Sri Lankan Deshiya Chikitsa

1. Introduction

Version followed: Deshiya Chikitsa (also spelled Desiya Chikitsa or Desheeya Chikitsa; in everyday speech hela wedakama, "Sinhala medicine") as defined and regulated by the Sri Lankan state under the Ayurveda Act No. 31 of 1961 and administered by the Ayurvedic Medical Council and the Department of Ayurveda, read alongside published Sri Lankan academic descriptions of its lineages and texts. This is a codified, state-recognised medical system, not a psychotherapy. The guide describes the system as its own regulators and scholars publish it, and then sets out the psychotherapist's own culturally responsive work alongside it. A psychotherapist does not practise Deshiya Chikitsa unless trained in it and registered with the Ayurvedic Medical Council.

What it is. Sri Lanka's indigenous medicine. The Ayurveda Act defines "Ayurveda" for legal purposes as including the Ayurveda, Siddha, Unani and Desiya Chikitsa systems of medicine and surgery, so Deshiya Chikitsa sits inside the same regulatory umbrella as Ayurveda while being treated by Sri Lankan sources as a distinct indigenous component [source: Ayurveda Act s 89; Wikipedia, Sri Lankan traditional medicine]. It is carried largely by paramparika (hereditary, family-lineage) physicians: a study of one district identified 18 medical genealogies and 325 indigenous physicians, with branches including snakebite treatment (sarpavisha wedakama), kadumbindum wedakama (as named in the source), bhutavidya (rendered in the source as demonology), treatment of dog bites, abscesses and sores, eye disease, skin disease, general ailments and psychiatric disorders (manasaroga) [source: Samarakoon, Rathnayake & Herapathdeniya 2021]. The Sri Lankan text Sarartha Sangrahaya, attributed by Sri Lankan scholars to King Buddhadasa (4th–5th century CE), is cited as a foundational local medical text [source: Manohara, Sandunika & Molligoda 2023].

Core idea of how healing happens (as the system describes it). Sri Lankan scholarship classifies illness, including mental illness, through the dosha framework shared with classical Ayurveda (vata, pitta, kapha and their combination) and adds categories such as poison-related and spirit-related (bhutaja) forms; treatment aims to restore balance through internal and external preparations and procedures given by the physician [source: Manohara et al. 2023]. These are the system's own concepts, described here as the tradition holds them, not as established physiology. Evidence of effectiveness for Deshiya Chikitsa treatments of mental disorders has not been established in independent systematic reviews [uncertain: not verified].

The psychotherapist's core idea. Change in the therapy room comes from the therapist's own work: understanding the client's explanatory model, respecting the client's chosen help-seeking, keeping medical and psychiatric safety in view, and collaborating with registered practitioners when the client wishes [synthesis].

2. Framework

This is not a staged therapy with a manual. What follows is (a) the structure of the system as regulators publish it, and (b) a phased framework for the psychotherapist's own work [synthesis for (b)].

(a) The system: who practises and who holds authority

Regulator. The Ayurvedic Medical Council, established under Act No. 31 of 1961, registers practitioners; the Commissioner of Ayurveda is its ex-officio chair [source: Ministry of Indigenous Medicine Performance Report 2014]. The Council keeps the registers, can refuse, suspend or cancel registration (including for misconduct), and makes rules on professional conduct; appeals go to the Minister [source: Ayurveda Act ss 18, 51, 57, 63].
Registers. A general register (by recognised qualification, or by the Council's satisfaction that the applicant has sufficient knowledge, experience and skill) and a special register for "special knowledge" in a particular branch [source: Ayurveda Act s 55]. Separate registers exist for pharmacists, nurses and massage therapists [source: Ayurveda Act ss 51, 56]. A route for paramparika physicians without institutional training began in 1956 and remains open; in 2021 traditional medical practitioners made up most of the registered workforce (22,709 against 3,402 Ayurveda, Siddha and Unani medical officers) [source: BIMSTEC 2023 report, p. 92].
Special-register branches. The 2014 registrations under the special register were listed as snake venom, fractures (bone-setting), eye diseases, skin diseases, boils and ulcers, hydrophobia, psychological, and burns [source: Performance Report 2014]. A "psychological" specialist category therefore exists, though small.
Offences. Practising Ayurvedic medicine or surgery for gain while unregistered, and using the title of registered practitioner or "Vaidya-carya" without registration, are offences [source: Ayurveda Act ss 64, 69]. In practice a district study found most lineage physicians unregistered (the study's text is internally inconsistent on this point) [source: Samarakoon et al. 2021; uncertain].
Institutions. Department of Ayurveda (teaching and research hospitals, herbal gardens, a National Institute of Traditional Medicine), Bandaranaike Memorial Ayurvedic Research Institute (Maharagama), Sri Lanka Ayurvedic Drugs Corporation, and teaching hospitals including Borella (from 1929) [source: Performance Report 2014]. University training is at the Institute (now Faculty) of Indigenous Medicine, University of Colombo; Siddha training at the University of Jaffna [source: Wikipedia; Samarakoon et al. 2021]. The ministry responsible has been renamed and merged several times; which ministry holds the portfolio today [uncertain: not verified].

(b) The psychotherapist's work: phases

Phase	Goal	Typical format	Move on when
1. Orientation	Learn the client's local care landscape; examine own assumptions	Before and during the first 1–2 sessions	You can name the practitioner types the client may use and your own biases
2. Cultural assessment	Elicit explanatory model, help-seeking, identity, spirituality	CFI core plus relevant modules, usually sessions 1–3	Client's view of cause, remedy and current helpers is recorded in their words
3. Safety screening	Identify urgent medical, psychiatric or safeguarding needs; route remedy questions to the prescriber	Within assessment, repeated when new treatments start	Urgent needs referred; prescriber informed with consent
4. Collaboration and referral	Coordinate with registered practitioners the client chooses	Letters, calls or joint meetings with consent	Roles and communication agreed, or client declines
5. Integration and review	Bring the client's healing experiences into therapy; review every 4–6 sessions	Ongoing within the therapy	Client reports coherence between care streams, or a conflict is surfaced and addressed

Session counts are not set by any source; the timings above are illustrative [synthesis].

3. Guiding principles

[source: Ayurveda Act; Performance Report 2014; Gomez et al. 2017; Wolffers 1988; otherwise synthesis as marked]

Alongside, not instead. You work beside the system; you do not prescribe, diagnose in its terms or perform its procedures. Practical meaning: never suggest remedies, oils or procedures [synthesis].
Authority sits with the regulator and the lineage. Registration with the Ayurvedic Medical Council is the public marker of legitimacy; lineage standing is the community's marker. Practical meaning: when a client names a physician, ask, without challenge, whether they are registered and which branch [source: Ayurveda Act s 55].
Medical pluralism is normal. Sri Lankan clients commonly move between psychiatric, Ayurvedic, lineage, religious and ritual help; in one Colombo psychiatry clinic, about one in five first sought traditional healers [source: Gomez et al. 2017]. Practical meaning: ask about all helpers, as routine.
Different helpers for different troubles. In village studies, mental illness was taken first to ritual healers (aduras) and Buddhist clergy, with Ayurveda playing a minor role [source: Wolffers 1988]. Practical meaning: do not assume a client using "traditional" care means Deshiya Chikitsa; clarify which helper [synthesis].
Attribute, do not adjudicate. Dosha imbalance, bhutaja illness and spirit causation are described as the client and tradition hold them. Practical meaning: use the client's terms back to them; neither endorse nor dismiss [synthesis].
Family is part of the decision. Family recommendation is a key driver of help-seeking and families usually pay [source: Gomez et al. 2017]. Practical meaning: with consent, include relevant family in planning.
Safety outranks preference. Snakebite, fractures, psychosis, suicidality and suspected harm need prompt medical or safeguarding action whatever other care is chosen [synthesis; snakebite timing: Silva et al. 2020].
Medicines belong to the prescriber. Never advise starting, stopping or combining any medicine or remedy. Practical meaning: route questions about remedies to the prescribing doctor or pharmacist [synthesis].
Consent for touch and procedures. Clients have the right to understand and refuse any physical treatment. Practical meaning: help clients prepare their own questions [synthesis].
Confidentiality across systems. Share nothing with another practitioner without explicit, specific consent [synthesis].
Avoid both errors. Do not pathologise culturally normative beliefs, and do not miss a treatable disorder behind them [synthesis].

4. Intervention inventory

The inventory below is the psychotherapist's own work. Deshiya Chikitsa diagnosis and treatment are carried out only by its registered physicians and lineage holders; no remedy, preparation, oil, dose or procedure is described here. Within the system, mental illness is addressed through the unmada classification (vataja, pittaja, kaphaja, tridoshaja, adhija, visaja and bhutaja forms as one Sri Lankan review lists them), with treatment categories of decoctions, medicated oils and ghee, nasal therapy and purification procedures, given by physicians [source: Manohara et al. 2023]; the classical Sri Lankan text Khanda Vaidya Grantha is also studied for its mental and behavioural disorder chapters [source: Sewwandi & De Silva 2018; uncertain: not verified]. Ritual and exorcist healing (for example the rites studied ethnographically by Kapferer) is a separate domain held by its own specialists and communities; it is an outsider's ethnography and no procedure is given here [source: Kapferer 1983 record].

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout work with Sri Lankan or diaspora clients; especially when you feel scepticism or idealisation about indigenous medicine [synthesis].
Steps: (1) Write down what you assume about "herbal" or "village" medicine and about spirit beliefs. (2) Note where those assumptions came from (training, media, family). (3) Identify which assumptions could lead you to dismiss or to over-endorse. (4) Bring this to supervision once early in the case. (5) Revisit after the explanatory-model interview.
Example language (illustrative, to yourself or a supervisor): "My reflex is to treat her physician as a risk; I want to check whether that comes from evidence about this case or from my training."
Watch for: Over-correction (agreeing that any remedy is safe) as much as dismissal. Working if: you can describe the client's view without evaluative words.

4.2 Mapping the client's care landscape

Purpose / when: First sessions; whenever a new helper appears. Sri Lankan sources show several distinct helper types: registered general Ayurveda physicians, special-register branch specialists (bone-setting, snakebite, eye, psychological and others), unregistered lineage physicians, ritual healers and religious clergy [source: Performance Report 2014; Wolffers 1988; Samarakoon et al. 2021].
Steps: (1) Ask who the client and family have consulted for this problem, in order. (2) For each, ask what kind of helper, what they said the cause was, what was done, and how it went. (3) Record the client's own names for helpers and treatments. (4) Ask which helpers they intend to keep seeing. (5) Draw a simple map together if useful.
Example language (illustrative): "Many families in Sri Lanka see more than one kind of healer. Who have you or your family gone to about this, starting from the first?" / "When you say the vedamahattaya, is that a family-lineage physician, a hospital Ayurveda doctor, or someone else?"
Watch for: Hesitancy to disclose (a sign the client expects disapproval). In the Colombo clinic sample most people who used traditional or faith healing were dissatisfied, so clients may carry disappointment or shame [source: Gomez et al. 2017]. Working if: the client volunteers further helpers over later sessions.

4.3 DSM-5-TR Cultural Formulation Interview (core)

Purpose / when: Structured cultural assessment at intake, for any presenting problem [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: (1) Introduce the interview as a way to understand the problem in the client's terms. (2) Work through its four domains in your own words: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; cultural factors affecting current help-seeking. (3) Use the client's words in the record. (4) Summarise back and correct. (5) Feed findings into the formulation and plan. Do not reproduce the manual's wording on forms; use the published instrument as licensed.
Example language (illustrative): "How would you describe this problem to your family, or to your Ayurveda doctor?" / "What do you think caused it?"
Watch for: Answers framed in dosha, heat and cold, diet, planetary or spirit terms; these are explanatory content, not symptoms. Working if: the client corrects or adds to your summary.

4.4 CFI supplementary modules

Purpose / when: When the core interview shows that a domain matters: explanatory model; level of functioning; social network; psychosocial stressors; spirituality, religion and moral traditions; cultural identity; coping and help-seeking; patient–clinician relationship; school-age children and adolescents; older adults; immigrants and refugees; caregivers [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Choose one or two modules suggested by the core. (2) For Sri Lankan clients, the help-seeking and spirituality, religion and moral traditions modules often apply (Buddhist, Hindu, Muslim or Christian frames may each shape meaning) [synthesis]. (3) For diaspora clients, add the immigrants and refugees module. (4) For family-driven care, consider the caregivers module with consent. (5) Record in the client's words.
Example language (illustrative): "Does your religion or your family's tradition say anything about why this has happened, or what should help?"
Watch for: Fatigue from long interviews; spread modules over sessions. Working if: the formulation includes cause, meaning and preferred help in the client's terms.

4.5 Eliciting the explanatory model

Purpose / when: Whenever the client or family uses system concepts (dosha imbalance, unmada, bhutaja illness, poisoning, karmic or spirit causes) [source: Manohara et al. 2023 for concepts; approach after Kleinman, Eisenberg and Good 1978: source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].
Steps: (1) Ask what the client calls the problem. (2) Ask what caused it and why now. (3) Ask what it does to the body and mind. (4) Ask how serious it is and how long it will last. (5) Ask what treatment they think is needed and from whom. (6) Ask what they fear most. (7) Note where the client's model and yours overlap and where they diverge; plan from the overlap.
Example language (illustrative): "Your physician said this is a vata problem. What does that mean to you, and what do you expect to change if it is treated?" / "You said some in your family think a spirit is involved. What do you think?"
Watch for: Family and client holding different models; ask each. Working if: the client experiences you as interested rather than testing them, and the plan uses their language.

4.6 Non-judgemental inquiry about remedies and treatments

Purpose / when: At intake and at each review; especially when the client takes psychiatric or other prescribed medicines [synthesis].
Steps: (1) Normalise: many people use both systems. (2) Ask whether they are taking or applying any Ayurvedic, lineage or home remedies, and from whom. (3) Ask whether their doctor and their physician each know about the other's treatment. (4) Do not comment on the remedy's safety or effect. (5) With consent, tell the prescribing doctor or pharmacist that remedies are in use and encourage the client to bring the products to that appointment. (6) Record that you routed it.
Example language (illustrative): "I don't advise on medicines or remedies, but your doctor needs the full picture. Would you be willing to take what you're using to your next appointment, or let me tell them?"
Watch for: Heavy-metal content has been reported in some Ayurvedic medicines, with a Sri Lankan co-author calling for culturally appropriate public education about toxicity risk [source: Dargan et al. 2008, via ScienceDaily]. Herb–drug interaction risks are for the prescriber to assess. Working if: the prescriber is informed and the client keeps disclosing.

4.7 Distinguishing culturally normative experiences from disorder

Purpose / when: When the client describes spirit influence, possession, sorcery or bhutaja illness, or when family attribute behavioural change to such causes [synthesis].
Steps: (1) Elicit the belief and its meaning without challenge. (2) Ask whether the belief is shared by family and community and how they view the person's experience. (3) Assess functioning, duration, distress and features beyond the shared belief (for example sustained disorganisation, mania, severe withdrawal, command hallucinations, self-neglect). (4) Consult a cultural broker or a clinician from the same background, with consent and without identifying details where possible. (5) Decide whether a psychiatric assessment is needed; if so, explain it in terms compatible with the client's model. (6) Keep both frames open in the record.
Example language (illustrative): "Many people in your community understand experiences like this as coming from a spirit. Alongside whatever your family is doing, I'd like a doctor to check that nothing else needs treatment. Would that be all right?"
Watch for: Unmada is itself framed by Sri Lankan scholars as correlating with psychotic and mood disorders [source: Manohara et al. 2023], so a client using the system's terms may already be describing serious illness. Working if: the client accepts assessment without feeling their belief was dismissed.

4.8 Medical urgency triage alongside indigenous care

Purpose / when: When a client or family member reports snakebite, a fracture or dislocation, a burn, a dog bite, acute confusion, or worsening psychiatric symptoms while using indigenous care. Snakebite, fractures, burns and hydrophobia (rabies) are recognised special-register branches [source: Performance Report 2014].
Steps: (1) Ask what happened, when, and what care has been received. (2) For snakebite or a possible rabies exposure, advise immediate hospital attendance whatever else is planned. (3) For a fracture or dislocation, encourage medical assessment (imaging) even if a bone-setter is also seen. (4) For acute psychiatric deterioration or suicidality, follow your standard crisis pathway. (5) Frame hospital care as compatible with continuing indigenous care. (6) Document advice given.
Example language (illustrative): "Whatever else your family decides, a snakebite needs the hospital today; the snakebite physician can still be part of the care afterwards."
Watch for: In a Sri Lankan hospital study, 14% of snakebite patients intentionally delayed treatment, and antivenom was often given hours after the bite [source: Silva et al. 2020]. Complications of traditional bone-setting are reported in medical literature from several countries [uncertain: not verified]. Working if: the person reaches medical assessment without abandoning the healer they trust.

4.9 Verifying registration and choosing collaborators

Purpose / when: When the client wants you to work with, or is relying heavily on, a named physician [source: Ayurveda Act ss 51, 55, 64, 69].
Steps: (1) Ask the client whether the physician is registered with the Ayurvedic Medical Council and in which register (general or special, and which branch). (2) If the client wishes, they or you (with consent) can confirm registration with the Council. (3) Note that many lineage physicians are unregistered; this is information, not a verdict on the client's choice [source: Samarakoon et al. 2021]. (4) Prefer collaboration with registered practitioners for formal care coordination. (5) Outside Sri Lanka, check local law: Sri Lankan registration does not license practice elsewhere [synthesis].
Example language (illustrative): "So I can work with them properly, do you know whether your physician is registered with the Ayurvedic Medical Council, and for what kind of treatment?"
Watch for: Clients feeling their healer is being investigated; keep it practical. Working if: you know who is treating what, and in which capacity.

4.10 Collaboration and referral with consent

Purpose / when: When the client wants their psychotherapy and indigenous care coordinated, or asks you for a referral to the system [synthesis].
Steps: (1) Clarify what the client wants each practitioner to know. (2) Obtain written, specific consent naming the practitioner and the information. (3) Share only what is needed: your role, the focus of therapy, safety concerns, and a request to be told of serious changes. (4) Ask the practitioner how they understand the problem and what they are providing, without asking them to justify it. (5) Agree who the client contacts in a crisis (usually the medical or mental-health service). (6) For referral requests, give information on registered practitioners and public Ayurveda hospitals rather than naming an individual you cannot vouch for [source: Performance Report 2014 for public hospitals].
Example language (illustrative, to a physician): "I'm seeing your patient for counselling about low mood, with her consent. I'd value knowing how you understand her condition, and I'll let you know if I become concerned about her safety."
Watch for: Being asked to endorse a treatment; decline politely and stay in role. Working if: the client experiences one team rather than competing advice.

4.11 Interpreters and cultural brokers

Purpose / when: When the client prefers Sinhala or Tamil, or when system terms need explaining [synthesis].
Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Brief the interpreter on confidentiality and on rendering terms like dosha, unmada or bhutaja literally, with a note on meaning rather than a substitute word. (3) Check the client's community fit with the interpreter (small diaspora communities raise confidentiality worries). (4) For meaning questions, consult a cultural broker or Sri Lankan clinician with consent. (5) Debrief the interpreter after emotionally heavy sessions.
Example language (illustrative): "When she uses a word from her physician, please say the word as she says it and then tell me briefly what it usually means."
Watch for: Interpreter softening spirit or stigma content. Working if: the client's terms appear unedited in your notes.

4.12 Working with the family

Purpose / when: Families often recommend and pay for help and steer between helpers [source: Gomez et al. 2017].
Steps: (1) Ask the client whom they want involved. (2) With consent, invite family to a session to hear their explanatory model. (3) Acknowledge efforts already made, including indigenous and religious care. (4) Agree a shared plan that names each helper's role and the safety steps. (5) Revisit when the family proposes a new helper.
Example language (illustrative): "You have tried hard to find the right help for your son. Can we look together at what each kind of help is for, and what we'll do if things get worse?"
Watch for: Family pressure overriding the client's wishes; check privately. Working if: family and client describe the same plan.

4.13 Integrating indigenous healing experiences into therapy

Purpose / when: When treatment by a physician, a pilgrimage, or ritual or religious care has meaning for the client [synthesis].
Steps: (1) Invite the client to tell what happened and what it meant, in whatever detail they choose. (2) Do not ask for ritual or treatment details beyond what the client offers. (3) Identify what the client took from it (hope, relief, family support, a new understanding). (4) Link those to therapy goals. (5) If the experience was distressing or disappointing, process that like any other experience.
Example language (illustrative): "What did that treatment mean for you? Is there anything from it you'd like to carry into what we're doing here?"
Watch for: Disappointment or shame after care that did not help; most people in one clinic sample reported traditional or faith healing did not relieve their symptoms [source: Gomez et al. 2017]. Working if: the client can hold both care streams without feeling forced to choose.

4.14 Supporting informed consent for physical treatments

Purpose / when: When the client is having bone-setting, oil treatments, massage or purification procedures and is anxious, has a trauma history, or is unsure of their rights [synthesis]. Massage therapists have their own register under the Act [source: Ayurveda Act s 51].
Steps: (1) Ask how the client feels about the treatment and the touch involved. (2) Affirm that they may ask what will happen, ask for a same-gender practitioner or a chaperone, and stop at any point. (3) Help them rehearse a question or a stop signal. (4) Make clear that touch should never be sexual; any genital or intimate contact beyond what was explained and agreed should be reported. (5) Review afterwards. Do not describe or recommend techniques.
Example language (illustrative): "You have the right to ask what each step involves and to say stop. Would it help to practise how you'd say that?"
Watch for: Dissociation or flashbacks around treatment; disclosures of inappropriate touch (move to safeguarding). Working if: the client reports feeling in control of their care.

4.15 Safeguarding when a practice harms

Purpose / when: When you learn of restraint, beating, deprivation of food or sleep, sexual abuse, accusations against a child, or delay of urgent medical care in the name of any healing practice [synthesis].
Steps: (1) Separate respect for the tradition from the specific harmful act. (2) Assess immediate risk. (3) Follow your jurisdiction's adult and child safeguarding procedures, and consult your safeguarding lead. (4) Where a registered practitioner is involved, misconduct can be raised with the Ayurvedic Medical Council, which may suspend or cancel registration [source: Ayurveda Act s 57]. (5) Tell the client what you are doing and why, unless that increases risk. (6) Document facts, not judgements about the tradition. Never name minors in shared records beyond what procedure requires.
Example language (illustrative): "I respect that your family turned to this healer. What you've described, being tied and hit, is something I have to act on to keep you safe."
Watch for: Abuse framed as tradition, and tradition misread as abuse; consult a cultural broker when unsure. Working if: risk is reduced and the client stays engaged.

4.16 Addressing stigma and help-seeking barriers

Purpose / when: When stigma or low awareness of treatment delays care, which a Sri Lankan clinic study identified as barriers [source: Gomez et al. 2017].
Steps: (1) Ask what people around the client would think of them seeing a psychiatrist or counsellor. (2) Explore the client's own beliefs about mental illness. (3) Offer an understanding of therapy that fits their explanatory model. (4) Discuss whom they can safely tell.
Example language (illustrative): "Some people worry that coming here means they are 'mad'. Has that worry come up for you or your family?"
Watch for: Preference for a spiritual or physical label over a psychiatric one; you can work with the label the client uses. Working if: attendance stabilises and disclosure increases.

4.17 Diaspora and transnational care

Purpose / when: With Sri Lankan clients abroad who import remedies, consult physicians by phone, or travel home for treatment [synthesis].
Steps: (1) Ask about remedies brought from home or bought online, and route them to the prescriber. (2) Ask about planned treatment trips and their timing relative to therapy. (3) Plan continuity, including crisis contacts while away. (4) Explore loss of access to home helpers as a stressor.
Example language (illustrative): "If you're going home for treatment next month, let's plan how we'll stay in touch and what you'll do if things get hard while you're there."
Watch for: Products outside local regulation, which European legislation is noted to protect against poorly [source: Dargan et al. 2008, via ScienceDaily]. Working if: there is a written continuity plan.

5. Handling problems

The Sri Lankan sources describe help-seeking patterns and regulation; they do not give guidance on therapy problems. All responses below are [synthesis] unless a source is named.

Client wants you to say whether their physician's treatment works. Decline to judge, without dismissing. Say that remedies are for their physician and prescribing doctor to discuss, and that your role is to help with how they are coping. Offer to pass questions to the prescriber with consent.
Client stops psychiatric medicine because a physician or relative advised it. Do not advise either way. Urge prompt contact with the prescriber, explain why you are concerned in terms of their safety, and, with consent, inform the prescriber. Increase contact and review risk.
Family insists the problem is spirit-caused and refuses psychiatric assessment. Elicit their model fully (4.5); acknowledge it; propose assessment as an addition rather than a replacement (4.7); involve a respected community or religious figure if the client wishes. If risk is high, follow crisis procedures regardless of agreement.
Client has used several helpers without relief and feels hopeless. Validate the effort; in one clinic sample most who used traditional or faith healing were dissatisfied [source: Gomez et al. 2017]. Use the disappointment as therapy material and rebuild hope around specific, small goals.
Stuck therapy because two models compete (dosha or spirit vs. psychological). Look for the overlap: stress, sleep, diet, family conflict, meaning. Agree targets that fit both. Avoid debates about cause.
Rupture: the client felt you disrespected their tradition. Name it, apologise for the impact, ask what felt dismissive, and repair by reflecting their view accurately. Review your self-examination notes (4.1).
Non-adherence to therapy tasks during an indigenous treatment course. Ask whether the physician gave rules (diet, rest, routines) that conflict with homework; adapt tasks rather than ask the client to break those rules.
Overwhelm from too many helpers and conflicting advice. Help the client list each helper and what they are for (4.2); identify one coordinating person; with consent, communicate with key practitioners (4.10).
Physical complication after a procedure (worsening pain, deformity, burn, wound infection). Advise urgent medical assessment; do not comment on the procedure. If misconduct is suspected, inform the client of the right to complain to the Ayurvedic Medical Council [source: Ayurveda Act s 57].
Snakebite or animal bite disclosed in passing. Treat as urgent (4.8) [source: Silva et al. 2020].
Disclosure of harmful treatment (restraint, beating, sexual contact). Move to safeguarding (4.15) the same day.
Client asks you to refer them to a "good" lineage physician. Do not name individuals; explain registration and public Ayurveda hospital options [source: Performance Report 2014; Ayurveda Act s 55].
Therapist doubts about own competence. Seek consultation with a clinician familiar with Sri Lankan medical pluralism; do not attempt to learn or apply the system's diagnosis.
Concerns about remedy contamination or interactions. Route to the prescriber or pharmacist (4.6); do not advise stopping [source: Dargan et al. 2008, via ScienceDaily].
Confidentiality worries in a small community (interpreter or healer knows the family). Discuss openly; offer an interpreter from outside the community or a telephone interpreter; share only what the client consents to.

Sources

Web sources:

Books and manuals cited:

Kapferer, B. (1983). A Celebration of Demons: Exorcism and the Aesthetics of Healing in Sri Lanka. Bloomington: Indiana University Press (2nd ed. 1991, Berg / Smithsonian Institution Press). Outsider ethnography [uncertain: not verified].
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Cultural Formulation Interview [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258 [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].

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