Complementary Therapies in Clinical Practice 21 (2015) 1e6 Contents lists available at ScienceDirect Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp The biopsychosocial spiritual model applied to the treatment of women with breast cancer, through RIME intervention (relaxation, mental images, spirituality)* rio Ricci a, b, Ana Catarina Araújo Elias a, b, *, Marcos Deside b rgio Henrique Diaz Rodriguez , Stela Duarte Pinto b, Joel Sales Giglio c, d, Lo Edmund Chada Baracat a, b ~o Paulo (FMUSP), Brazil Department of Obstetrics and Gynecology of the Faculty of Medicine, University of Sa ~o Paulo (ICESP), Brazil Institute of Cancer of the State of Sa c Department of Medical Psychology and Psychiatry of the Faculty of Medical Sciences, State University of Campinas (FCM UNICAMP), Brazil d Jungian Association of Brazil (AJB) Linked to the International Association for Analytical Psychology (IAAP)), Brazil a b a b s t r a c t Keywords: Spirituality Brief psychotherapy Psychosomatic medicine Imagery (psychotherapy) Complementary therapy This postdoctoral study on the application of the RIME intervention in women that had undergone mastectomy and were in treatment, aimed to promote psychospiritual and social transformations to improve the quality of life, self-esteem and hope. A total of 28 women participated and were randomized into two groups. Brief Psychotherapy (PB) (average of six sessions) was administered in the Control Group, and RIME (three sessions) and BP (average of ﬁve sessions) were applied in the RIME Group. The quantitative results indicated a signiﬁcant improvement (38.3%) in the Perception of Quality of Life after RIME according to the WHOQOL, compared both to the BP of the Control Group (12.5%), and the BP of the RIME Group (16.2%). There was a signiﬁcant improvement in Self-esteem (Rosenberg) after RIME (14.6%) compared to the BP of the Control Group (worsened 35.9%), and the BP of the RIME Group (8.3%). The improvement in well-being, considering the focus worked on (Visual Analog Scale), was signiﬁcant in the RIME Group (bad to good), as well as in the Control Group (unpleasant to good). The qualitative results indicated that RIME promotes creative transformations in the intrapsychic and interpersonal dimensions, so that new meanings and/or new attitudes emerge into the consciousness. It was observed that RIME has more strength of psychic structure, ego strengthening and provides a faster transformation that BP, therefore it can be indicated for crisis treatment in the hospital environment. © 2015 Elsevier Ltd. All rights reserved. 1. Introduction From the twentieth century to the present moment the possible transformation of the biomedical model (focus on the mechanisms * Postdoctoral Study by the ﬁrst author entitled “Resignifying the experience of being a breast cancer patient by using the RIME intervention for quality of life promotion”, under the supervision of the sixth author, co-supervised by the second author, with the collaboration of third, fourth and ﬁfth authors. Mastology Service of the Gynecology Discipline of the Faculty of Medicine, University of S~ ao Paulo (FMUSP) and Hospital Psychology Service of the Institute of Cancer ~o Paulo. Address: Avenida Doutor Arnaldo, 251 e Cerqueira Ce sar, of the state of Sa S~ ao Paulo e SP, Brazil. CEP: 01246-000. * Corresponding author. Rua Juquis, 391 ap.62B, Bairro Moema, CEP 04081-010 S~ ao Paulo, SP, Brazil. E-mail address: [email protected] (A.C.A. Elias). http://dx.doi.org/10.1016/j.ctcp.2015.01.007 1744-3881/© 2015 Elsevier Ltd. All rights reserved. of organic disease) into the biopsychosocial model (focus on the subject, interrelating the biological, psychological and social factors) has been an important study object. Leading researchers advocate bidirectional dialogue and integration between the two models , i.e., that studies are conducted demonstrating the beneﬁts and contributions for medical treatments by the inclusion of sociopsychic factors, however, that the importance of biological treatment is also observed with the advanced technology of the biomedical model, for the social and psychological well-being of the patient. The ﬁndings of the study reported in this article are in accordance with the proposal cited above , since it was observed that, faced with the diagnosis of breast cancer, patients experienced signiﬁcant distress and despair, loneliness and anger, however, such anxieties were minimized by clinical treatment, with 2 A.C.A. Elias et al. / Complementary Therapies in Clinical Practice 21 (2015) 1e6 emphasis on biomedical excellence. This enabled the emergence of other psychological suffering, which apparently had no connection with the disease yet inﬂuenced the perception of quality of life and the self-esteem of patients, and that were worked on through the RIME intervention (Relaxation, Mental Images and Spirituality) resulting in improved perception of quality of life in general, the ampliﬁcation of self-esteem, as well as the promotion of creative transformations in the intrapsychic and interpersonal dimensions of these patients, so that new meanings and/or new attitudes emerged for awareness, thus applying the biopsychosocial and spiritual model to the treatment. The integration of the spiritual dimension of the human being to the biopsychosocial model has been an important object of study in the academic community. Spirituality is related to the transcendent, to the sacred aspects of the existence and to the universe, and in a search of the PubMed database, 1109 relevant articles were found on the clinical application of spirituality for mental health , which corroborates this statement. The RIME intervention integrates relaxation techniques, guided imagery and elements of spirituality, with a transpersonal symbolic approach and was developed in the Master's degree [3e5] of the ﬁrst author to resignify the Symbolic Pain of Death (Psychic Pain and Spiritual Pain) of patients without the possibility of a cure. In the ﬁrst author's doctorate [6e8] a training program was developed for health professionals and both the experience of the professionals, as well as that of the patients, in the application of RIME were studied. The results suggested that RIME promotes quality of life, dignity and improved psycho-spiritual well-being in the dying process, as well as psycho-spiritual beneﬁts to the health professionals that apply it. The beneﬁts achieved with the application of RIME in patients with Alzheimer's dementia and their carers were also studied, where improvements in interpersonal communication and in socio-emotional and spiritual aspects were observed in the caregivers and the patients . This article refers to the postdoctoral research of the ﬁrst author who studied the beneﬁts of RIME in patients with the possibility of a cure, choosing the treatment of breast cancer. This type of cancer more affects women around the world, both in developing and developed countries. For Brazil, in 2014, 57,120 new cases of breast cancer are expected, with an estimated risk of 56.09 cases per 100,000 women . In a systematic literature review  factors such as quality of life, hopelessness and self-esteem were considered important sources of resilience (ability to emerge from adverse situations strengthened and transformed for the better), in coping with somatic diseases, and faced with these ﬁndings, the authors  concluded that such factors need to be considered and possibly incorporated into psychological and psychiatric care for physically ill individuals. The aim of this study was to apply the RIME intervention with mastectomized women undergoing breast cancer treatment, with the possibility of a cure, in order to elicit the transcendent function , i.e., as a facilitator for the establishment of dialogue between the conscious and unconscious contents, favoring the sociopsycho-spiritual transformation of these patients, with the intention of positively affecting the ‘quality of life’ and psychological aspects of ‘hopelessness’ and ‘self-esteem’. 2. Methods This study was approved without restrictions by the Research Ethics Committee of the Faculty of Medicine, University of S~ ao Paulo, under process number: 70430, dated: 08/08/2012. During the year 2013, 34 patients who had undergone mastectomy and were in the breast reconstruction and adjuvant treatment process, with the possibility of a cure, were referred by the Plastic ~o Surgery Outpatient Clinic of the Cancer Institute of the state of Sa Paulo (ICESP). Of these, 28 were screened and randomly divided into ﬁve groups, draw in the presence of the physicians of the Mastology Outpatient Clinic of ICESP, with each group of patients divided in two to compose the Control Group, who received up to twelve sessions of Brief Psychotherapy (PB), from co-author 4, and the RIME Group, who received three sessions of RIME from the main author, and up to twelve sessions of BP from co-author 4. The BP described in this study, in short, is psychotherapy with a deﬁned focus, over a limited number of sessions, and conducted through verbal expression. After one year of screening the study was subjected to statistical analysis, considering the sample size required for the difference between the groups to be longitudinally signiﬁcant, considering a type one error of 5% and power of 95%. From this, according to the study aims, it was concluded that the sample of 28 patients was sufﬁcient, including the withdrawal of three patients from the RIME Group and three patients from the Control Group for personal reasons. A comparative, descriptive, exploratory method was used with a quantitative-qualitative approach. A qualitative approach was based on Analytical Psychology [12e16], for the symbolic interpretation of the data, with the processing of the data performed through thematic content analysis [6e8]. The development of the qualitative results was performed by consensus analysis, in a group composed of the principal investigator and co-authors 3, 4 and 5, with qualiﬁed knowledge in Analytical Psychology and Hospital Psychology. The quantitative analysis was performed by a statisti~o Paulo School of Nursing, through the cian of the University of Sa ‘mixed effects model’ method. The socio-demographics data of the RIME Group and Control Group were subjected to Fisher's exact test and Welch's t test, showing no signiﬁcant differences, i.e., p values greater than 0.05, as shown in Table 1. The instruments for the qualitative data collection were recorded semi-structured interviews and graphical representations, before the 1st session and after the 3rd session of RIME. The instruments used to collect the quantitative data for the RIME Group and Control Group were the WHO Quality of Life-Bref instrument/ WHOQOL Bref ; Rosenberg's Self-Esteem Scale ; Beck's Hopelessness Scale (BHS) ; and the Visual Analog Scale, colored facial expressions model [6e8], which were applied after the signing of the TFPIC (RIME and Control Groups), after the 3rd session of RIME (RIME Group), and after the BP (RIME and Control Groups). The main theoretical bases used for the development of RIME were Analytical Psychology [12e16] and Near Death Experiences [20e24]. The RIME application is initiated by the induction of a state of mental relaxation through slow, deep breathing and listening to soft music, previously chosen by the patient; next the visualization of an image of nature is induced, also chosen by the patient (a beach, waterfall, garden, ﬁeld or lake) where a Supreme Spiritual Being of Light that emanates absolute and unconditional Love, previously deﬁned by the patient according to their religion, waits to accompany them in the experience. The Spiritual Being of Light has a dual representation: in the symbolic, socio-psychic dimension, it represents the Self  (internal source) and in the spiritual dimension it represents the psychic contact of the patient with the Beings of Light (external source) [20e24], i.e., with Unconditional Love, the Sacred, represented by the cultural dimension of their religion. The RIME intervention is structured through four basic images of possible archetypal character, related to the alchemical phases and operations  and refers to the Symbols of Transformation . From the nigredo raw content, the solutio is performed to reach A.C.A. Elias et al. / Complementary Therapies in Clinical Practice 21 (2015) 1e6 Table 1 Socio-demographic data comparison between the RIME Group and Control Group. p-Valuea Group Control RIME N N % % Religion Catholic Protestant Spiritualist Other 5 4 1 1 45.5 36.4 9.1 9.1 4 2 3 2 36.4 18.2 27.3 18.2 0.689 Education Up to elementary High school Higher education 7 3 1 63.6 27.3 9.1 3 6 2 27.3 54.5 18.2 Marital status Single Married/stable union Divorced/separated Widowed 0 4 4 3 0.0 36.4 36.4 27.3 2 6 3 0 18.2 54.5 27.3 0.0 0.355 0.147 Reconstruction Immediate with expander Immediate with abdominal ﬂap Other Operated breast Right Left Bilateral Age a b creative potential that emerges from the unconscious and that should be integrated into the consciousness, developed and experienced [12e16]. On completion of the experience, when the patient symbolically prepares to return from the star to the place they left (beach, waterfall, garden, ﬁeld or lake), down the white staircase, they also receive a blue cloak, symbolizing protection. The average application time of the experience is 25 min, plus the time required for the verbal expression before and after the RIME application. In the RIME Group three sessions of RIME were applied by the principal investigator with each patient, with an interval of at least one week between one session and the next, followed by up to twelve sessions of BP by co-author 4. In the Control Group up to twelve sessions of BP were applied with each of the patients by coauthor 4. The BP was terminated when the patient and the psychologist felt that the proposed focus had been sufﬁciently covered. The average number of BP sessions for the RIME Group was ﬁve sessions and six sessions for the Control Group. 3. Results 0.672 8 2 1 72.7 18.2 9.1 7 1 3 3.1. Quantitative results 63.6 9.1 27.3 0.790 Complication in the reconstruction Physio/radio/chemo 3 3 3 0 50.0 50.0 0.0 3 5 2 30.0 50.0 20.0 2 11 18.2 100.0 2 10 20.0 100.0 1.000 1.000 Mean SD Mean SD p-Valueb 52.45 12.23 48.00 8.00 0.326 Fisher's exact test. Welch's t-test. the albedo through two images. 1st) Water represented by a waterfall, beach/ocean or river, where the patient washes and dissolves their suffering, their shadow content. The suffering mentioned and chosen by the patient is dissolved. 2nd) Colorful robes, where the patient experiences them all and then mentally chooses the color of robe that they prefer, with reference to the colors of the chakras postulated by Oriental traditions. Symbolically, the movement of progression or regression of the libido  is observed and the transcendent function  is elicited. The induced colors are: red, orange, yellow (warm colors/lower or terrestrial chakras, suggesting progression of the libido); green, sky blue, royal blue (cool colors, higher or psychic chakras, suggesting regression of the libido); pink, violet, white, silver, gold (mixed hot and cold colors together/spiritual chakras, suggesting that the transcendent function was elicited). Then, through the third image, coagulatio is performed to reach citrinitas. The quality chosen by the patient is coagulated with their well-being and quality of life. 3rd) In a star, the same color chosen for the robe, reached via a white staircase, the patient receives golden seeds that are deposited by the Supreme Spiritual Being of Light that emanates absolute unconditional Love in the forehead, throat, heart, navel, hands and feet of the patient, to enlighten their thoughts, words, feelings, emotions, actions and pathway, considering the desired quality. Finally, through the fourth image, the coniunctio is performed to reach rubedo. 4th) The Supreme Spiritual Being of Light that emanates absolute, unconditional Love delivers a red box containing a gift to the patient, as a symbolic reference to a speciﬁc aspect of the According to the statistical analysis shown in Table 2, comparing the RIME Group with the Control Group, the quantitative results indicated signiﬁcant improvement (38.3%) in the Perception of Quality of Life according to the WHOQOL  after RIME compared to both the BP of the Control Group (12.5%) and the BP of the RIME Group (16.2%). Signiﬁcant improvements in Self-esteem (Rosenberg)  after RIME (14.6%) compared to the BP of the Control Group (35.9% worsened) as well as the BP of the RIME Group (8.3%). The improvements in the BHS (hopelessness)  were similar in both the RIME Group and the Control Group: RIME ¼ 20.1%, RIME þ PB ¼ 27.1%, BP 11.1%. The improvement in well-being considering the focus worked (Visual Analog Scale) [6,7] was signiﬁcant in the RIME Group (bad well-being to good well-being), as well as in the Control Group (unpleasant well-being to good wellbeing). None of the three treatments, RIME, RIME þ BP, or BP, presented signiﬁcant improvements in the domains of the WHOQOL  or in the satisfaction with health of the WHOQOL . 3.2. Qualitative results The qualitative analysis was performed in order to comprehend the process and the meaning of the transformation that occur through RIME. The categories were developed based on Analytical Psychology [12e16], for the symbolic interpretation of the data, with the processing of the data performed through thematic content analysis [6e8]. The development of the categories was performed by consensus analysis, in a group composed of the principal investigator and co-authors 3, 4 and 5, with qualiﬁed knowledge in Analytical Psychology and Hospital Psychology, based on semistructured interviews before and after each session of RIME. A) With regard to the FOCUS FOR TRANSFORMATION, i.e., the behavior, emotion or feeling chosen by the patient to be worked on and transformed through RIME, two categories were found: Category 1) SELF-VALORIZATION to transform the relationships, whether at the marital, family, work, or spiritual level. Category 2) SELF-VALORIZATION to transform the sequelae of the disease. B) With regard to the analysis of the SYMBOLIC DIMENSION OF THE SELF three categories were found: 4 A.C.A. Elias et al. / Complementary Therapies in Clinical Practice 21 (2015) 1e6 Table 2 Quantitative results/comparison of the results of the scales in the three phases: 1st phase: after signing the TFPIC (RIME Group and Control Group); 2nd phase: after application of the three RIME sessions (RIME Group); 3rd phase: after application of up to twelve sessions of Brief Psychotherapy (RIME Group and Control Group). p-Valuea Group Control Mean ~o da QV Percepça Post TCLE Post RIME Post PB ~o com a Saúde Satisfaça Post TCLE Post RIME Post PB Físico Post TCLE Post RIME Post PB gico Psicolo Post TCLE Post RIME Post PB Social Post TCLE Post RIME Post PB Meio Ambiente Post TCLE Post RIME Post PB WHOQOL total Post TCLE Post RIME Post PB Rosenberg Post TCLE Post RIME Post PB BHS Post TCLE Post RIME Post PB EVA Post TCLE Post RIME Post PB RIME SD 3.07 1.77 3.45 0.69 3.55 1.21 3.55 0.82 2.90 0.68 3.09 0.61 3.51 0.76 3.47 0.48 3.85 0.62 3.60 0.66 3.97 1.42 3.63 1.30 3.61 0.72 3.46 0.46 8.36 6.17 11.36 4.78 4.91 3.11 4.36 3.47 4.55 2.70 7.09 2.07 Improvement Mean SD 12.5% 3.29 4.55 3.82 1.90 0.52 1.40 0.0% 3.55 3.64 3.55 1.44 1.12 1.44 6.3% 3.09 3.59 3.35 0.97 0.87 1.29 1.3% 3.50 3.56 3.42 0.67 0.70 1.27 6.3% 3.54 3.63 3.60 1.05 0.89 1.43 8.6% 3.54 3.73 3.42 0.58 0.64 1.30 4.2% 3.50 3.78 3.52 0.79 0.61 1.28 35.9% 8.73 7.45 8.00 5.52 5.73 5.39 11.1% 4.36 3.45 3.18 3.59 3.30 2.44 56.0% 3.45 6.91 7.82 2.02 2.59 2.89 RIME Control RIME þ PB Control RIME RIME þ PB 0.032 0.792 0.010 0.865 1.000 0.810 0.228 0.766 0.198 0.740 0.931 0.555 0.503 0.542 0.932 0.139 0.539 0.214 0.141 0.558 0.203 0.068 0.109 0.735 0.819 0.690 0.809 0.461 0.146 0.300 Improvement 38.3% 16.2% 2.6% 0.0% 16.4% 8.5% 1.7% 2.2% 2.5% 1.7% 5.2% 3.5% 7.8% 0.5% 14.6% 8.3% 20.8% 27.1% 100.0% 126.3% Bold¼indication of improvement in the perception of quality of life in the RIME Group.Italic¼indication of self-esteem improvement in the RIME Group. a Mixed effects model. Category 1: TRANSFORMATION of the FEMININE representation from absent or devourer to the loving or protective, of the MASCULINE from the intangible, absent or impotent to the tangible, potent and loving, and of the DIVINE from the intangible, inaccessible and impersonal to the close, accessible and loving. Category 2: INTEGRATION into the consciousness of the capacity for selfcare, self-valorization, self-conﬁdence; of the deserving of the protection of Divine love; of the existence of internal resources; and of new external possibilities for the expression of the potential. Category 3: PATHWAY to BREAK PRIMITIVE AND RIGID DEFENSES, allowing an opening for the development of repressed conﬂicts, WITHOUT PSYCHICALLY DISRUPTING THE PATIENT. C) With respect to the symbolic comprehension of the COLOR OF THE ROBE/STAR, one category was found: “There are indications the RIME intervention ELICITS THE TRANSCENDENT FUNCTION, this transcendent function may occur with movement of regression of the libido, with movement of progression of the libido, or reciprocating progression/ regression”. D) With regard to the fourth image/the gift found in the red box, the SYMBOLS OF TRANSFORMATION that emerged were: ➢ Representations of the mineral world (n ¼ 6): Golden seeds. Blue “smoke”. Carpet full of stars of all colors. A.C.A. Elias et al. / Complementary Therapies in Clinical Practice 21 (2015) 1e6 Crown with shiny stones. Crown full of green stones. Golden crown with emerald stones. Two crystals. ➢ Representations of the vegetable world (n ¼ 3): Red Rose. Red Roses. Bouquet of ﬂowers. Pink rose. Orange rose. Tulip. ➢ Representations of the animal world (n ¼ 1): White dove in white box. ➢ Representations of the human world (n ¼ 8): Sense of healing. Feeling of Love, of Care/Caring, of Peace. Quality “courage”. Child/baby. Feeling of emptiness. Shining red breast. Golden heart. Reassuring message on a paper drinking straw. Gold pendant with a photo of her daughter and son together. White Robe. Blue box with card (ticket) written “Believe, Trust and Forgive”. Very pretty poster written: “Always Believe”. Photographs of places and family members, acquaintances, but with reference to the future and happiness. The analysis [12e16,25] of these Symbols of Transformation suggested representations of healing and wholeness, expressed in the category: “Mediated by the symbols of transformation (presents), the unconscious archetypal potential entered into the consciousness: with the potential for psychic transformation, usually with energy for its constellation, and representing beacons of light illuminating the darkness of the unconscious for the expression of the creative femininity”. E) The graphical representation aimed to identify feelings, emotions or thoughts faced with cancer at the moment of diagnosis and at the moment of treatment (in the breast reconstruction and adjuvant treatment process), and in the consensus analysis the authors observed that the symbolism of the drawings was transformed for the better in the drawings of all patients after the third session of RIME, suggesting that this intervention facilitates the introduction into the consciousness of self-curative resources and minimizes the traumatic memory. 4. Discussion The importance of subjective transformations and positive changes in the lives of cancer survivors, from the perspective of the biopsychosocial and spiritual model, which goes beyond the event of sickness, are being reported in the academic literature [26,27]. This study aimed to promote socio-psycho-spiritual transformations through RIME, focusing on the transformation of the psychological distress chosen by the patient, not necessarily related to breast cancer, in order to contribute to the quality of life and selfesteem and to minimize the hopelessness of these patients. Comparing the RIME intervention with the BP applied with the Control Group, considering the statistical analysis, it was observed that the RIME had more strength in psychic structuring and ego strengthening than the BP, even though both caused a signiﬁcant improvement in the perceived quality of life and self-esteem of the patients. Regarding the promotion of hope and the transformation of the focus (psychological distress chosen by the patient to be worked on), the results between RIME and BP were similar, however it was observed that RIME produced a faster transformation, since three RIME sessions were performed, compared to an average of six BP sessions in the Control Group. Although BP is an intervention consecrated in Psycho-Oncology , the results are relevant for the indication of RIME for psychological treatment in a crisis situation in the hospital context, considering hospitalization, pre- and post-surgery monitoring, and the outpatient clinic. 5 No signiﬁcant improvements were related to the BP of the RIME Group patients, compared to improvements achieved by the RIME itself, suggesting that three RIME sessions are sufﬁcient to promote the transformation. It was observed that RIME does not provide a cognitive, rational solution for the problems and suffering of patients, but facilitates the perception of the strength of their own life drive to solve the problem, i.e., the ability to recognize one's own potential and energetic force and the possibility of being able to construct a better, more integrated life. In summary, the RIME Intervention promotes the empowerment of the libido , as a constructive force, in women with breast cancer, with the possibility of a cure. To identify the social and psychological suffering of cancer patients in the medical setting, and to assist them in obtaining appropriate psychosocial services is an important factor of discussion in the literature [28,29]. The qualitative analysis of the data indicated that the main suffering, the focus for transformation of the women with breast cancer of the RIME Group, was the need for self-valorization, which was also observed in the BP of the Control Group. The main psychological transformations found, mediated by the symbolic elements of the RIME, were the transformation of the feminine representation from the absent or devourer to the loving or protector, of the masculine from the intangible, absent or impotent to the tangible, potent and loving, and of the divine from the intangible and inaccessible to the close, accessible and loving. Such representations in women refer to personality structures, with the feminine representation being related to the main personality, with characteristics related to feelings and intuition (Eros), and the masculine representation related to a subpersonality called animus, which operates at an autonomous and less conscious level, with characteristics related to rationality and objectivity (Logos) . The Divine representation refers to the connection of the personality with the sacred . The transformation of these basic personality structures indicates a healthy and regenerating movement of the libido , disassociating from the death drive polarity, to the life drive polarity, and enabling integration into the consciousness of the capacity for self-care, self-valorization, selfconﬁdence; of deserving of the protection of Divine love; of the existence of internal resources; and of new external possibilities for the expression of the potential. The aim of this study was for RIME to elicit the transcendent function , that is, to facilitate the integration into the consciousness of the healing and constructive potential of the patients, extending the capabilities of self-valorization and positive action, and strengthening the personality through the symbolic union of the opposites [12e16]. This was achieved by observing the category found in the symbolic analysis of the colors of the robes and of the gift offered by the Spiritual Being of Light, in the red box. There is an important neuroscientiﬁc discussion about the mind brain relationship. In empirical studies by leading researchers [20e24,30] support is given to the hypothesis that the consciousness (mind, psyche) and brain are separate entities, i.e., consciousness is not produced by the brain but manifested through it, having characteristics of not being local, and that transformations in the dynamics of the consciousness can alter the thoughts and emotions expressed through the brain dynamics. Considering the results found in this study, working with the transformation of the personality of the patients through the psychic dynamic, the consciousness, from a symbolic perspective, aligns us with the hypothesis that the mind is not produced by the brain. Conﬂicts of interest statement None declared. 6 A.C.A. Elias et al. / Complementary Therapies in Clinical Practice 21 (2015) 1e6 Acknowledgments We thank Dr. Eduardo Gustavo Pires de Arruda, Dr. Alexandre Siqueira Franco Fonseca and Dr. Eduardo Montag for the referral of the patients of the Plastic Surgery Outpatient Clinic of the Institute ~o Paulo (ICESP). of Cancer of the state of Sa References  Lane RD. Is it possible to bridge the biopsychosocial and biomedical models? Biopsychosoc Med 2014;8(1):3.  Moreira-Almeida A, Koenig HG, Lucchetti G. Clinical implications of spirituality to mental health: review of evidence and practical guidelines. Rev Bras Psiquiatr 2014;36(2):176e82. ^utica na a rea de Cuidados Pal Elias ACA, Giglio JS. Intervenç~ ao Psicoterape lica da Morte de Pacientes Terminais iativos para re-signiﬁcar a Dor Simbo s de Relaxamento Mental, Imagens e Espiritualidade. Rev Psiquiatr Clín atrave 2002;29(3):116e29. ^ncias de Natureza Espiritual relacionados  Elias ACA, Giglio JS. Sonhos e Vive a Fase Terminal. 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