Siddha

1. Introduction

Version followed: Siddha as the Government of Tamil Nadu Department of Indian Medicine & Homoeopathy and India's national regulatory framework (Ministry of Ayush; National Commission for Indian System of Medicine Act 2020; Central Council of Indian Medicine curricula) describe it; the psychotherapist's role is framed by the DSM-5-TR Cultural Formulation Interview (CFI). Siddha as practised in Sri Lanka and the Tamil diaspora may differ [uncertain: not verified].

Siddha (Siddha maruthuvam) is a codified Tamil medical system, practised mainly in Tamil Nadu and Tamil-speaking communities, taught through degree programmes and regulated in India as one of the "Indian Systems of Medicine". It is not a psychotherapy, and a psychotherapist does not practise it: diagnosis and treatment within Siddha belong to registered Siddha practitioners. This guide covers what the system holds, who holds authority over it, the safety issues regulators and clinicians raise, and the psychotherapist's own culturally responsive work alongside a client who uses Siddha care. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy, Fundamental Concepts; SCC Online summary of NCISM Act 2020]

Core idea of change, as the tradition holds it: health is an equilibrium of the five elements, which shape three humours (wind, bile and phlegm; in Tamil vatham/vali, pitham/azhal, kapham/iyyam) and the bodily constituents; illness is a disturbance of that balance, and treatment restores it through food, medicines and external therapies, summed up in the maxim "Food is Medicine – Medicine is Food". Within this frame, mental illness is described as humoural imbalance that also disturbs the mental faculties counted among the system's 96 principles. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy; Miraaj, Krishna & Sritharan 2026] For the psychotherapist, change happens through your own work: understanding the client's explanatory model, keeping them safe across two systems of care, and supporting coordinated, consented collaboration. [synthesis]

2. Framework

This section has two parts: (A) the Siddha system's own structure, described so you understand what your client is receiving, and (B) the phased framework for your own work. There is no Siddha-derived psychotherapy protocol with a set session count; part B is [synthesis] built on the CFI.

A. The Siddha system as its official bodies describe it

• Theory. Five elements; three humours; seven bodily constituents (udal thathukkal) that reflect humoural imbalance; 96 principles (thathuvam) that make up the person, including physical, physiological, mental and intellectual components. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy] The mental faculties named among the 96 include manam (mind), buddhi (intellect), sitham and agangaram (ego-sense). [source: Miraaj et al. 2026] Spiritual and yogic dimensions (the Siddhars as accomplished adepts; links with Saiva Siddhantha) are part of how the tradition understands itself; they are described here as the tradition holds them. [source: Miraaj et al. 2026, a paper from a Saiva Siddhantha department; detail uncertain: not verified]
• Diagnosis. "Eight types of examination" (envagai thervu): tongue, complexion, speech, eyes, touch/palpation, urine, stools and pulse (naadi), with pulse used to confirm; modern diagnostics are also accepted. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy] In psychiatric presentations, Siddha authors report a predominance of pitham-type pulse findings. [source: Miraaj et al. 2026]
• Mental-health concepts. Siddha literature groups 18 psychiatric conditions as Kirigai noi, attributed to the Siddhar Agathiyar and further described by Yugi Munivar, among the 4,448 diseases the tradition enumerates. Siddha authors draw parallels with schizophrenia, mania, depression, neurotic, convulsive and substance-related conditions. [source: Miraaj et al. 2026] Siddha clinicians have used a "Kirigai Score scale" to assign a Kirigai type in a Siddha psychiatry outpatient clinic. [source: Dharani, Abinayaa & Muthukumaran 2023] An earlier psychiatric account is Somasundaram, Jayaramakrishnan & Sureshkumar 1986 [uncertain: not verified]. These are Siddha's own categories; they are not DSM or ICD-11 diagnoses.
• Therapies (categories only). Herbal medicines (forms such as choornam, kudineer, vadagam); mineral and metal medicines (such as parpam and chenduram); external and "physiotherapy" methods (thokkanam and varmam touch therapies, medicated oil application, fomentation, herbal steam); surgical-type methods named in the system (incision, excision, heat application, bloodletting, leech application). [source: Tamil Nadu Department of Indian Medicine & Homoeopathy] Materia medica is grouped as plant (thavaram), inorganic/mineral (thadhu, including mercury and sulphur compounds) and animal (jangamam). [source: Wikipedia, Siddha medicine] Postgraduate curricula include kayakalpam (rejuvenation) with eight yogas, and varmam and thokkanam. [source: CCIM MD (Siddha) regulations 1994] The 2023 Siddha psychiatry case report used an oil bath, external medication, thaarai (a pouring therapy) and varmam. [source: Dharani et al. 2023] No formulas, doses or procedures are given in this guide.
• Who holds authority. In India: Ministry of Ayush (policy); National Commission for Indian System of Medicine, which under the NCISM Act 2020 (assent 20 September 2020) has a Board of Unani, Siddha and Sowa-Rigpa and a Board of Ethics and Registration; only people on the State or National Register may practise as qualified practitioners or sign medical certificates; a National Exit Test is provided for licensing. [source: SCC Online, NCISM Act 2020] Training: BSMS degree (about 5.5 years), MD (Siddha) and PhD, for example through the Tamil Nadu Dr. M.G.R. Medical University; the National Institute of Siddha (Chennai) and the Central Council for Research in Siddha are the national teaching and research bodies; medicines are referenced to the Siddha Pharmacopoeia of India under the Drugs & Cosmetics Act 1940. [source: Wikipedia, Siddha medicine; CCIM MD (Siddha) regulations] In Tamil Nadu the state Department of Indian Medicine & Homoeopathy runs Siddha services. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy] WHO's ICD-11 Traditional Medicine Module 2 (implementation announced January 2024) includes Siddha terminology, developed with the Ministry of Ayush. [source: Drishti IAS, ICD-11 TM Module 2] Regulation in Sri Lanka, Malaysia, the UK, North America and elsewhere: [uncertain: not verified]; outside India, Siddha practitioners are generally not covered by a dedicated statutory register [uncertain: not verified].
• Evidence status. No independent systematic review of Siddha for mental-health conditions is cited here [uncertain: not verified]. Published Siddha psychiatric reports include single case reports without controls. [source: Dharani et al. 2023] The Indian Medical Association and a 2018 Supreme Court of India judgment have used the word "quackery" about such systems, while the Indian state funds and regulates them; this contest over legitimacy is part of the client's context. [source: Wikipedia, Siddha medicine]

B. Phases of the psychotherapist's work alongside Siddha [synthesis]

Re-enter Phase 2 whenever a new remedy, a new practitioner, pregnancy, a child's treatment, deterioration or new physical symptoms appear. [synthesis]

3. Guiding principles

[source: APA DSM-5-TR CFI for principles 1–3; CDPH Lead in Ayurvedic Remedies for 5; NCISM Act 2020 for 6; remainder synthesis]

1. The client's definition of the problem comes first. Practical meaning: begin with their words (for example a Kirigai type, a humoural imbalance, "heat" in the body) before offering yours.
2. The CFI informs, it does not decide. Practical meaning: APA states it should not be the sole basis for a diagnosis; use it alongside a full assessment.
3. Ask everyone about all forms of help. Practical meaning: routinely ask about Siddha, Ayurvedic, herbal and religious help, and what the client's family suggests.
4. Neither endorse nor dismiss. Practical meaning: describe Siddha concepts as the system holds them; do not tell the client that Siddha works or that it is quackery.
5. Safety is medical, not yours to adjudicate. Practical meaning: when metal-mineral preparations, pregnancy, children, or medication interactions are possible, route to a physician or prescriber; never advise starting, stopping or changing any medicine or remedy.
6. Know who is qualified. Practical meaning: in India, a qualified Siddha practitioner is on a State or National Register; elsewhere, ask about training and registration and record what you learn.
7. Stay in your lane. Practical meaning: you do not diagnose by pulse, recommend formulas, perform varmam or thokkanam, or set diets; you explore, coordinate and treat within your licence.
8. Consent governs every contact. Practical meaning: written consent before speaking to the Siddha practitioner, with the client deciding what is shared.
9. Two systems, one plan. Practical meaning: aim for a shared understanding of who treats what, so the client is not caught between practitioners.
10. Risk overrides frame. Practical meaning: psychosis, mania, suicidality or severe depression are assessed and managed by current standards whatever explanation the client holds.
11. Culture is more than Siddha. Practical meaning: Tamil identity, caste, religion, migration, gender and family structure shape the presentation as much as the medical system does.
12. Examine your own stance. Practical meaning: notice whether you lean towards romanticising or dismissing Siddha, and how that shapes your questions.

4. Intervention inventory

All interventions below are the psychotherapist's own work. Siddha diagnosis, medicines, varmam, thokkanam, oil therapies, thaarai, kayakalpam and diet prescription are carried out only by registered Siddha practitioners and are not described as procedures here. Example language is illustrative throughout. [source for the system facts referred to: Tamil Nadu Department of Indian Medicine & Homoeopathy; NCISM Act 2020; Miraaj et al. 2026]

4.1 Cultural humility and self-examination

• Purpose / when: Before and throughout work with any client using Siddha; especially when you notice strong reactions to the system. [synthesis]
• Steps: (1) Before the first session, note what you already believe about Siddha and Tamil medical traditions, and where that came from (media, colleagues, the "quackery" debate, admiration of ancient systems). (2) Note what you do not know: Tamil terms, the regulatory picture, the client's region and religion. (3) Decide what you will learn from the client and what you will learn from reliable sources, so the client is not made your teacher on everything. (4) After sessions, review whether your questions were open or leading. (5) Take questions you cannot resolve to supervision or a cultural consultant.
• Example language (illustrative): "I know a little about Siddha from reading, but I'd much rather understand how it works for you and your family."
• Watch for: Over-interest that turns the session into an anthropology interview; quiet dismissal (changing the subject when the client mentions their vaidyar); assuming every Tamil client uses Siddha. Working: the client volunteers more about their care over time and corrects you without hesitation.

4.2 Cultural Formulation Interview (core 16 questions)

• Purpose / when: Early assessment (Phase 1) with any client whose care or explanation of distress draws on Siddha. [source: APA DSM-5-TR CFI]
• Steps: (1) Read the APA introduction, in your own words, explaining that you want to understand the problem from the client's point of view. (2) Work through the four domains: cultural definition of the problem; cultural perceptions of cause, context and support, including the role of cultural identity; cultural factors affecting self-coping and past help seeking; cultural factors affecting current help seeking, including the clinician–patient relationship [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (3) Use the client's own terms in later questions (if they say "too much heat" or name a Kirigai type, use that phrase). (4) If a family member attends, consider the Informant Version. (5) Record answers in the client's words. (6) Write a brief cultural formulation linking their explanatory model, stressors, supports, help-seeking and what they expect from you. (7) Do not use the CFI as the only basis for diagnosis. The CFI may be reproduced for clinical use with patients under APA's stated terms; do not modify it.
• Example language (illustrative): "Sometimes people describe a problem differently to their family than to doctors. How would you describe what's happening to someone at home?"
• Watch for: Short or guarded answers that may reflect fear of being judged for using Siddha; the client giving the "medical" answer they think you want. Working: the client offers their own explanation and names other helpers, including the Siddha practitioner.

4.3 CFI supplementary modules: Explanatory Model, Coping and Help Seeking, Spirituality, Religion, and Moral Traditions, Cultural Identity, Immigrants and Refugees

• Purpose / when: When the core CFI shows Siddha is central to the client's understanding, when religion and the Siddhar tradition matter to them, or when migration shapes access to care. [source: APA DSM-5-TR CFI (module list)]
• Steps: (1) Pick one or two modules, not all. (2) Explanatory Model: explore what the client thinks caused the problem, why now, how it works in the body and mind, what will help, what they fear. (3) Coping and Help Seeking: map every helper in order (family, temple, Siddha practitioner, GP, psychiatrist, online sources) and what each said. (4) Spirituality, Religion, and Moral Traditions: if the client links Siddha with Saiva or other religious life, ask what that means for them, without asking for ritual details. (5) Cultural Identity: language, Tamil identity, region, caste where the client raises it, generation in the diaspora. (6) Immigrants and Refugees: for Sri Lankan Tamil clients in particular, ask about migration history, war-related loss and access to familiar care. (7) Add findings to the formulation.
• Example language (illustrative): "When your Siddha doctor felt your pulse and said your pitham was raised, what did that mean to you?"
• Watch for: Asking the client to defend Siddha's validity; mistaking a culturally ordinary explanation for a delusion. Working: you can explain the client's model back to them in a way they recognise.

4.4 Working with Siddha mental-health concepts (Kirigai and humoural language)

• Purpose / when: When the client or their Siddha practitioner has named a Siddha diagnosis, such as one of the 18 Kirigai conditions, or describes distress in humoural terms. [source: Miraaj et al. 2026; Dharani et al. 2023]
• Steps: (1) Ask what the Siddha diagnosis is called and what the practitioner told them about it. (2) Ask what it means for prognosis, treatment and family reputation. (3) Keep it as the client's frame: record it as "diagnosed by Siddha practitioner as …" rather than translating it into a DSM label. (4) Separately carry out your own standard assessment (mood, psychosis, anxiety, substance use, trauma, risk). (5) If your assessment and theirs differ, name both and discuss what each implies for care; do not set them up as competing truths. (6) Where Siddha authors draw parallels with schizophrenia or mania, treat this as their mapping, not an equivalence. [source: Miraaj et al. 2026] (7) Look for points of overlap the client values (sleep, diet, routine, family support) and build on them. [synthesis]
• Example language (illustrative): "Your Siddha doctor sees this as an imbalance that affects the mind. I'd like to understand it that way too, and also look at it with the tools I use. Then we can see where they agree."
• Watch for: The label carrying stigma within the family; the client believing a Siddha diagnosis rules out psychiatric treatment or vice versa. Working: the client can hold both descriptions and use each where it helps.

4.5 Asking about Siddha consultation and the full remedy inventory

• Purpose / when: Every intake and every review; essential before any coordination with a prescriber. [source: CDPH Lead in Ayurvedic Remedies (principle of asking all patients); synthesis for Siddha]
• Steps: (1) Ask normalising, specific questions: Siddha, Ayurveda, herbal, temple remedies, products from India or Sri Lanka, online purchases, products bought for children. (2) Ask the client to bring the packets, labels or prescriptions to the next session or photograph them. (3) Note the product name, maker, who prescribed it, when started, and whether the prescriber of any psychiatric medicine knows. (4) Do not comment on safety or efficacy of the product yourself. (5) With consent, pass the list to the GP, psychiatrist or pharmacist. (6) Record it.
• Example language (illustrative): "Many people use Siddha or other traditional medicines alongside tablets from the doctor. Would you be willing to show me everything you're taking, so your doctor has the full picture?"
• Watch for: Concealment because of earlier ridicule by a doctor; products sent by relatives the client does not think of as "medicine". Working: the inventory grows over time and the client starts mentioning changes unprompted.

4.6 Medical liaison for metal-mineral preparations and interactions

• Purpose / when: When the inventory includes Siddha mineral or metal medicines (such as parpam or chenduram), unlabelled products, or remedies used in pregnancy, by children, or with psychiatric medicines. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy (that metal and mineral medicines are part of Siddha); CDPH Lead in Ayurvedic Remedies]
• Steps: (1) Explain that some traditional Indian medicines have been found to contain lead, mercury or arsenic, and that a doctor can check. California's public health department states that rasa shastra preparations can intentionally contain metals and that contamination has been found in products made in India and the USA; its guidance concerns Ayurvedic products, and its application to Siddha products is an inference [uncertain: not verified]. A Siddha herbo-mineral formulation studied in animals retained measurable mercury after traditional processing, although its authors concluded it was safe. [source: CORE record, Santha Santhrothaya Mathirai study] A case report of cerebral oedema attributed to heavy metals from Siddha medicine has been published [uncertain: not verified]. (2) With consent, refer to the GP or physician, who decides on any testing (CDPH advises clinicians that a venous blood lead test is the diagnostic test). (3) Flag urgency to the physician for pregnancy, infants and children, who are at greatest risk. (4) Never advise the client to stop the remedy; the decision belongs to the client with the physician and the Siddha practitioner. (5) Flag to the prescriber any combination of Siddha medicines with psychiatric medicines; the prescriber or pharmacist assesses interactions. (6) Record what you advised and what the client chose.
• Example language (illustrative): "I'm not the right person to judge any medicine, Siddha or otherwise. Some traditional products have been found to contain metals, so it may be worth asking your GP for a simple check. Would that be all right?"
• Watch for: Physical signs the physician should hear about (CDPH lists fatigue, abdominal pain, poor appetite, anaemia, and at very high levels encephalopathy and seizures); cognitive or mood change that might be physical, not psychological; the client feeling accused. Working: the physician has the inventory and the client remains engaged with both systems.

4.7 Verifying credentials and choosing whether to collaborate with the Siddha practitioner

• Purpose / when: When the client wants you to talk with their Siddha practitioner, or when coordinated care would reduce risk. [source: SCC Online, NCISM Act 2020; synthesis for steps]
• Steps: (1) Ask the client who the practitioner is, where they trained (BSMS, MD (Siddha)), and whether they are registered. (2) In India, registration should be on a State Register or the National Register maintained under NCISM; outside India, record the training and any professional body the practitioner names, noting there may be no statutory register. (3) Distinguish registered practitioners from unqualified sellers of remedies; harm from unqualified practice is a concern Indian courts have raised. [source: Wikipedia, Siddha medicine, quoting the 2018 Supreme Court judgment] (4) Obtain written consent specifying what you may share and receive. (5) Make contact as a fellow professional: introduce your role, ask how they understand the client's condition and treatment plan, share only what is consented, agree how you will contact each other if risk rises. (6) Tell the client what was discussed.
• Example language (illustrative, to the practitioner): "I'm seeing your patient for psychotherapy, with their permission. I'd value your understanding of their condition and the plan you've set, so we don't pull in different directions."
• Watch for: Pressure to endorse a treatment or to stop psychiatric medicine; a practitioner unable or unwilling to state training. Working: a shared understanding of roles and an agreed route for urgent concerns.

4.8 Shared care plan across psychiatry, primary care and Siddha

• Purpose / when: Phase 2 onward, when the client uses Siddha alongside psychiatric or primary care. [synthesis]
• Steps: (1) List each practitioner and what they are treating. (2) Agree with the client, in writing, who to call for what (urgent risk, physical symptoms, medicine questions, Siddha treatment). (3) Note the client's own priorities in each system. (4) Review the plan whenever a new remedy, practitioner or symptom appears. (5) Share it with each practitioner as the client consents.
• Example language (illustrative): "Let's write down who looks after which part, so if something changes you know exactly who to call."
• Watch for: The client feeling forced to choose; conflicting instructions on diet or medicine. Working: fewer crises, and the client reports changes to the right person.

4.9 Distinguishing culturally framed distress from psychiatric disorder, and risk assessment

• Purpose / when: When a Siddha explanation accompanies symptoms such as delusions, hallucinations, mania, severe depression, or self-harm thoughts. Siddha authors themselves link Kirigai conditions to presentations resembling schizophrenia, mania and depression, so serious illness may be present under a Siddha label. [source: Miraaj et al. 2026; standard practice, synthesis]
• Steps: (1) Treat a Siddha explanation (humoural imbalance, heat, a named Kirigai type) as a cultural belief that is shared within the client's community, not as evidence of psychosis in itself. (2) Ask whether family and community members share the explanation; idiosyncratic elaborations beyond what the community holds need fuller assessment. (3) Carry out a standard mental state examination and risk assessment, including suicidality, using your service's current protocol; any lethal-means discussion is limited to safe storage and removal. (4) Where uncertain, consult a Tamil-speaking clinician or cultural consultant. (5) If psychosis, mania or high risk is present, arrange psychiatric assessment by usual pathways, explaining to the client and family that this does not cancel their Siddha care. (6) Document both your formulation and the client's.
• Example language (illustrative): "I hear that your Siddha doctor is treating this. Because you've told me you sometimes think about not being alive, I also need to make sure you're safe. Can we talk about that together?"
• Watch for: Delayed psychiatric care while a course of Siddha treatment runs; the family hiding symptoms to avoid stigma; your own over- or under-reading of culturally ordinary beliefs. Working: risk is assessed and managed, and the client continues the care they value.

4.10 Discussing external and touch-based Siddha therapies

• Purpose / when: When the client receives varmam, thokkanam, oil application, fomentation, steam, thaarai or other external therapies, especially if they have a trauma history. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy; Dharani et al. 2023 (therapies named)]
• Steps: (1) Ask how the therapy feels for them and whether it helps. (2) Explain, in general terms, that in any touch-based therapy they can ask what will happen beforehand, refuse or stop at any time, and ask for a chaperone. (3) For clients with trauma, especially sexual trauma, plan with them how they might communicate limits, and prepare for possible reactions. (4) Make clear that touch is never sexual and that intimate areas should be discussed only in clinical terms; if the client reports touch they did not agree to or that was sexual, follow safeguarding and reporting procedures (see 4.15). (5) Physical complaints after a therapy (pain, burns, injury) go to the physician. (6) You do not demonstrate or perform any of these therapies. [synthesis for steps 2–6]
• Example language (illustrative): "In any hands-on treatment you're entitled to ask what will happen and to say stop at any point. Would it help to think through how you'd say that?"
• Watch for: Dissociation or distress during or after treatments; deference that makes refusal hard. Working: the client reports feeling in control during treatments, or chooses a different practitioner if they do not.

4.11 Integrating Siddha diet, routine and body practices into therapy

• Purpose / when: When the client values the Siddha principle that food is medicine, or follows diet, routine, yoga or rejuvenation regimens set by a practitioner. [source: Tamil Nadu Department of Indian Medicine & Homoeopathy (food is medicine); CCIM MD (Siddha) regulations (kayakalpam, eight yogas); synthesis for steps]
• Steps: (1) Ask what diet or routine has been advised and how the client relates to it. (2) Where it overlaps with your treatment goals (regular sleep, meals, activity, calm), link it explicitly to your work, for example in behavioural activation or sleep work. (3) Do not set diets yourself and give no weight or calorie targets. (4) Watch for restriction that may feed an eating disorder or obsessional concerns about purity of food; discuss with the client and, with consent, the Siddha practitioner and physician. (5) If yoga is part of their care, treat it as their practice and support consistency without prescribing postures or breathing methods.
• Example language (illustrative): "You said the regular mealtimes your Siddha doctor suggested help you feel steadier. Shall we build our weekly plan around that rhythm?"
• Watch for: Rigid restriction, guilt about "wrong" foods, weight loss the physician should know about. Working: routines support mood and sleep without becoming a source of anxiety.

4.12 Using the client's frame as a bridge in your own modality

• Purpose / when: Phase 3, when the client finds the language of balance helpful. [synthesis]
• Steps: (1) Ask permission to use their words. (2) Translate your intervention into their frame without claiming equivalence: for example, emotion regulation framed as restoring balance, or a thought record as noticing what disturbs the mind. (3) Check that the client still sees the intervention as yours, not a Siddha treatment. (4) Keep the evidence base of your own intervention intact.
• Example language (illustrative): "You describe feeling 'overheated' when you're angry. In therapy we can practise noticing that early and finding ways to cool down, alongside what your Siddha doctor is doing."
• Watch for: Appropriating Siddha terms in ways the client finds inaccurate; blurring of roles. Working: higher engagement with homework and the client using the bridge language themselves.

4.13 Working with family, interpreters and cultural brokers

• Purpose / when: When family members decide on or pay for care, when the client prefers Tamil, or when you need help understanding the context. [source: APA DSM-5-TR CFI (Informant Version; Social Network and Caregivers modules); synthesis for steps]
• Steps: (1) Ask the client whom they want involved and what they may know. (2) Use a trained professional interpreter, not family, for assessment and risk discussions; brief the interpreter on confidentiality and on not adding explanations. (3) Ask the client whether a cultural broker (a Tamil-speaking clinician, community health worker or other trusted person) would help, and how confidentiality will be handled. (4) In family sessions, explore each member's view of the illness and of Siddha and biomedical care. (5) Address disagreements about treatment openly, with the client's wishes central.
• Example language (illustrative): "Your parents feel strongly about Siddha treatment, and your psychiatrist has suggested medicine. Could we hear what each of you hopes for?"
• Watch for: The client silenced in family meetings; interpreters from the same small community. Working: the family supports a plan the client has agreed to.

4.14 Addressing stigma, legitimacy conflict and identity

• Purpose / when: When the client feels caught between Tamil cultural pride in Siddha, family expectations and dismissive messages from biomedical services, or is ashamed of using either. [source: Wikipedia, Siddha medicine (IMA and court criticism alongside state support); synthesis for steps]
• Steps: (1) Ask about past experiences of being judged for using Siddha or for using psychiatric care. (2) Acknowledge that the status of Siddha is contested in India itself, and that the client does not have to resolve that to get help. (3) Explore what Siddha means for their identity (language, heritage, family history). (4) Note racism or dismissal the client has met in services and address it as a real barrier, including within your own service. (5) Support the client to make informed choices without having to reject either system.
• Example language (illustrative): "It sounds like a doctor once laughed at you for using Siddha. That must have made it hard to mention it again. You won't be judged for it here."
• Watch for: Shame that leads to concealment; a client using you to argue against family. Working: the client speaks openly about all their care.

4.15 Safeguarding

• Purpose / when: When there is risk to the client or others linked to any care, Siddha or otherwise: delay of urgent medical or psychiatric care, toxicity concerns in children or pregnancy, unqualified practice, or unwanted or sexual touch. [source: CDPH Lead in Ayurvedic Remedies (children and pregnancy at risk); Wikipedia, Siddha medicine (court concern about unqualified practitioners); synthesis for steps]
• Steps: (1) Identify the concern specifically (who, what, when). (2) For an adult with capacity, discuss the risk, offer medical review, and respect informed choices while documenting them. (3) For children, or where a child is given remedies of concern or denied urgent care, follow your local child-protection procedure and consult the safeguarding lead; do not name minors in shared records beyond what procedures require. (4) For sexual or unwanted touch, support the client to report to police and to the relevant regulator (in India, the State Medical Council or NCISM structures), and follow mandatory reporting duties where you practise. (5) Product concerns can be reported to the national medicines or public health regulator. (6) Avoid treating Siddha use itself as a safeguarding concern.
• Example language (illustrative): "I'm concerned that your son's fits haven't been seen by a hospital doctor yet. Can we talk about getting him checked today, alongside his Siddha care?"
• Watch for: Overreaction that pathologises a family's culture; underreaction that leaves a child at risk. Working: risk is reduced and the family stays in contact with services.

4.16 Documentation and confidentiality

• Purpose / when: Every session. [synthesis]
• Steps: (1) Record the client's explanatory model in their words and any Siddha diagnosis as reported. (2) Record the remedy inventory, medical liaison and the client's informed choices. (3) Record consents for each contact. (4) Avoid evaluative language about Siddha in notes the client or other practitioners may read.
• Example language (illustrative): "I'll write down that you're seeing a Siddha practitioner and what they told you, in your words. Is there anything you'd prefer I don't include?"
• Watch for: Notes that read as dismissive; missing consents. Working: records another clinician could pick up and use.

5. Handling problems

The sources used here do not address psychotherapy problems with Siddha users directly; all guidance in this section is [synthesis] unless a source is named.

• Client wants you to say whether Siddha works. Response: say honestly that your role is not to judge Siddha treatment, that its evidence for mental-health conditions is limited to small reports as far as you know, and that you will support informed choices and safety checks. Avoid both endorsement and dismissal. (Illustrative: "I can't tell you whether this medicine works. I can help you weigh it up and make sure your doctors know what you're taking.")
• Client stops psychiatric medicine in favour of Siddha treatment. Response: do not argue or instruct; explore the reasons (side effects, stigma, family pressure, belief), assess risk, and with consent inform the prescriber promptly. Offer a joint conversation with the prescriber. The decision about medicines stays between the client and prescriber.
• Client refuses medical review of metal-mineral remedies. Response: explain the reason once more in plain terms (citing that public health bodies advise asking about and testing for metals in traditional Indian remedies) [source: CDPH Lead in Ayurvedic Remedies]; respect an adult's informed refusal and document it; revisit at review. If a child or pregnancy is involved, consult your safeguarding lead.
• Stuck: the client attributes everything to humoural imbalance and sees no role for psychological work. Response: return to the CFI question about what help they expect; offer a bounded piece of work on something they want (sleep, family conflict, worry) framed in their terms (4.12); agree a review point.
• Resistance arising from earlier ridicule by clinicians. Response: name the experience, apologise for what services did where appropriate, and show through your questions that their care is welcome in the room (4.14).
• Overwhelm: the client is juggling several practitioners and conflicting advice. Response: build or revise the shared care plan (4.8); help the client choose which questions go to which practitioner; reduce the number of decisions per week.
• Non-adherence to homework. Response: check whether tasks conflict with Siddha routines or diet; align timing with their daily pattern; use their own words for the task.
• Rupture: the client feels you have taken the psychiatrist's side, or the Siddha practitioner's. Response: acknowledge it directly, restate your role as theirs, not either system's, and invite them to tell you when it happens again.
• The Siddha practitioner and the psychiatrist disagree. Response: avoid triangulation; with consent, facilitate a written exchange or joint call on specific questions; keep the client's priorities central; escalate to the treating psychiatrist when risk is involved.
• Siddha practitioner advises against psychotherapy or psychiatric care. Response: explore with the client what was said and why; ask for consent to talk with the practitioner (4.7); do not ask the client to choose sides.
• Practitioner credentials unclear, or remedies sold by an unregistered seller. Response: share neutrally that in India only registered practitioners may practise as qualified Siddha practitioners [source: SCC Online, NCISM Act 2020], help the client ask about training and registration, and route physical concerns to the physician.
• Physical symptoms appear during treatment (tiredness, abdominal pain, confusion, seizures). Response: urgent medical review; do not assume a psychological cause [source: CDPH Lead in Ayurvedic Remedies for the symptom list].
• Trauma reactions during touch-based therapies. Response: see 4.10; work on grounding and assertive communication; support the client to change practitioner or therapy if they choose.
• Psychotic or manic deterioration while under Siddha treatment for a Kirigai condition. Response: follow 4.9; arrange psychiatric assessment; frame it to the family as additional help, not a replacement.
• Diaspora access issues (remedies sent from India or Sri Lanka, no local Siddha practitioner). Response: include imported products in the inventory (4.5); explore the client's loss of familiar care as part of migration grief; do not attempt to substitute for Siddha care.
• Your own discomfort or strong opinion about Siddha. Response: take it to supervision; review recent sessions for leading questions (4.1).

Sources

Web sources:

• Fundamental Concepts – Department of Indian Medicine & Homoeopathy, Government of Tamil Nadu
• Central Council of Indian Medicine: regulations and syllabus for MD (Siddha), 1994 (hosted by NCISM)
• Presidential assent: National Commission for Indian System of Medicine Act 2020 (SCC Online, 25 September 2020)
• Miraaj R, Krishna S, Sritharan A (2026). A textual study of Kirigai disorders in Siddha Medicine. University of Jaffna
• Dharani K, Abinayaa P, Muthukumaran M (2023). A Case Report on Kirigai Noi Type in Comparison with Schizophrenia Classification using the Kirigai Score scale. Journal of Siddha 7(1): 5–7
• Somasundaram O, Jayaramakrishnan T, Sureshkumar M (1986). Psychiatry in Siddha (Tamil) system of medicine. Indian Journal of Psychological Medicine 9: 38–45 (repository record; content [uncertain: not verified])
• A Scientific approach on the Validation of Santha Santhrothaya Mathirai (SSM), a Siddha Herbo-Mineral Preparation (CORE record)
• Lead in Ayurvedic Remedies: A Warning to Clinicians – California Department of Public Health
• American Psychiatric Association. DSM-5-TR Cultural Formulation Interview
• ICD-11 TM Module 2 Launch: Global Integration of Ayush Medicine (Drishti IAS, 13 January 2024)
• Siddha medicine – Wikipedia (used for training, pharmacopoeia and legitimacy debate, with its cited sources)
• APA DSM-5-TR Section III overview

Books and manuals cited:

• American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Section III, Cultural Formulation [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].