author is a Research Productivity Scholarship Holder from the National Council for Scientific and Technological Development (CNPq).
