Giumbelli, Emerson; Toniol, Rodrigo. What is spirituality for?

New relations between religion,

health and public spaces. In: Blanes, Ruy; Mapril, Jose; Giumbelli, Emerson (orgs). Secularisms
in a Postsecular Age? Religiosities and Subjectivities in Comparative Perspective, 2017. pp.
147-167

What is spirituality for? New relations between religion, health and public spaces

Emerson Giumbelli and Rodrigo Toniol

In May of 1984, during the 37th World Health Assembly, a historic decision was
taken: the spiritual dimension was integrated to the healthcare strategy of the
member states of the World Health Organization (WHO).

Fourteen years later, the special group of the WHO executive committee, formed to
revise the entitys constitution, proposed that the documents preamble, where it
defines health, be altered to: health is a dynamic state of complete physical, mental,
spiritual and social well-being, and not only the absence of diseases or illnesses.

In January 1998, the members of the executive committee endorsed the proposal
and the resolution was adopted by WHO (Khayat, 1998:2009) (emphasis ours).

Although they are significant because they were adopted by an agency with

global influence, these resolutions are not exceptional acts in the legitimization of the

tie between health and spirituality. They are associated to other statements, which since

1980 present various modulations between the terms health and spirituality, creating

consequences for the connection between these terms in multiple dimensions. In this

period, we can observe a substantial growth in the number of university research

centers, laboratories and departments dedicated specifically to the relationship between

health and spirituality.1 This growth, beyond consolidating a new analytical horizon for

the medical sciences, has also contributed to the proliferation of the use of the category

1
The more prominent and traditional research centers include: Center for Spirituality, Theology
and Health (Duke University); Program in Spirituality and Medicine (Howard University
Hospital); Center for Spirituality, Health and Disability (University of Aberdeen); Center for
Spirituality and Healing (University of Minnesota); Spirituality Mind-Body Institute (Columbia
University); Center for Spirituality and Health (University of Florida).
spirituality in the field of healthcare studies.

In terms of the variety of meanings that the term spirituality can assume, to the

degree that studies that analyze it are multiplying, the scope of the impact of the

spirituality factor suggested by these investigations is notable. For example, to cite

just a few studies: Garssen, Uwland and Visser (2014) affirm that there is a positive

association between the spirituality of patients with cancer and well-being; Brewer-

Smyth and Koening (2014) recognize that, in cases of childhood trauma, the resilience

of more spiritualized people is greater than that of those who are not spiritualized;

Berntson and Hawkley (2008), in turn, affirm that there is a significant correlation
2
between spirituality and autonomic cardiac control. Particularly since 2000, the

declarations about the connection between health and spirituality extend in an even

broader manner: congresses have been organized focused exclusively on the issue,

courses in medicine and spirituality are offered in undergraduate schools in the

healthcare sciences, research lines related to the issue have been established in graduate

programs and research and study centers dedicated to spirituality have been opened at

hospitals.

In Brazil, beyond the medical research, the relationship between healthcare and

spirituality has also found support in two state actions, the National Policy for

Humanization and the National Policy for Integrative and Complementary Practices

(PNPIC), were launched by the Ministry of Health in 2004 and 2006 respectively.

Integration and democratization are keywords in the first program, whose objectives are

transversal to Brazils public Single Healthcare System (SUS), the comprehensive state-

financed services offered free of charge to all citizens in the country. According to the

documents of the National Humanization Policy, to humanize is (...) to offer quality

2
For a detailed analysis of these and other clinical studies that evaluate the impact of the
spirituality factor in health, see: Toniol, 2015.
care, articulating technological advances with support and improved care environments

and working conditions for the professionals (apud Boldrini 2012: 64). In fact, one of

the targets of the policy is the users of the SUS, whose participation in the services

should be increased. The approval of the Bill of Rights of Healthcare Users, is related to

this effort, and was drafted in 2006 by a decree of the Ministry of Health. Two of the

principles that support this Bill deserve to be transcribed: Every citizen has the right to

humanized, protective treatment, free of any discrimination and All citizens have the

right to care that respects their person, their values and their rights.3

Published two years after the release of the National Humanization Policy, the

National Policy of Integrated and Complementary Practices is designed to assure and

promote access, through SUS, to traditional Chinese medicine, homeopathy,

phytotherapy, terminalism and anthroposofic medicine. With a national scope, this

decree also stimulates the formulation of other policies, aimed at the states and

municipalities, which add new therapies to those called for in the national policy. 4 The

variations between the therapies called for by each of the laws, however, does not go

against two forms of convergence between them. First, all of these policies promote

healthcare practices that are not part of the tradition of the country, and are not

integrated to the dominant healthcare system (WHO, 2000:1). In this sense, they

converge because of the marginal and non-hegemonic character of the therapies that

they support. Second, these policies identify the alternative and complementary

therapies as technologies that are especially adjusted to holistic healthcare approaches.

According to a Ministry of Health document, the provision of alternative therapies in

3
http://portal.saude.gov.br/portal/saude/cidadao/area.cfm?id_area=1114. Accessed on 8 May
2012.
4
The policy in Rio Grande do Sul state, for example, recommends, beyond the practices
described in the PNPIC, floral therapies, reiki, corporal practices, community therapy and diet
therapy. The municipal government of Santo ngelo, in the interior of this state, passed law
n3.597, on 23 March 2012, which calls for the implementation of hypnosis, yoga, chromo
therapy, iridology and others in the citys public healthcare services.
SUS would be an opportune manner to consolidate a perspective from which disease,

its diagnosis and treatment [are seen] simultaneously from physical, emotional,

spiritual, mental and social aspects, revealing individuals in their totality" (Brasil,

2009: 56).

By presenting this extensive and varied investment of the medical sciences and

healthcare agencies in Brazil aimed at cultivating the pairing of health and spirituality,

we are not interested simply in reflecting on it, or deriving from it hypotheses about

broad transformations in the ontological principles of Western medicine, suggesting its

opening in direction to new paradigms. As an alternative to this, we shift our reflections

from the characteristics of the tie between health and spirituality, to the effects of its

legitimization. Isnt this process also instituting new modalities of the presence of

religion in public spaces? How do different individuals constitute themselves and

interact in the framework of these new modalities? Does the equation that establishes

spirituality as health impose a new regime of questions to analysts interested in the

issues of secularism and secularization?

The pertinence of these issues does not minimize the relevance of the other: after all,

what is spirituality? It is necessary to clarify that we are not referring to spirituality as a

noun, but as a category. This shift is similar to that made by Dutch anthropologist Peter

Van der Veer, who affirms:

Scholar would like to avoid this term [spirituality] as much as possible

because of its vagueness. This is most easily done by trating it as a
marginal term (...). I want to suggest that is not a correct approach and
that spirituality is in fact a crucial term in our understanding of
modern society. (...) I will habe to clear the ground for a new
perspective on spirituality that does not make it into a marginal form
of resistence against secular modernity, but instead shows its
centrality to the modern project (...) (Veer, Peter van der; 2014:7).
 It thus involves recognizing that first, we can identify deep historic roots of the

term in mysticism, in Gnosticism, Hermeticism and in a broad range of ancient

traditions, and second, even if it appears to depend crucially on its association with the

East, spirituality is in fact a category tributary to Western modernity. The argument is

not trivial and its demonstration depends on a broad genealogical effort, whose

undertaking deviates from the more general objectives of this chapter.5 We mention it to

emphasize that which the recognition of the link of this category with modernity warns

us of: spirituality is an historically located concept and its very emergence is the historic

product of discursive processes. 6

Veers considerations also advance the argument that spirituality is a category

forged in modernity and indicates the terms tie with two others, religion and the

secular. For Veer, the spiritual and the secular were simultaneously produced as

two alternatives connected to institutionalized religion in the Euro-American

modernity (Veer, 2014:36). Our analysis will reflect on the consideration of this tie,

focusing not on religion, but on what is presented in the name of spirituality. We seek

to show, based on concrete situations, how spirituality permits the presence of certain

religious agents and discourses in secular spaces. Inversely, to configure a tension

between two trends, spirituality can be conceived as something that, from a secular

perspective, produces or reproduces the marginality of religion as a curative agent.

Although our analysis is limited to a specific hospital space, we think that based on it

we can raise more general questions about the configuration of social spheres around

which modernity is defined.

5
The careful work of Catherine Albanese (2007) is an example of the recent studies taken to
produce genealogies of the concept of spirituality in the West.
6
The similarity between this affirmation and what Talal Asad (1993:29) says about the category
of religion is not irrelevant although it should also not be extended beyond the methodological
plane.
 In dialog with the proposal of this book, in this chapter we steer these complex

relationships between the secular, the religious and spirituality in direction of the

concrete. As delineated in the introduction, we understand that this analytical movement

towards the concrete and the subjective will allow us to know more about the plural,

heterogeneous and processual character of the secular/religious conundrum, and thus

move beyond the monolithic, immobilized configurations that often flourish in the

public sphere.

We assume as the universe of empiric interest activities in the realm of a public

hospital in Porto Alegre, the capital of Brazils most Southern state. It is one of the main

hospital networks serving the population of this city, maintained totally by state

resources. 7 We first analyze the action of the group aimed at the organization of

religious assistance to patients and employees. Although the group combines

representatives of various religions, a Lutheran pastor stands out in the preparation of

the discourse that supports the relationship between spirituality and health. We address

the arguments of this pastor in the context of his activities in the hospital and discuss the

scope and limits that the dimension of religious assistance offers to the valorization of

spirituality. In parallel, the oncology sector of this hospital offers therapeutic practices

aimed at spirituality. Different holistic therapies serve the patients there while the

chemotherapy is administered. For the medical coordinator of the sector, the provision

of these therapies has a dual justification: it is based on clinical studies that certify

spirituality as a determining factor for recovery for cancer patients; it is an attempt to

decrease the number of users that abandon their treatment for religious reasons, by

offering a practice that involves spirituality within the hospital itself. Nevertheless,

7
The Grupo Hospital Conceio (GHC) includes 4 hospitals and more than 12 community
healthcare clinics, presenting itself as the largest public hospital network in Southern Brazil. Cf.
http://www.ghc.com.br/default.asp?idmenu=1, accessed on 08.05.2012. The activities
addressed in this text are concentrated in one of the hospitals in this network.
contrary to the medical argument, for some patients it was precisely the way that the

spiritual dimension of health is used that led them to refuse the therapy offered. In this

section we analyze some of the consequences of the therapeutic use of spirituality,

presenting, on this basis, the emergence of some configurations that associate the

spiritual, the religious and the secular at a public hospital.

Finally, in a conclusive section, we seek to delineate considerations that escape

the antinomy that requires the term spirituality to be an analytical category or object of

analysis.

Spirituality as religious assistance8

The Inter-Religious Forum is responsible for the management of religious

spaces (chapels and rooms) in the GHC hospitals and for the organization and

regulation of religious assistance to patients and employees of these hospitals.9 Its

origins date to the diversification of religious assistance, which until the late 1990s had

been exclusively Catholic. In the first years of the 2000s, an ecumenical forum was

created that brought together participants of Evangelical churches. In 2007, the forum

assumed the designation inter-religious, opening itself to representatives of other

religions: Pentecostal churches, Afro-Brazilian religions, Kardeckist Spiritism, Seicho-

no-ie, the Messianic Church and others. Representatives of these various groups could

volunteer to provide religious assistance at the hospital (to become what it denominates

as visitors) at different hours to occupy the inter-religious spaces.10 Some of them

8
The data in this section were produced in the Project Religious Presence in Public Space in
Brazil in Three Realms, which was supported by a productivity grant from CNPq, coordinated
by Giumbelli. Vitria da Fonseca Pereira and Fernanda Marques, undergraduate students in the
social sciences course at UFRGS, participated in the research activities, which took place
between 2011 and 2013.
9
The only information on the site of the GHC about the Forum are at
http://www.ghc.com.br/default.asp?idMenu=cidadania, accessed on 19.01.2015.
10
For more information about the composition of the Inter-Religious Forum of the GHC, and a
comparison of its various proposals for religious spaces in public institutions in the city of Porto
Alegre, see Giumbelli (2013, 2016).
participate in the coordination of the Inter-Religious Forum. Although it is an instance

recognized by the administration of the GHC, which is represented on the Forum,

alongside the representatives of various religions, the Forum does not have a strict

institutional structure. As we will see, limits exist to consolidating the proposal and

work of the Inter-Religious Forum, which is significant because of its mere existence.

In 2011, a Work Plan circulated among its participants, signed by the

Coordination of the Inter-Religious Forum of the GHC. 11 After providing some

information about the GHC, and presenting a brief history of the Forum, the text

declares a commitment to the Bill of the Rights of Healthcare Users specifically, the

two principles presented earlier and with the guarantees to religious liberty expressed

in the Universal Declaration of Human Rights and in Brazils Constitution of 1988

principally the right to integral health, which is not only the absence of disease, but is

the situation of physical, mental, social and spiritual well-being of each person. The

text affirms:

The Forum and the Administration of the GHC consider spiritual assistance
to be an important part of the integrality and humanization of care, as called
for by SUS, which must take place in an integrated manner and transversally
with the other healthcare services.

It is perceived that, in this understanding, the principles of religious liberty and

the rights of users, associated to the idea of humanization, function as justifications for

the proposal of the notion of integral health and its link to the religious assistance

services.

The theme of religious assistance deserves a more general comment, before we

return to the concepts that inspire it at GHC.12 Religious assistance corresponds to the

right recognized in laws and declarations of people whose work or condition

11
This text was not published, as far as we know. We received it from direct contacts with the
coordinators of the Inter-Religious Forum of the GHC.
12
Inspiring studies about this issue include Sullivan (2009) and Beckford & Gilliat (1998). For
Brazil, see Leite (2014) and Simes (2012).
subjects them to long periods in collective institutions such as hospitals, prisons and

barracks. Brazil exemplifies a situation that is far from rare. On one hand, religious

assistance is defined as a right of people who request it; in practice, what often happens

is that, with greater or lesser agreement from hospitals, prisons and barracks, different

organizations or religious agents offer care or hold worship services regardless of

demand. A tension is thus created between two principles, peoples requests and the

offer of religious agencies. In the case of hospitals, each of them, by means of norms

and or procedures, conciliates not without confronting or producing conflicts these

two principles. At GHC, they seek to respect the principle of demand and at the same

time, organize the supply within a framework committed to religious pluralism. This

plurality, however, is itself organized according to certain concepts. Some of them, as

we will show, depend on the ties between spirituality and health.

In declarations and texts related to GHCs Inter-Religious Forum, it is common

to find the idea of spirituality is health. In his dissertation, Boldrini (2012: 97)

concluded that the public agents of this hospital openly affirm that religiosity is good

and necessary for the recuperation of the ill. The study includes declarations by

coordinators of the Inter-Religious Forum such as: as medical care is important to a

persons recovery, spiritual assistance is also important; it is scientifically proven that

70% of the cures of disease only take place because people believe in something

greater; religion, can be a partner in the patients physical, psychic health (idem:95-

97). In 2011, this discourse was used in a more articulated manner by one of the

coordinators of the Forum, who had a prominent role in the training and education

courses aimed at the visitors registered for the religious assistance.13 This educational

13
The regulation determines that the participation in these courses, with attendance of 100%, is
required for registration and issue of the corresponding identity card. Since 2007, courses of this
nature have been organized by the Forum. In 2010 and 2011, they were divided into five
sessions, addressing the following issues, according to a definition of the Inter-Religious
program is one of the attributions assumed by the Inter-Religious Forum, and, from our

perspective, is a privileged space for perceiving the subjectivity expected for a visitor.

The coordinator to which we refer is a Lutheran pastor, leader of a congregation

in the neighborhood where GHCs largest hospital is located. Since 2002 he has worked

as a volunteer in the hospitals Pain and Palliative Care Service, providing spiritual

care for patients in a terminal phase and their families.14 His presentations during the

course for visitors make explicit references to the Ministry of Healths humanization

policy. His preference and this is expressed in other manifestations of the coordination

of the Inter-Religious Forum is for the term spirituality instead of religion. The

later would be specific and institutional; while spirituality is generic and depends on

the understanding of each individual. Moreover, spirituality is constitutive of human

beings, their creations and their endeavors. It is thus possible to speak in spiritual

intelligence or say that one company is more spiritualized than another. The pastor

also affirms that human beings are composed of various dimensions: biological,

psychological, social and spiritual; illnesses reveal an imbalance between these

dimensions. Spiritual assistance is thus important to cultivate this dimension that is

constitutive of human beings, contributing to the balance that characterizes the state of

health.

Winnifred Sullivan (2014), based on a recent legal case in the United States,

raises points that are pertinent to our discussion. An institution which offers, with

public resources, healthcare to war veterans and their families includes among its

Forum: the importance and the role of Spiritual Assistance, concepts and principles of SUS,
administrative norms and those about hospital hygiene and infection specific to a hospital and
specific to GHC.
14
Records of its activity in: http://projetoeliezer.blogspot.com.br/p/quem-somos.html, accessed
on 08.05.2012; http://www.ghc.com.br/noticia.aberta.asp?idRegistro=7011, accessed on
19.01.2015. The pastor is a member of the Christian Association of Spiritual Hospital Assistants
of Brazil, which has operated since 2008 with this name, organizing courses and events. For
more information, see Boldrini (2012). About the relationship between palliative care and
religiosity/spirituality, see Menezes (2006).
services those of spiritual assistance. In this concept, the diagnosis of a patients

healthcare problems encompass a type of spiritual evaluation, which corresponds to

planning that spiritual care in the treatment (which may or may not be accepted by the

patient). Correlatively, the chaplains hired by this institution are considered by it to be

part of the medical staff. The author concludes: at least in the U.S., while law still

regards itself as secular, all citizens are increasingly understood to be universally and

naturally religious and in need of spiritual care. This care is provided by state

agencies and not directly by the churches; this means, according to Sullivan, that

religion has been as occurred in the 19th century, but in other ways naturalized,

supported by law.

It seems that we see something similar happen in the discourse expressed by the

coordination of the Inter-Religious Forum. One issue to analyze more carefully, in the

two cases, is the role of religious groups in the articulation and support for this

discourse. What are the mediations that credential a religious person to offer spiritual

assistance? Does the same discourse pronounced by a Catholic authority, a Lutheran

pastor or an adept of Afro-Brazilian religion have the same effects or the same

implications? Another point and we will emphasize this refers to how, in these

discourses, one can shift between various meanings of religious. For example, how

can religious references be used in a manner that can be conciliated, by certain points of

view, with the principle of secularity? For Sullivan, the idea of spiritual assistance

integrated to the diagnosis and treatment of healthcare is equivalent to a new religious

establishment. But this was not the understanding of the U.S. court that disqualified a

complaint that state support to the veterans institution would be illegitimate. Avoiding

the legal arguments of the debate, what we would like to highlight in the case of the
Inter-Religious Forum is the tension that is created between various instances of

religious and spiritual.

According to the declarations of the Forum coordination, one of the objectives

of the spiritual assistance (the expression is used more than religious assistance, which

is significant) is To provide all the religious denominations the opportunity to express

their feelings of faith, peace and solidarity for the other, consolidating the principles of

participation, citizenship and humanization in hospital care.15 Faith, peace and

solidarity thus appear to be strategies that allow the religious discourse to access

hospital care. If we use this affirmation as a reference, it is possible to note

differences in the way that the spokespersons for the various religious groups conduct

the events of the education course for visitors. During his presentation, the Lutheran

pastor cites Jesus Christ as a paradigm, independently, he emphasizes, of acceptance

of his divine nature; similarly, he mentions a biblical passage to illustrate what is

spirituality when contrasted with religion. The Catholic priest and the

representative of an Afro-Brazilian religion have a discourse similar to the pastor, each

one with specific references. Meanwhile, the representatives of some Pentecostal

churches present a discourse that is not very different from what can be seen in their

temples: witnesses of conversion and of the power of Lord Jesus who performs

Wonders. While some Pentecostals report miraculous cures, one of the coordinators of

the Forum emphasizes the importance that, in certain cases, the visitor know how to

help a patient die with dignity and that, religious assistance always exists not to gain

congregants, but to provide support.

It is thus possible to perceive a certain hierarchy of the discourses in the realm of

the Inter-Religious Forum of the GHC. Even if everyone has the right to speak, the

15
The declaration is found in the Work Plan mentioned in a previous note.
arguments that use the idea of miracle in general assumed by Pentecostal agents are

seen as improper. An attempt is made to make a distinction between proselytism and

assistance. If spirituality produces health, this mechanics does not directly involve

divine providence. It involves the existence of a belief and, above all, the presence of a

religious agent. It is precisely the constitution of this agent her or his subjectivation

that is at play in the debates that occur during the events promoted by the Forum. We

also see the discursive articulation that allows the presence of religion, converted into

spirituality, in the hospital space. It is in this form, tied to support, that spirituality can

even acquire therapeutic strength.

But this is not so simple. At the same time that the GHC recognizes the Inter-

Religious Forum, designating employees to participate in its coordination, there are

signs that reveal the existence of limits to the acceptance of the idea of spirituality is

health. There are no records of any pronouncement of an authority of the GHC that

assumes this resistance. But it can be perceived in other forms. One of the coordinators

of the Forum, when seeking to substantiate the importance of spiritual assistance, during

the course for the visitors, criticized doctors who are not capable of offering this

recognition. Pires (2009), in his study about GHC professionals, reports complaints

from a nurse about religious procedures that disrespect hospital hygiene norms or

interfere in the autonomy of patients (:17). Another text, the result of a study conducted

with medical teams that work at GHC health clinics, makes two interesting observations

(Alves, Junges, Lpez 2010). One is that the existence of inter-religious spaces was not

cited by any of the professionals interviewed. The other finding is that these employees,

even expressing respect for spirituality/religiosity, at no time mention it as a

resource to be used in their therapy (:435).

 In regard to these tensions around the place of a religious presence, it is worth

mentioning a request by the Lutheran pastor to whom we referred. It is significant that it

was expressed in a declaration before city council members of Port Alegre, to whom he

presented his work in the Pain and Palliative Care Service of the GHC.16 At this time,

the pastor requested the creation of a function of chaplain or spiritual assistant in

public hospitals. This would give a professional status and remuneration to what is now

voluntary service. This request appears to have caused a disturbance even among

colleagues on the Inter-Religious Forum, who understand it as a voluntary activity. But

it can be seen as a consequence of the idea that confers greater presence and legitimacy

to the religious representatives in the hospitals, approximating them to the situation

described by Sullivan (2010). As a counterpart, the direction of the GHC, in May 2012,

warned that the visitors must have greater care for infection control procedures. And

currently, the presentation of the Pain and Palliative Care Service on the GHC website

does not even mention the work of the Lutheran pastor.17

Spirituality as therapeutic technique18

The legitimacy of the phrase spirituality is health is not, as we showed

previously, separate from the discourses produced by actors from the medical sciences.

Until now, we presented how its use produced tensions in the Inter-Religious Forum

that, based on the notion of the spiritual, found new configurations to accommodate

religion in the hospital space. It is interesting to insist on the consequences of this

16
This event took place on 01/12/2011, at an ordinary session of the Porto Alegre City Council,
cf. http://200.169.19.94/documentos/notas/docs/365/original/114SessoOrdinria01DEZ2011.htm,
accessed on 19.01.2015.
17
Cf. http://www.ghc.com.br/carta/internacao_hnsc.html, accessed on 19.01.2015
18
The data in this section were produced in a doctoral study by Rodrigo Toniol, which
investigated the incorporation of alternative therapies in Brazils public health system. The
fieldwork, as well as the interviews and collection of materials that support the reflections
presented here, were conducted between March 2012 and December 2013.
phrase in another dimension, the therapeutic. After all, what it appears to suggest is that,

to the same way that spirituality must be recognized as one of the aspects that shape

health, the production of a healthy life can also be obtained via spirituality. In this case,

the question ratifies the question we raised about the different uses and effects of

spirituality in the discourses of the religious actors of the Forum, which is: do different

forms of medicine have the same capacity to mobilize spirituality in their therapeutic

dimension? The justifications of the official public health agencies that argue for the

provision of alternative therapies appear to indicate some responses to the question. The

text of the National Policy of Integrative and Complementary Practices, as well as other

state and municipal laws with similar purposes, is explicit about the distinct capacity of

these therapies to escape the biological [models] supported by the use of

medication,19 offering as an alternative, practices based on an approach that makes

integrality the foundation for diagnosis and treatment.

At GHC, specifically in the hospitals oncological care sector, the connections

between alternative therapies, health and spirituality are more explicitly elaborated. The

Rio Grande do Sul hospital was a pioneer in the use of alternative therapies in the

country. In 2009, the director of the oncological center invited two therapists to

voluntarily conduct reiki sessions for patients while they received chemotherapy

medication. In the official documents of the administrative agencies of public health in

Brazil, reiki is described as a a technique for the capture, transformation and

transmission of energy conducted through the hands (in Japanese Rei signifies the

universal cosmic energy and Ki signifies vital energy). It promotes the balance of

vital energy, applied by the imposition of the hands technique (Reikian) on the patient,

19
Source: Secretaria Estadual de Sade do Rio Grande do Sul. Resoluo n 695/13. Poltica
Estadual de Prticas Integrativas e Complementares, 2013. Mimeo.
through which a pattern of harmonic waves is transmitted, reviving the natural

electromagnetic field, offering equilibrium to the physical body.20

Supported politically by the Ministry of Health under the PNPIC, this therapy

had, for the doctors in the sector, justifications of a clinical nature. One of the directors,

who did part of his studies in the United States, where he learned about research about

the impact of the spirituality factor in health, affirmed:

There are now many studies that show this relationship between
spirituality and health. This is something more or less known by the
scientific community. We [at the hospital Conceio] think that this
should be incorporated into our daily activity. And these therapies are
an attempt to do so. They are not invasive and have this characteristic of
being holistic. So it is a way to attend this element as well.
To the clinical justifications that identify the therapeutic value of the attention to

spirituality, the same director added an argument of a pragmatic nature.

We have no systematic study here of the impact that this has had for our
patients, but there is a pragmatic question that we are able to measure:
before people would give up the treatment for religious reasons,
because the pastor said that he would perform a miracle, and with reiki
this decreased.
It is worth emphasizing some mediations implied in these considerations. The multiplicity of

studies of the medical sciences dedicated to spirituality is, at least, a factor that legitimizes the

issue of health and spirituality for doctors and administrators. The recognition of the pertinence

of the topic that, at one moment, had the WHO organization affirm the spiritual dimension of

health, also has a repercussion in another direction, that which identifies the power of the

therapeutic use of spirituality. In Brazil, the PNPIC has precipitated these discourse and used

the holistic nature of the alternative therapies as a justification for their association with the

therapeutic perspective of the spiritual. The argument of the oncologist at GHC is similar to this,

and, like the public policy, considers the alternative therapies as a group, made compatible by

their holistic quality. The technical differences between the practices it aggregates are

secondary. In this case, is it important which therapy is offered, whether it is reiki or, for

20
Source: Secretaria Estadual de Sade do Rio Grande do Sul. Resoluo n 695/13. Poltica
Estadual de Prticas Integrativas e Complementares, 2013. Mimeo
example, yoga, which according to PNPIC is also a holistic practice? The reflection about this

question depends on comparative frameworks which are not available to us, but we can derive

from the more general problem that it raises a focus for the description that follows: how does

spirituality emerge specifically in the daily practice of reiki sessions?

Each day 100 to 300 people pass through the oncological care sector of the Hospital

Conceio. They are patients from all of Rio Grande do Sul state who come to consult with

specialists, conduct exams and receive chemotherapy in sessions that can last 20 minutes to six

hours. The users who fill the corridors of that sector of the hospital are grouped by the type of

cancer that they have. Contrary to the consultations, which are scheduled according to the

priorities for attendance of the specific groups of patients, the chemotherapy sessions are held

according to medical prescription, so that in a single day, users with different types and stages

of the disease come together while they receive the medications. The main room for

chemotherapy of the hospital is at the end of the hall of consultation rooms, on the second floor.

A row with nine seats is followed by cardiac control equipment and by machines that regulate

the dosage and time of medications injected and occupy most of the space. On the opposite side,

closets and refrigerators store the materials that will be used during the day. In the two adjacent

rooms, where the chemotherapy is also conducted, the seats are replaced by stretchers, which

serve the more debilitated patients.

Every day new users initiate their treatment sessions, while others maintain a routine of

chemotherapy that extends for months or even for years. In addition to the doctors, nurses and

technicians who care for them, since 2010 reikian therapists also come to attend them. When

implemented, the offer of this therapy was not unprecedented at the hospital, given that since

the middle of the decade of 2000 the employees of the institution have had a holistic therapist

available to them in the worker health sector. 21 Nevertheless, the reasons that this therapy is

offered in oncology are unique and do not necessarily coincide with the justifications of other

experiences of the provision of the PICs.

21
This sector exclusively serves hospital employees, so that the experience of providing reiki in
oncology, although it is not unprecedented, was the first at Conceio aimed at a broader public.
 Three times a week, Silvia, a reikian therapist, attends the patients in the chemotherapy

room. The reiki sessions last just under ten minutes and are conducted while the users receive

the medications. Although the procedure is not mandatory, it is recommended to the patients by

the hospital oncologists. Carrying a form for noting the users served and aromatic oil on her

hands, Silvia passes among all the stretchers and seats offering reiki. Far from being exceptional

acts in the routine of the chemotherapy treatments at that hospital, the reiki sessions are

incorporated into the sectors daily activity. This continuity between reiki and the conventional

clinical procedures is expressed, for example, in the fact that the therapist uses the same smock

as the nurses and doctors, or even by the moment in which the reiki sessions are conducted,

after the initiation of the application of the medication and before the clinical evaluation of the

patient.

In the chemotherapy room, this technique of energetic manipulation is usually

conducted in two forms: by the imposition of hands on the regions of the chacras of the patients

and by use of the reiki symbols. When she offers the treatment, Silvia explains to the users

that the technique has the capacity to strengthen the immunological system and to help the

patient feel, in her words, more relaxed and confident before the challenges of the disease.

The sessions are always held in the same way: they begin with the imposition of the hands on

the energetic centers of the patients (known as the chacras) and, in the other step, the therapist

concentrates the energetic work on the part of the body affected by the cancer, making signs

with her fingers over this region that reproduce symbols of the reiki cure. Silvia never touches

the users, who keep their eyes closed. Although they do not visually accompany the session,

most of them say that they feel the warmth of the energetic exchange as the therapist moves the

position of her hands.

Pedro, a 67-year-old patient, in his fifth chemotherapy session at the hospital, was

emphatic about the reiki that he has received since he began the treatment:

This reiki is very good. It provides a peace for us who are in this
situation. I was very happy when she [Silvia] came. I close my eyes,
but feel where her hand is. It gives a warmth, like a tingling. While she
does this I pray...I dont know if this is correct. But I do. One day I
 asked if she could do a little on my wife, who always accompanies me
and at times tires from the whole routine.

Although the reiki sessions are normally accepted by the patients, the cases in which

they are refused are not rare, and in most cases, are justified, as shown by the following report,

for religious reasons.

In July 2013, Silvia concluded a new step of her training in reiki therapy that allowed

her to incorporate new symbols of cure in her technique. She was also allowed to administer

reiki at a distance, a modality of energetic manipulation in which the treatment does not

require proximity between the patient and the reikian therapist. Although the procedure was

similar, with the new symbols of cure, Silvia needed more time to complete each session. The

symbols, which had been made with the fingers, and perceptible only by careful observers, were

now made in broader movements. The change, although subtle, had an immediate effect on the

number of acceptances and rejections of the therapy by the patients.

One of the first times when she saw the new movements of the therapist, Jandira, a 53-

year-old patient who had been undergoing treatments for cancer for 5 years, protested: I always

liked this treatment [reiki] that they do here, but now I understand that this is something a bit

strange. She [Silvia] explained to me that it is about energy, but for someone who is Christian,

the energy is God. The therapist, who was close to the conversation, still tried to argue, Dona

Jandira, this has nothing to do with religion. It is a therapy. We work with the cosmic energy,

this is spirituality, its not religion. People confuse these things a lot. Thanking Silvia for the

offer, Jandira once again refused the treatment and said that she would pray for the therapist.

After Jandira, two other users rejected the reiki session alleging religious incompatibility with

the practice.

The ethnography of the therapeutic offer of reiki at GHC, analyzed based on its

interface with the pairing of health and spirituality, also winds up referring to the religious. In

the case briefly described here, this connection assumes contrasting forms in three moments.

First in the argument of the oncologist who recognized in the therapeutic use of the spirituality

the possibility of offering a clinical alternative, to the patients, to the offer of a religious cure.
Second, in the alleged distinction, made by the therapist, between religion and spirituality,

suggesting that treating the spiritual is first of all, a technical expertise. And third, some

patients, contrary to that suggested by the oncologist, recognize the capacity of reiki as caring

for spirituality not as a quality that makes the practice something parallel to religion, but as one

of the determinant aspects that characterize a latent antagonism between the spiritual and the

religious. Given this situation, we are not interested in establishing definitions of what is

spirituality, but in making visible its capacity to produce new configurations for us to consider

the religious and the secular. In this way, we intend to shift the centrality of the question what

is spirituality? And as an alternative, ask: what is spirituality for and what can it do?

What can spirituality do?

The authors of this text came to the same research location through independent

paths. But it is significant that this hospital attracted their attention. Because true

experiments are conducted at this hospital of the possibilities created by the tie between

spirituality and health. We sought to show how these possibilities are related with the

strength and recognition acquired by the notion of integrality, something that is related

to both a global context and to national and local healthcare policies. The hospital that

we studied, in a large Latin American city, is part of this context. Accompanying

situations like this reveals more general vectors and exposes tensions that surround the

work and the life of distinct social agents. We see that the need to trace distinctions

between religion and spirituality is something recurrent. To characterize as spiritual the

assistance in one case, and in another the techniques, is an operation that is crucial to

permitting their presence in the secular environment of a public hospital. This implies a

distinction between the fields or planes, but also the production of subjects whose

existence and legitimacy depend on this distinction.

 To go farther in the understanding of what is produced with the recourse to the

idea of spirituality, it is also necessary to consider some of the differences that exist

between the cases accompanied. They illustrate virtualities and limits for the

approximation between spirituality and health. The presence of reiki in a clinical

environment, as a support for biomedical procedures, is supported by the notion of

integrative and complementary practices (PICs). This notion, in turn, reveals the

reformulations through which the very concept of medicine has passed. This allows that

it be open to taking in practices that are not hegemonic from the therapeutic perspective

and that are related, considering the religious field, to minority traditions. This is the

case of reiki in Brazil. Meanwhile, the spiritual assistance defended by the coordinators

of the Inter-Religious Forum is based on another foundation. It is the principle of

religious freedom. This is what permits the presence of the religious agents without

specifically therapeutic qualifications in the hospital environment. What they require,

based on this presence, and in a way that erases differences between beliefs that occupy

unequal positions in the religious field, is their competence to care for the spiritual

dimension on which patients health depend. Therefore, if reiki is spiritual because it is

a technique, the assistance is spiritual because of the agents who provide it.

Meanwhile, the limits that both face are based on distinct arguments. The spiritual

assistance, which is based on the presence of the religious agents, suffers, according to

the doctors, a restriction based on the following principle: religion is a dimension

extrinsic to medical treatment, requiring a form of care that is independent of the

therapeutic. Reiki, in turn, is pragmatically accepted because it helps to block the

influence of religion, even when it runs the risk, by the part of patients, of being

confused with it.

 We hope that the brief analyses presented in this chapter demonstrate the

pertinence of treating spirituality as the historic product of discursive processes. To

approximate the routines and structure of a hospital requires conjugating discourses to

specific institutional practices and configurations and it is in the encounter of these

vectors that certain results are defined. We emphasize that these definitions particularly

mark possibilities that are created for the notion of spirituality. That is, the result does

not correspond to a precise substance or to a univocal direction. Spirituality is a

category that is important because it allows altering the form of organizing reality. With

its presence, the relationship between the secular and the religious is redimensioned,

without the distinction being dissolved. The secular can accept a technique, which if not

for the possibility of characterizing it by its link with spirituality, could be seen as

religious. The religious, when conceived in terms of spiritual assistance, can be present

in secular spaces and be accepted as an ally in therapeutic care. But precisely because

the distinctions between the religious and the secular are not dissolved, they continue to

act to organize reality, and can even be reinforced by combining with spirituality. Thus,

what is at stake is also the definition of the domains that constitute reality and society,

causing a reformulation of the distinction of the religious in relation to other spheres.

To think of the category of spirituality in the realm of the possibilities also offers

the chance to escape the antinomy that requires us to consider it as an object or as a

concept. We recognize that in the analyses presented here we treat spirituality as an

object, that is, as a product of certain articulations between institutional discourses,

practices and configurations. But we do not deny that the dissemination of the category

captures transformations that are underway, some of them related precisely with the

relations between the religious and the secular. That the word be elevated to a concept,

in the realm of the human sciences (Fuller, 2008), thus appears to be among the
possibilities that it offers, to the degree to which it allows treating aspects that other

notions particularly that of religion have more difficulty grasping. But this operation

becomes problematic when it produces a substantive opposition between spirituality and

religion. Because it is exactly the conviviality and the alternance between these

categories that appears to be most interesting. After all, we sought to show how, in a

public hospital, spirituality could serve to maintain religious agents in secular

environments or to introduce practices with a therapeutic status that, from a certain

perspective, acquire a religious character. Spirituality can be the opposite of religion;

and at the same time can be its new avatar in public spaces.

References:

Ai, Amy L., Ruth E. Dunkle, Christopher Peterson, and Steven F. Boiling. "The role of
private prayer in psychological recovery among midlife and aged patients following
cardiac surgery." The Gerontologist 38, no. 5 (1998): 591-601.

Alves, Joseane de Souza, Jos Roque Junges, and Laura Ceclia Lpez. "A dimenso
religiosa dos usurios na prtica do atendimento sade: percepo dos profissionais da
sade." Mundo sade (Impr.) 34, no. 4 (2010): 430-436.

Beckford, James A., and Sophie Gilliat. Religion in Prison:'Equal Rites' in a Multi-
Faith Society. Cambridge University Press, 1988.

Bell, Virginia, and David Troxel. "Spirituality and the Person with Dementia-A View
from the Field."Alzheimer's Care Today 2, no. 2 (2001): 31-hyhen.

Boldrini, Marcos Iob. "Desconfessionalizao dos espaos religiosos e assistncia

religiosa em hospitais de Porto Alegre." Dissertao de mestrado, Programa de Ps-
Graduao em Cincias Sociais, PUC-RS. (2012).

Brewer-Smyth, Kathleen, and Harold G. Koenig. "Could spirituality and religion

promote stress resilience in survivors of childhood trauma?."Issues in mental health
nursing 35, no. 4 (2014): 251-256.
Fuller, Robert C. Spirituality in the flesh: Bodily sources of religious experiences.
Oxford University Press, 2008.
 Garssen, Bert, Nicoline F. Uwland-Sikkema, and Anja Visser. "How spirituality helps
cancer patients with the adjustment to their disease." Journal of religion and health 54,
no. 4 (2015): 1249-1265.

Giumbelli, Emerson Alessandro. "O que um ambiente laico?: espaos (inter)

religiosos em instituies pblicas." Cultura y Religin. Chile. Vol. 7, n. 2, p. 32-
47 (2013).

Giumbelli, Emerson. "Public Policy and Religious Diversity Interreligious Spaces in

Two Hospitals in a Brazilian Capital City." Latin American Perspectives (2016).

Idler, Ellen L., and Stanislav V. Kasl. "Religion among disabled and nondisabled
persons II: Attendance at religious services as a predictor of the course of
disability." The Journals of Gerontology Series B: Psychological Sciences and Social
Sciences 52, no. 6 (1997).

Khayat, M. H. "Spirituality in the Definition of Health The World Health

Organizations Point of View." Obtenido de Swiss Academy of Medicine and Ethics:
http://www. medizin-ethik. ch/publik/spirituality_ definition_health. htm (1998).

Koenig, Harold G., Linda K. George, and Bercedis L. Peterson. "Religiosity and
remission of depression in medically ill older patients."American Journal of
Psychiatry (1998).

Koenig, Harold G. "Concerns about measuring spirituality in research." The Journal

of nervous and mental disease 196, no. 5 (2008): 349-355.

Leite, Fbio Carvalho. Estado e Religio: a liberdade religiosa no Brasil. Juru Editora.
(2014).

MENEZES, Rachel Aisengart. "Religiosidade e interpretao da morte." Religio e

sociedade 26, no. 1 (2006): 174-197.

Paim, Jairnilson Silva, and Lgia Maria Vieira da Silva. "Universalidade, integralidade,
equidade e SUS." BIS. Boletim do Instituto de Sade (Impresso) 12, no. 2 (2010): 109-
114.

Pires, Diovani Schreiber. "Assistncia religiosa na hospitalizao: uma abordagem

exploratria da ateno espiritual em Hospital Pblico." Monografia do Curso de
Especializao em Informao Cientfica e Tecnolgica em Sade, GHC/Fiocruz.
(2009).

Pressman, Peter, John S. Lyons, David B. Larson, and James J. Strain. "Religious belief,
depression, and ambulation status in elderly women with broken hips." Am J
Psychiatry 147, no. 6 (1990): 758-760.

Pressman, Peter, John S. Lyons, David B. Larson, and James J. Strain. "Religious belief,
depression, and ambulation status in elderly women with broken hips." Am J
Psychiatry 147, no. 6 (1990): 758-760.
SIMES, Pedro. "Assistncia Religiosa no Sistema Socioeducativo: A viso dos
operadores do direito." Religio e Sociedade 32, no. 1 (2012): 130-156.

SULLIVAN Winnifred Religion Naturalized: The New Establishment. Courtney

Bender and Pamela E. Klassen, eds. After Pluralism: Reimagining Religious
Engagement. New York: Columbia University Press (2010).

Sullivan, Winnifred Fallers. A ministry of presence: Chaplaincy, spiritual care, and the
law. University of Chicago Press, 2014.

Sullivan, Winnifred Fallers. Prison religion: Faith-based reform and the constitution.
Princeton University Press, 2009.

Tanyi, Ruth A. "Towards clarification of the meaning of spirituality." Journal of

advanced nursing 39, no. 5 (2002): 500-509.

Tix, Andrew P., and Patricia A. Frazier. "The use of religious coping during stressful
life events: main effects, moderation, and mediation." Journal of consulting and clinical
psychology 66, no. 2 (1998): 411-422.

Toniol, R. "Integralidade, holismo e responsabilidade: etnografia da promoo de

terapias alternativas/complementares no SUS." Etnografias em servios de
sade (2014): 153-178.

Toniol, Rodrigo. "Espiritualidade que faz bem: Pesquisas, polticas pblicas e prticas
clnicas pela promoo da espiritualidade como sade." Sociedad y religin 25, no. 43
(2015): 110-146.

Consulted documents

Brasil. Ministrio da Sade (MS). Secretaria de Ateno Sade. Departamento de

Ateno Bsica. "Relatrio do 1 seminrio Internacional de Prticas Integrativas e
Complementares em Sade." (2009).

Frum Inter-Religioso do GHC. Plano de Trabalho, 2011. Mimeo.

Santo ngelo, Lei n3.597. Publicada em 23 de maro de 2012. Mimeo.

Secretaria Estadual de Sade do Rio Grande do Sul. Resoluo n 695/13. Poltica

Estadual de Prticas Integrativas e Complementares, 2013. Mimeo

Zhang, Xiaorui, and World Health Organization (WHO). "General guidelines for
methodologies on research and evaluation of traditional medicine." World Health
Organization (2000): 1-71.