Chinese spirit-medium (tongji, wu) healing

1. Introduction

Version followed: Chinese spirit-mediumship as it is practised today among Minnan (Hokkien)-descended communities in Taiwan, Singapore and Malaysia (Penang), as described by Taiwanese historical scholarship (Lin Fu-shih, Academia Sinica), Singapore and Penang ethnography (Margaret Chan; Jean DeBernardi; Boon-Ooi Lee and Laurence Kirmayer), with the psychotherapist's own work structured by the DSM-5-TR Cultural Formulation Interview (CFI) and Kleinman's explanatory-model approach. Historical wu (巫) is covered only as background.

What it is. A tongji (童乩, Mandarin) or jitong (乩童), called dang-ki / tangki in Hokkien and dang-gi in Taiwanese scholarship, is a spirit medium whose body, in the understanding of devotees, is possessed by a god, deity or spirit; while possessed the medium is regarded as the deity incarnate, and clients and community regard the speaker as "not the person, but instead the deity" [source: Chan 2020, BiblioAsia; Lee & Kirmayer 2019 as summarised by Dhar 2020]. Older Chinese sources call such intermediaries wu or wuxi (巫覡, shamans); the terms 童乩/乩童 became common in Taiwanese records only from the 19th century, and Hakka speakers use 乩僮 or 僮子 [source: 嵇童 1993, 台灣童乩]. Related figures elsewhere include masong in Thailand and tatung in West Kalimantan [source: Chan 2020]. Devotees consult mediums for illness, misfortune, blessing, divination about career, wealth and relationships, and interpersonal conflict [source: Lee & Kirmayer 2019 via Dhar 2020; Lee, Kirmayer & Groleau 2010].

How change is understood, as the tradition and its scholars describe it. In the tradition's own terms, healing is conducted by the possessing deity, not by the human medium [source: Lee, Kirmayer & Groleau 2010]. Illness is commonly attributed to spirits or supernatural forces (plague gods, malicious ghosts, angry ancestors, curses, a frightened soul, 靈魂受驚), to moral faults, and also, in part, to causes recognised by Chinese and Western medicine; treatment is "ritual healing" (儀式治療) that may include exorcism, prayer, deity-given prescriptions, massage and referral to medical care [source: Lin Fu-shih, 醫者或病人, translated in brief]. Scholars frame the effect, from outside the tradition, as symbolic healing within a shared meaning system that may unfold over several sessions [source: Lee, Kirmayer & Groleau 2010], and as "embodied relational" healing that restores bodily, emotional, relational and spiritual health in a semi-public, communal setting rather than only removing symptoms [source: Lee & Kirmayer 2019 via Dhar 2020]. These are scholarly interpretations, attributed as such; the spiritual account is the community's own and is neither affirmed nor dismissed here.

What this guide is. This is not a therapy the psychotherapist performs. A psychotherapist does not conduct possession, consultation, exorcism, talisman work or divination, and nothing here describes how those are done. The guide covers the psychotherapist's own culturally responsive work with clients who are devotees, family members of devotees, or mediums themselves: assessment with the CFI, the client's explanatory model, telling culturally normative possession trance apart from disorder, collaboration with the client's own community healers when the client wishes, integration of consultation experiences into therapy, and safeguarding [synthesis, structured on APA CFI materials and Kleinman 1981].

Who holds authority. Within the tradition, authority is understood to rest with the possessing deity speaking through the medium [source: Chan 2020; Tan Chee-Beng review of DeBernardi 2006]. In Singapore, tangki groups are typically informal cults centred on a charismatic medium that celebrate their deity's feast days and often dissolve when the medium dies; they usually operate independently of Chinese temples, whose management committees (often local businessmen) generally keep their distance from those claiming to speak for gods, though the two sometimes cooperate at festivals [source: Chan 2020]. No state licensing or registration body for spirit mediums in Taiwan, Singapore or Malaysia is identified in the sources used here [uncertain: not verified]. Historically, the practice has been banned or suppressed: Qing law against 師巫邪術 ("heterodox arts of masters and shamans"), Japanese colonial police regulations from 1908 used to arrest mediums in Taiwan, and the Nationalist (KMT) campaign 破除迷信 ("eliminate superstition"); 20th-century Nationalist and Communist governments in China also worked to eliminate it [source: 嵇童 1993; Chan 2020]. The legitimate pathway for a client is their own family, temple and devotional community, not a therapist's referral list [synthesis].

2. Framework

There is no published clinical protocol for psychotherapy alongside tongji healing; the phases below are the psychotherapist's own work, built on the CFI and the explanatory-model approach [synthesis; source: APA CFI 2013; APA CFI Supplementary Modules; Kleinman 1981].

Phase A. Preparation and self-examination (before and throughout). Goal: recognise your own assumptions about possession, "superstition" and self-wounding, and the history of psychiatrists and missionaries labelling mediums as mentally ill or fraudulent [source: 嵇童 1993; Lin, 醫者或病人]. Move on when you can describe the client's practice in their terms without implicit judgement [synthesis].

Phase B. Cultural assessment (typically sessions 1 to 2). Goal: the core CFI (16 questions in four domains, used with the client's own words for the problem) plus the supplementary modules that fit: Explanatory Model; Spirituality, Religion and Moral Traditions; Coping and Help-Seeking; Social Network; Cultural Identity; Immigrants and Refugees; Patient–Clinician Relationship; Caregivers for family [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf; https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Format: individual, with an interpreter for Hokkien, Teochew, Hakka, Cantonese or Taiwanese where needed; family or an informant with consent. Move on when you know the client's name for the problem, perceived cause, what consultation with a medium has meant to them, and what help they want now [synthesis].

Phase C. Differential assessment: normative experience or disorder (as needed, often overlapping B). Goal: tell possession trance accepted as part of collective cultural or religious practice (outside ICD-11 6B63 possession trance disorder) from involuntary, unwanted, distressing trance states, and from panic, psychosis, mood disorder, neurological illness or substance effects [source: ICD-11 6B63; Khoe & Gudi 2022]. Move on when a working formulation is agreed with the client, with medical or psychiatric review completed where indicated [synthesis].

Phase D. Shared formulation and plan (session 2 to 4). Goal: a formulation that holds the client's explanatory model and the clinical view side by side; agreement on whether and how the therapist and the client's community healers will be in contact; what the therapy will address [synthesis]. Move on when the client endorses the plan and consent and confidentiality boundaries are written down [synthesis].

Phase E. Therapy with integration (ongoing; length set by the presenting problem). Goal: the evidence-based treatment indicated for the presenting problem, delivered in a way that respects concurrent consultations and integrates their meaning [synthesis]. Periodic review: about every 4 to 6 sessions revisit the explanatory model, help-seeking and any change in the client's involvement with a medium [synthesis].

Throughout: safeguarding. Injury, coercion, exploitation, involvement of minors in self-wounding, or delay of urgent medical care override sequencing [synthesis].

3. Guiding principles

The psychotherapist works alongside, never inside, the tradition. Practical meaning: you do not interpret omens, endorse or contest a deity's words, or advise on ritual; you work with what the client brings [synthesis; scope per Section 1].
Attribute, do not adjudicate. Practical meaning: say "in your understanding, the god said…" rather than treating possession as fact or as delusion [synthesis].
Use the client's own terms. Practical meaning: write tangki, tongji, dang-gi, 靈魂受驚, "bad luck" in the notes as the client uses them; the core CFI tells the interviewer to reuse the client's terms [source: APA CFI].
Avoid both pathologising and missing illness. Practical meaning: possession trance within accepted collective practice is not a disorder under ICD-11, but religious content can sit on top of panic or other illness [source: ICD-11 6B63; Khoe & Gudi 2022].
Being a medium is not evidence of mental disorder. Practical meaning: illness often figures in becoming a medium (成乩), but not every medium has been ill and only a small share of those illnesses are psychiatric [source: Lin, 醫者或病人].
Expect plural help-seeking. Practical meaning: assume clients may combine biomedicine, Chinese medicine and temple consultations; ask about all of them [source: Lee, Kirmayer & Groleau 2010; Kleinman 1981].
The self may be relational. Practical meaning: frame goals around harmony, roles and family as well as individual autonomy, and do not treat a client's emphasis on emotional restraint as avoidance by default [source: Lee & Kirmayer 2019 via Dhar 2020].
Remember the history of suppression and stigma. Practical meaning: expect secrecy about consultations; name that you are not there to judge [source: 嵇童 1993; Lin, 醫者或病人].
Authority lies with the community, not with you. Practical meaning: the client chooses whether and which medium or temple they consult; you never recommend a particular medium or seek ceremonies for a client [synthesis].
Consent governs every contact. Practical meaning: no contact with a medium, temple or family member without the client's explicit, specific, revocable consent [synthesis].
No advice on medicines, herbs or talismans that are consumed. Practical meaning: route any question about prescribed medication, herbal prescriptions given in a consultation, or ingested items to the prescriber or a physician [synthesis].
Safety first. Practical meaning: injury, coercion, financial exploitation, sexual abuse and children's involvement in harmful practices trigger standard safeguarding duties regardless of religious framing [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own. None describes how a medium works. Example language is illustrative unless quoted. [source per item]

4.1 Cultural humility and self-examination

Purpose / when: before first contact with a devotee or medium client, and whenever you notice a reaction (amusement, alarm, disgust at self-wounding, wish to "correct" a belief) [synthesis].
Steps: (1) Note your own religious or secular frame and any learned label for mediumship ("superstition", "hysteria", "fraud"). (2) Read about the historical labelling: Taiwanese psychiatrists and others have described mediums as having low intelligence, immature personality or schizophrenia, and Christian writers hoped Christianity would replace them [source: 嵇童 1993]. (3) Note the counter-evidence: fieldwork finds illness important in becoming a medium but only a small share of it psychiatric, and describes mediums as an underprivileged group often facing poverty and limited education [source: Lin, 醫者或病人]. (4) Use the clinician-reflection prompts of the Patient–Clinician Relationship module (how your identity, culture and any interpreter shape the encounter) [source: APA Supplementary Modules]. (5) Take it to supervision or consultation with a colleague from the community.
Example language (illustrative, to yourself or a supervisor): "What do I actually believe is happening when this client says the god spoke? How would that leak into my questions?"
Watch for: questions phrased to test belief ("Do you really think…"); over-identification (agreeing with spiritual interpretations to please). Working: the client discloses consultations more freely over time [synthesis].

4.2 Core Cultural Formulation Interview

Purpose / when: first or second assessment session with any client from a community where mediumship is practised, and whenever the problem is explained in spiritual terms [source: APA CFI].
Steps: (1) Introduce the interview as a way to understand the problem from the client's perspective, with no right or wrong answers. (2) Work through the four domains in order: cultural definition of the problem; cultural perceptions of cause, context and support (perceived causes, stressors and supports, role of cultural identity); cultural factors affecting self-coping and past help-seeking (formal, informal and traditional); cultural factors affecting current help-seeking (what the social network suggests, and the clinician–patient relationship). (3) Reuse the client's own words for the problem in later questions, as the interviewer instructions direct. (4) Do not use the CFI as the sole basis for diagnosis. (5) Summarise back and record the client's terms verbatim [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf, paraphrased; the form may be reproduced by clinicians for use with their patients].
Example language (illustrative): "When you tell your family about this, what do you call it?" / "Besides doctors, have you gone anywhere else for help, such as a temple or a medium? What happened, and did it help?"
Watch for: the client giving a "medical" answer first and a spiritual one only later; mention of a consultation as an aside. Working: the client names the problem in their own idiom (e.g., soul fright, bad luck, an ancestor's anger) and describes past help-seeking without hesitating [synthesis].

4.3 Explanatory Model module and Kleinman's explanatory-model enquiry

Purpose / when: whenever the client's account of cause, course or treatment differs from the clinical one; Kleinman developed the explanatory-model concept largely from Taiwanese fieldwork with folk healers, temple practitioners, Chinese-style and Western-style physicians [source: UC Press page for Kleinman 1981; APA Supplementary Modules].
Steps: (1) Using the Explanatory Model module, explore perceived cause, prior experience of the problem, others known with it, media influences, effects on body, mind and spirit, expected course, and preferred ways of dealing with it [source: APA Supplementary Modules, paraphrased]. (2) Listen for causes the tradition names: spirits or plague gods, malicious ghosts, angry ancestors, curses, a frightened soul (靈魂受驚), moral faults, alongside medical causes [source: Lin, 醫者或病人]; spiritual collusions causing bad luck or ill health (Hokkien hoandiah, chhiongdioh) and "mending luck" are reported from Penang [source: Tan Chee-Beng review of DeBernardi 2006]. (3) Map the client's sectors of care (family, temple and medium, Chinese medicine, biomedicine) and what each is expected to do [synthesis on Kleinman 1981]. (4) Ask what the medium (or deity, in the client's understanding) said the cause was, and what the client thinks of that. (5) Write a two-column formulation: client's model and clinical model, with points of overlap [synthesis].
Example language (illustrative): "In your understanding, what started this?" / "When the god spoke through the tangki, what did he say was wrong? Does that fit with how it feels to you?" / "What would getting better look like, in your family's eyes?"
Watch for: layered or shifting models (moral fault plus stress plus spirit), which are common and not a sign of confusion; a model that blocks urgent care. Working: the client can hold both explanations without feeling one must win [synthesis].

4.4 Spirituality, Religion and Moral Traditions module

Purpose / when: when devotion to a deity, temple or medium's group is part of daily or family life, or a source of conflict [source: APA Supplementary Modules].
Steps: (1) Ask about affiliation, family religious background, and the role of practice at home and in the community. (2) Explore how the tradition helps coping and where it strains it (obligations, costs, family disagreement, conversion conflicts). (3) Ask about any discrimination or conflict linked to the practice. (4) Note moral teaching the client values: Penang mediums' teaching draws on Daoism, Buddhism and Confucianism, including self-cultivation and filial piety [source: Tan Chee-Beng review of DeBernardi 2006]. (5) Do not ask the client to describe rituals in detail; ask about meaning, not procedure [synthesis].
Example language (illustrative): "What place does the temple, or this god, have in your family's life?" / "Is there anyone in the family who disagrees with going to the medium?"
Watch for: intergenerational or interfaith conflict (e.g., a converted relative); shame about the practice linked to the history of anti-superstition campaigns [source: 嵇童 1993]. Working: the client can name both comforts and strains of the practice [synthesis].

4.5 Coping and Help-Seeking and Social Network modules

Purpose / when: mapping all current help, including medium consultations, Chinese medicine, natural remedies and family advice [source: APA Supplementary Modules].
Steps: (1) Use Coping and Help-Seeking to list self-coping, spiritual practices, remedies, help from religious communities, doctors, mental-health professionals and other healers; the module's guide itself gives "spirit possession" as an example of how a person may name a problem [source: APA Supplementary Modules]. (2) Use Social Network to learn what family, friends and the worship community know, advise and whether the client wants them involved. (3) Record what was recommended at consultations in general terms: reported methods include advice, talismans (fu), rituals against harmful spirits, and also acupuncture and herbs [source: Lee & Kirmayer 2019 via Dhar 2020]; spoken words, talismans and physical manipulation were usually combined [source: Lee, Kirmayer & Groleau 2010]. (4) If anything consumed or applied to the body was recommended (herbal prescriptions, talisman preparations reported as sometimes consumed), note it and tell the client you will pass it to their doctor or prescriber; give no view on it [synthesis].
Example language (illustrative): "Can we make a list of everyone who is helping with this, the doctor, the temple, family, anything you take or do yourself? I won't judge any of it; it helps me not to work against them."
Watch for: a consultation that recommended stopping a medicine (route to the prescriber at once); costs the client cannot afford. Working: a complete list the client checks and corrects [synthesis].

4.6 Cultural Identity, Immigrants and Refugees, Older Adults, and Caregivers modules

Purpose / when: diaspora clients (e.g., Minnan-descended Singaporean or Malaysian Chinese, Taiwanese abroad), older devotees, and family carers [source: APA Supplementary Modules; community scope from Chan 2020].
Steps: (1) Cultural Identity: languages and dialects used at home and at the temple, migration history, gender, class, religion. (2) Immigrants and Refugees: losses, ties to home temples, access to a familiar medium abroad. (3) Older Adults: views of ageing and how age shapes illness and care. (4) Caregivers (with the carer, not the patient): the carer's role, traditions guiding care, family support and how they can be supported clinically [source: APA Supplementary Modules, paraphrased].
Example language (illustrative): "Which language do you pray in, and which do you think in when you're upset?" / (to a carer) "What does your tradition expect of you in looking after your mother?"
Watch for: loss of access to a home temple experienced as grief; carers caught between a medium's advice and a medical team's. Working: identity factors that matter most are named and appear in the formulation [synthesis].

4.7 Telling normative possession trance apart from disorder

Purpose / when: the client, a relative, or a referrer reports trance, possession, a deity or spirit speaking, amnesia or episodes of shaking [source: ICD-11 6B63; Khoe & Gudi 2022].
Steps: (1) Establish context: is the trance part of accepted collective religious practice (the medium's role, a festival), voluntary and wanted? ICD-11 possession trance disorder requires the trance to be involuntary and unwanted and excludes trance that is accepted "as a part of a collective cultural or religious practice" [source: ICD-11 6B63]. (2) If involuntary or distressing, describe features: altered consciousness, replacement of identity by a possessing one, sense of being controlled, duration, recurrence, distress and impairment [source: ICD-11 6B63, paraphrased]. (3) Screen for differentials ICD-11 lists or excludes: schizophrenia, acute and transient psychotic disorder, substance or medication effects, neurological disease, sleep-wake disorders [source: ICD-11 6B63]. (4) Look for panic features: abrupt onset, peak within minutes, preserved memory; in a Singapore case, episodes attributed to evil spirits were reformulated as panic disorder with culturally shaped content, the religious content being "a red herring" for diagnosis [source: Khoe & Gudi 2022]. Features reported as typical of possession trance in that case report include altered consciousness, amnesia, deity-like behaviour, short duration and fatigue afterwards [source: Khoe & Gudi 2022]. (5) Arrange medical or psychiatric review (EEG, imaging, bloods, toxicology as the medical team decides) before settling on a non-medical explanation [synthesis; the case report notes the absence of toxicology as a limitation]. (6) Consult a cultural broker or community member about whether the presentation fits local norms, with consent [synthesis]. (7) Share the formulation in terms that do not require the client to give up their explanation.
Example language (illustrative): "In your temple, when the god comes, how do people know it's the god and not something else?" / "These episodes, do they come when you choose, at the temple, or do they come on their own and frighten you?" / "Your faith explains why this happens; the doctors and I can also help the attacks themselves. The two can go together."
Watch for: missing illness because content is religious; pathologising a medium's sanctioned trance; community members themselves saying a person's possession is "not right" (a culturally meaningful signal) [synthesis]. Working: a diagnosis or a "no disorder" conclusion the client and clinicians can both live with; the Singapore case team reported that accepting the patient's interpretation supported alliance and adherence [source: Khoe & Gudi 2022].

4.8 Working with a client who is a medium, or who feels called

Purpose / when: the client is a tangki, a medium's helper, or reports illness or dreams they or their family read as a call; in Singapore, some people are believed to be spiritually "children" by birth date and time and may serve the gods, and one medium became a medium after a deity appeared in a dream [source: Chan 2020].
Steps: (1) Do not treat the calling or the role as a symptom. (2) Ask what the role means to them and their family; becoming a medium (成乩) often involves illness or trauma and is framed by scholars as the "wounded healer" (受創的醫者) [source: Lin, 醫者或病人]. (3) Assess the presenting problem on its own terms (depression, anxiety, relational strain). Ethnography reports mediums whose own depressive, anxious or hallucinatory experiences and long-standing anger changed through their practice [source: Lee & Kirmayer 2019 via Dhar 2020]. (4) Explore practical strains: combining the role with a regular job (many Singapore mediums hold one), night consultations, fatigue, poverty, family dependence [source: Chan 2020; Lin, 醫者或病人]. (5) Clarify confidentiality: the client's clients and devotees are not yours to discuss; the client decides what of their spiritual role enters notes [synthesis]. (6) If calling-related distress is involuntary and impairing, follow 4.7 and refer for medical review.
Example language (illustrative): "Being chosen by the god sounds like it carries both honour and weight. What is heaviest about it right now?"
Watch for: therapist curiosity turning into requests for ritual detail (do not ask); amnesia after trance being misread as dissociative disorder (mediums are reported to forget sessions afterwards) [source: Lee, Kirmayer & Groleau 2010]. Working: the client distinguishes their role from the problem they came with [synthesis].

4.9 Responding to reported ritual self-wounding

Purpose / when: a client is a medium or devotee involved in festivals where, as reported, mediums in trance cut themselves with swords or mace-like weapons or are pierced with rods or skewers, with blood used in exorcism and on talismans; one Taiwanese account notes the practice is reported as bloody but not painful during possession [source: Chan 2020; 嵇童 1993]. Not every medium does this [source: Tan Chee-Beng review of DeBernardi 2006].
Steps: (1) Do not equate ritual self-wounding within sanctioned practice with non-suicidal self-injury or suicidality. (2) Ask about physical after-effects and whether wounds are seen by a doctor (infection, bleeding, blood-borne virus exposure) and support medical care [synthesis]. (3) Separately, ask about any self-harm outside the ritual context and assess it with standard risk assessment [synthesis]. (4) If a minor is involved in self-wounding, or anyone is pressured to take part, follow safeguarding (4.14).
Example language (illustrative): "In the festival, the cuts are part of the god's work, as you see it. Outside of that, has there been any time you hurt yourself, or thought about it?"
Watch for: the client expecting shock; wounds not healing. Working: the client can talk about it without defending the practice [synthesis].

4.10 Interpreters and cultural brokers

Purpose / when: the client's language of distress or devotion is Hokkien, Teochew, Hakka, Cantonese or Taiwanese, or the client's community norms are unclear to you. Consultations studied in Singapore were in Hokkien, shared by healer and client, and the authors suggest shared language may support the healing relationship [source: Lee, Kirmayer & Groleau 2010].
Steps: (1) Use a trained interpreter, not a family member or the medium's helpers, for assessment [synthesis]. (2) Brief the interpreter on confidentiality and on not softening or correcting religious content. (3) Check the interpreter's own stance on mediumship (some may hold Christian or secular views that colour translation; Christian hostility to mediums is documented in Taiwan) [source: 嵇童 1993; synthesis]. (4) For cultural brokerage, ask a community member chosen with the client's consent about local norms, without disclosing identity unless consented [synthesis]. (5) Debrief the interpreter afterwards, using the Patient–Clinician Relationship module's attention to how interpreters shape the encounter [source: APA Supplementary Modules].
Example language (illustrative, to interpreter): "Please translate exactly, including words for gods, spirits or luck. If a term has no English equivalent, give me the original and a short gloss."
Watch for: the client switching to dialect for spiritual content; an interpreter who knows the client's temple. Working: the client's key idioms appear in the original language in your notes [synthesis].

4.11 Collaboration with the client's own medium, temple or family healers (only when the client wishes)

Purpose / when: the client is consulting a medium and wants the two kinds of help to fit together, or a consultation outcome affects therapy (e.g., advice about family conflict) [synthesis]. No formal referral programme between mental-health services and Chinese spirit mediums is identified in the sources used here [uncertain: not verified].
Steps: (1) Ask whether the client wants any contact at all; the default is none. (2) If yes, agree in writing exactly what may be shared, with whom (the medium, a helper, a family elder, a temple committee member), for what purpose, and that consent can be withdrawn [synthesis]. (3) Let the client choose the person; do not seek out or recommend a medium; in Singapore, mediums usually act independently of temple committees, so a temple's management may not speak for a medium's group [source: Chan 2020]. (4) Make contact respectfully, in the client's preferred language, about practical coordination (timing, the client's goals, medical concerns), not about ritual content [synthesis]. (5) Never ask to attend or observe a consultation or festival on the client's behalf; never comment on a deity's pronouncements [synthesis]. (6) Record the contact and what was shared.
Example language (illustrative, to client): "Some people like their doctor or therapist and their temple to know about each other; others prefer to keep them separate. Either is fine. What would you like?" / (to a medium's helper, with consent) "[Client] asked me to let you know that they're seeing me for the worry and sleep problems, and that they value what they receive at the temple."
Watch for: pressure from family to involve or exclude a medium; any advice from a consultation to stop medical treatment (route to the prescriber and discuss with the client). Working: the client experiences the two as complementary; in the Singapore case report the team acknowledged the patient's plan for a religious consultation and discussed how medication could complement it [source: Khoe & Gudi 2022].

4.12 Integrating consultation experiences and advice into therapy

Purpose / when: the client returns from a consultation with a diagnosis, instruction or moral advice, or a sense of relief or fear [source: Tan Chee-Beng review of DeBernardi 2006 on "specific diagnoses and concrete remedies"].
Steps: (1) Ask what was said and how the client felt about it, without evaluating its truth. (2) Explore meaning: ethnography reports advice favouring harmony and emotional control (e.g., "Take things easy") and moral faults such as greed and arrogance treated as forms of illness [source: Lee & Kirmayer 2019 via Dhar 2020]. (3) Find links with therapy goals (e.g., anger regulation, family reconciliation) and use the client's framing where it helps [synthesis]. (4) Where the advice conflicts with safety or with treatment, name the conflict plainly and problem-solve with the client, not against the medium [synthesis]. (5) Track perceived helpfulness: in a Singapore study of 21 patients, most rated the consultation helpful, some could not follow all recommendations, some were unsure pending concrete results, and one found it unhelpful [source: Lee, Kirmayer & Groleau 2010]; ask which applies.
Example language (illustrative): "The god told you to let go of the anger at your brother. What would letting go look like this week?" / "It sounds like part of the advice is hard to follow. Which part?"
Watch for: guilt at being unable to follow instructions; fear after an ominous pronouncement (assess anxiety and safety). Working: the client uses the advice as a resource rather than a source of dread [synthesis].

4.13 Working with families and the devotional community

Purpose / when: the problem is relational, family members hold different explanatory models, or the client's healing is understood as communal; ethnography describes consultations in semi-public temple settings where clients arrive early and stay to share their stories, involving family and community in healing [source: Lee & Kirmayer 2019 via Dhar 2020].
Steps: (1) With consent, invite relevant family members; use the Social Network and Caregivers modules [source: APA Supplementary Modules]. (2) Elicit each person's explanatory model; let differences be spoken without forcing a single cause [synthesis]. (3) Agree a shared goal that respects relational values (harmony, filial obligation) while protecting the client's safety and voice [synthesis]. (4) Discuss how confidentiality works in therapy compared with the open, communal sharing at temples [synthesis on Lee & Kirmayer 2019 via Dhar 2020].
Example language (illustrative): "Each of you has a way of understanding what is happening to Mei. Can we hear each one, without deciding yet who is right?"
Watch for: family pressure on the client to consult or stop consulting; a relative speaking for the client. Working: the family can support one plan [synthesis].

4.14 Safeguarding

Purpose / when: injury, coercion, financial exploitation, sexual misconduct, involvement of a minor in self-wounding or harmful practice, or delay of urgent medical care is disclosed or suspected [synthesis]. Specific safeguarding guidance on Chinese spirit-medium practices from child-protection bodies is not identified in the sources used here [uncertain: not verified].
Steps: (1) Hold the line that religious framing does not change your duty; the threshold is the same as for any harm [synthesis]. (2) For minors: assess consent and assent, exposure to self-wounding, schooling and sleep (night consultations), and pressure to take a role; Singapore ethnography records one medium beginning trance at 16 [source: Chan 2020]; consult your safeguarding lead. (3) For delay of medical care, involve the treating doctor promptly; a Singapore patient attributed a delayed surgery to evil spirits being "after" her [source: Khoe & Gudi 2022]. (4) For financial exploitation or sexual misconduct by anyone in a healing role, follow adult-safeguarding and criminal reporting procedures [synthesis]. (5) Explain to the client what you must do and why, in a way that separates the harm from the tradition [synthesis]. (6) Never name a minor in notes shared outside the service beyond what safeguarding requires.
Example language (illustrative): "I respect your faith and the temple. My concern is only this injury, and I have a duty to make sure he's safe. Here is what happens next."
Watch for: misreading sanctioned adult practice as abuse; missing abuse framed as spiritual. Working: safety is secured and the family stays engaged [synthesis].

4.15 Coordinating with medical care

Purpose / when: any prescribed medicine, herbal prescription or ingested item is involved, or physical or neurological causes need excluding [synthesis].
Steps: (1) Never advise starting, stopping or changing a medicine or remedy. (2) With consent, pass a list of all remedies (including deity-given prescriptions, which are reported as part of ritual healing [source: Lin, 醫者或病人]) to the prescriber or GP. (3) Ensure medical review for new trance-like episodes, seizures, or injuries [source: Khoe & Gudi 2022 on EEG and imaging in work-up; synthesis]. (4) Support the client in telling their doctor about consultations if they wish.
Example language (illustrative): "I'm not the right person to say whether that remedy is safe with your tablets, but your doctor is. Shall we write it down for your next appointment?"
Watch for: the client hiding remedies from doctors for fear of ridicule. Working: the prescriber has the full list [synthesis].

4.16 Addressing stigma, suppression and racism in services

Purpose / when: the client is secretive, apologetic or defensive about consulting a medium, or has met dismissal in health services [synthesis].
Steps: (1) Acknowledge, briefly and accurately, that the practice has been banned, policed and labelled "superstition" (Qing law, Japanese colonial police regulations from 1908, the KMT 破除迷信 campaign) and that mediums have been called mentally ill by psychiatrists [source: 嵇童 1993; Lin, 醫者或病人]. (2) Use CFI question 16 and the Patient–Clinician Relationship module to ask about past experiences of cultural misunderstanding or racism in care [source: APA CFI; APA Supplementary Modules]. (3) Repair: say what you will do differently [synthesis].
Example language (illustrative): "Some people have been laughed at by doctors for going to a tangki. Has anything like that happened to you? I'd like to do better."
Watch for: politeness masking distrust. Working: fuller disclosure and steady attendance [synthesis].

5. Handling problems

The sources used here do not address psychotherapy problems directly; all responses below are [synthesis] unless a source is given.

Client will not talk about consultations (stuck, guarded). Likely fear of ridicule given the history of suppression and "superstition" labelling [source: 嵇童 1993]. Response: normalise plural help-seeking once, then leave it; return via CFI past help-seeking later. Illustrative: "Many people I see go to temples as well as doctors. You don't have to tell me about it, but you're welcome to."
Client wants you to agree that a spirit is the cause (or to say it is not). Response: decline to adjudicate, affirm the meaning, refocus on what the client wants to change. Illustrative: "I can't speak about the spirit world; that belongs to your tradition. What I can help with is the sleeplessness and fear. Shall we start there?"
Resistance to medical or psychiatric review because the problem is "spiritual". Response: present review as ruling out bodily causes that could also be present, not as replacing the spiritual account; the Singapore case team's acceptance of the patient's interpretation coincided with acceptance of treatment [source: Khoe & Gudi 2022]. Never pressure the client to stop consultations.
Non-adherence because a consultation's advice conflicts with treatment. Response: ask what was advised and what the client wants; involve the prescriber; with consent, coordinate (4.11). Do not argue with the deity's words; discuss the client's own choice.
Overwhelm or fear after an ominous pronouncement. Response: grounding, safety assessment, and exploration of what the client's tradition offers for such fears; ask whether the client wants to return to the same or another trusted source within their community. Do not offer spiritual counter-interpretations.
Trance-like episode in session. Response: keep the environment safe, speak calmly and simply, do not challenge the identity speaking, wait; afterwards ask what the client remembers and arrange medical review if the episode was unwanted or new (4.7). Inform the client in advance, if episodes are known, how you will respond.
Rupture: client feels you have pathologised their faith or their role as medium. Response: name it, apologise specifically, use CFI question 16 to ask what would help [source: APA CFI]; restate that being a medium is not in itself a diagnosis [source: Lin, 醫者或病人].
Rupture: client feels you sided with a family member who opposes the practice (often across religious conversion). Response: return to each person's explanatory model (4.13); clarify that your role is the client's wellbeing, not the family's religious dispute.
Medium client feels confidentiality norms clash with communal ways of healing. Response: explain what therapy confidentiality protects and what the client may choose to share; ethnography contrasts communal sharing at temples with individualistic confidentiality norms [source: Lee & Kirmayer 2019 via Dhar 2020].
Financial strain or perceived exploitation by a consultation. Response: explore without accusing; distinguish customary offerings the client chooses from coercion; safeguarding if coercion or fraud (4.14).
Ritual self-wounding raises the therapist's alarm. Response: separate your reaction from clinical risk; assess wounds and any non-ritual self-harm (4.9); supervision.
Minor involved in trance or self-wounding. Response: safeguarding consultation; assent and consent; do not presume abuse or dismiss risk (4.14).
Therapist asked to attend a consultation, festival or to take part. Response: decline politely; offer to coordinate in other ways (4.11). Taking part blurs roles and is outside the therapist's standing in the tradition.
Interpreter or colleague shows contempt for the practice. Response: change interpreter; raise the issue in team consultation; record the client's experience if it affected care [synthesis on APA Supplementary Modules attention to interpreters].
Uncertainty whether a presentation is culturally normative. Response: seek a cultural broker with consent and a culturally experienced psychiatric colleague; hold the formulation open rather than forcing a label [synthesis on ICD-11 6B63].

Sources

Web sources:

Books and articles cited:

DeBernardi, J. (2006). The Way That Lives in the Heart: Chinese Popular Religion and Spirit Mediums in Penang, Malaysia. Stanford University Press.
Kleinman, A. (1981, paperback). Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. University of California Press. [uncertain: original hardback year not verified]
Lee, B.-O., & Kirmayer, L. J. (2019). Dang-ki healing: an embodied relational healing practice in Singapore. Transcultural Psychiatry (online 1 July 2019). Content used via the Dhar (2020) summary [uncertain: not verified against the full article].
Chan, M. (2006). Ritual Is Theatre, Theatre Is Ritual: Tang-ki Chinese Spirit Medium Worship [uncertain: not verified].

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