Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 012
Guide XI-012

Nepali jhankri healers

Nepal
A 39 · L 50 · M 1119 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: there is no treatment manual for this tradition. The psychotherapist's work described here follows the DSM-5-TR Cultural Formulation Interview (CFI) as published by the American Psychiatric Association, and Nepal-based research on healers and mental health by Brandon Kohrt and colleagues (chiefly Pham, Kaiser, Koirala et al. 2020; Pham, Koirala and Kohrt 2020; Pham 2019; Kohrt and Harper 2008; Kohrt and Hruschka 2010; Kohrt 2014). Most of this research is by outsiders (non-Nepali or foreign-trained researchers working with Nepali colleagues), and the guide says so where it matters.

What it is. Dhami-jhankri (also spelled jhakri, jhãkri) is a Nepali term for healers who work with spirits, deities and other unseen forces on behalf of people who are ill or in misfortune. In the Nepal research this guide draws on, dhami-jhankri were the largest group of traditional healers in one central middle-hills village (23 of 29 healers), alongside lama (generally Buddhist), jyotisi (astrologers), baidhya (ayurvedic healers), naturopathic healers and pujari and jajmani (priests) [source: Pham 2019]. Healers of this kind are found among many of Nepal's peoples; Paudel (2025) lists jhakri, bombo, lama and dhami as distinct healer types among Tamang communities, and links the forest spirit-guru banjhakri tradition mainly to the central and eastern hills and to Chepang, Kham Magar, Limbu and Kami communities [source: Paudel 2025]. Paudel describes jhakris as healers who enter trance and are possessed by, usually benevolent, helping spirits, and states they are the only Nepali healers who do so [source: Paudel 2025]. These are the tradition's and the scholars' accounts, not statements of fact by this guide.

Who holds authority. Authority rests within the tradition: in the accounts available, a person becomes a healer through a calling (fainting, trance episodes, recurring dreams or other events described by communities) and through gurus and lineage, and selection is said not to depend on caste or wealth; one Chepang jhakrini (woman healer) is quoted as saying "only gods decide who will be taken by banjhakri" [source: Paudel 2025]. Recognition comes from the healer's own lineage and the community that consults them. No state licensing or registration body for dhami-jhankri was found [uncertain: not verified]. The psychotherapist holds no authority within this tradition and does not perform, imitate or direct its healing, rituals or divination.

How it is used for mental health. Nepali families commonly combine healers and biomedicine. A paper in the Journal of Psychiatrists' Association of Nepal cites national data in which 6.7% of adults had consulted faith healers for mental disorders, compared with 6.5% who had consulted psychiatrists [source: Ghimire et al. 2025]. Patients often move between healers and clinics until they feel "satisfied in the soul" [source: Pham 2019; Pham, Koirala and Kohrt 2020]. Researchers describe healers as using magico-religious explanations together with processes also found in psychotherapy (symbolic transference, cognitive restructuring, meaning-making, catharsis, social support, alliance, empathy and raising expectations of recovery), with perceived benefit mainly for mild to moderate distress [source: Pham, Kaiser, Koirala et al. 2020; Pham, Koirala and Kohrt 2020].

Core idea of change for the psychotherapist. Change in the therapist's work comes from understanding the client's own explanatory model and help-seeking path, assessing accurately without pathologising culturally normative experience or missing illness, coordinating with the healers the client chooses, and helping the client integrate meanings from both systems into recovery they themselves define [synthesis, built on the CFI and on Pham et al. 2020].

2. Framework

This is not a therapy with phases set by the tradition. The phases below organise the psychotherapist's own work alongside a client who consults, or whose family consults, dhami-jhankri. Session counts are suggestions [synthesis].

Phase 0: Preparation (before and between clients). Goal: examine your own assumptions about spirits, possession, caste, gender and Nepali health practices; learn the local service landscape (psychiatry, community mental health, interpreters, Nepali community organisations). Move on when you can state your own likely biases and know whom to consult [synthesis].

Phase 1: Cultural assessment (sessions 1–2, can extend to 3). Goal: the CFI core (16 questions in four domains: cultural definition of the problem; perceptions of cause, context and support, including the role of cultural identity; self-coping and past help-seeking; current help-seeking, including preferences and the clinician-patient relationship) plus relevant supplementary modules [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Include who the client and family have consulted (healers, astrologers, lamas, doctors, drug retailers) and what each said. Move on when you have the client's own name for the problem, their view of its cause, their care path so far and their preferences now [synthesis].

Phase 2: Formulation and differential (sessions 2–3). Goal: a formulation in the client's terms and yours; distinguish culturally normative experiences (for example possession attributions, a healer's calling, distress named in heart-mind terms) from disorders needing specific treatment; screen for risk, substance use and medical causes. Consult a cultural broker when uncertain. Move on when the client agrees with a shared summary and safety is assessed [synthesis; CFI says it is not to be the sole basis for diagnosis: source APA CFI].

Phase 3: Shared plan and coordination (session 3–4 onward). Goal: agree what therapy will offer, how it fits with any healer the client is seeing, what consent covers contact with healers or family, and what safeguarding limits apply. Move on when the client has a plan they endorse, including any parallel healer care [synthesis; referral networks and partnership: source Pham 2019].

Phase 4: Ongoing work and integration (typically 6–16 sessions, flexible). Goal: treat what needs treating (using whatever evidence-based approach fits), make room for meanings from healing experiences, address shame, blame and social standing, and support family. Review at regular intervals against the client's own definition of being "better" [source for client-defined outcome: Pham 2019; rest synthesis].

Phase 5: Review, ending and follow-up. Goal: consolidate, plan for relapse signs in the client's idiom, leave the door open for return. Criterion: client-defined goals met or a reasoned onward referral [synthesis].

Format: individual sessions, with family sessions where the client wants them (families often coordinate care in Nepal: source Pham 2019); a trained interpreter where needed; in-person or video [synthesis].

3. Guiding principles

  • Work alongside, not inside, the tradition. You assess, treat and coordinate; healing rituals belong to healers the client and community recognise [synthesis].
  • Attribute, do not adjudicate. Describe spirits, possession, deities and witchcraft as the client and tradition hold them; neither confirm nor dismiss [synthesis].
  • The client's explanatory model comes first. Ask before explaining; the CFI is built on the person's own definition and view of causes [source: APA CFI].
  • Expect plural help-seeking. Movement between healers, astrologers, drug retailers and doctors is normal, not non-adherence; one patient in a case study consulted a drug retailer, an astrologer and three dhami-jhankri [source: Pham 2019].
  • Respect the hierarchy of resort. Families choose the order of helpers according to how they frame mind and body; your place in that order is the client's choice [source: Kohrt and Harper 2008; practical meaning synthesis].
  • Use less stigmatising frames. Heart-mind distress is socially acceptable to seek help for, while brain-mind dysfunction carries more stigma; choose language accordingly [source: Kohrt and Hruschka 2010].
  • Mind and body are not assumed to be fused. Do not presume a non-Western client is holistic; Kohrt and Harper found mind-body divisions prominent in Nepal [source: Kohrt and Harper 2008].
  • Recovery is defined by the client. Treat patients as partners whose sense of "better" matters [source: Pham 2019].
  • Common factors are shared ground. Alliance, empathy, validation and hope are what successful healers were rated highly on; build them deliberately [source: Pham, Koirala and Kohrt 2020].
  • Neither pathologise nor miss illness. Normative spiritual experience and serious mental illness can coexist; assess both [synthesis].
  • Consent governs all contact with healers or family. No contact without explicit, specific, revocable consent [synthesis].
  • Safety overrides deference. Physical harm, delay of urgent care and witchcraft accusations are safeguarding matters, whatever their framing [source for documented harms: Pham 2019; Himalayan Times 2020].
  • Do not take part in or broker ceremonies. Do not recommend healers or ceremonies outside the client's own community pathways [synthesis].
  • Medicines are for prescribers. Never advise starting, stopping or changing a medicine or a healer's remedy; route questions to the prescriber [synthesis].
  • Know the limits of outsider accounts. Much of the literature is outsiders' ethnography; check meanings with the client and cultural brokers [synthesis].

[source for section 1–3 framing: APA CFI; Pham 2019; Pham, Kaiser, Koirala et al. 2020; Pham, Koirala and Kohrt 2020; Paudel 2025; Ghimire et al. 2025]

4. Intervention inventory

All interventions below are the psychotherapist's own culturally responsive work. None involves performing, imitating or directing a healer's ritual, trance, divination or remedy. Example language is illustrative and should be adapted with an interpreter or cultural broker.

4.1 Cultural humility and self-examination

  • Purpose / when: Before the first session and whenever you notice a strong reaction (fascination, scepticism, alarm) to spirit or possession accounts [synthesis].
  • Steps: (1) Write down your own beliefs about spirits, possession, karma and healers, and what you assume about Nepali, caste, gender and rural or diaspora life. (2) Note where your training pulls you to label ("psychotic", "superstitious") or to romanticise ("ancient wisdom"). (3) Identify which accounts you have are outsiders' ethnographies. (4) Take one question to supervision or a Nepali colleague each month [synthesis].
  • Example language (to yourself or supervisor, illustrative): "What am I assuming about this family's choice to see a jhankri before coming here?"
  • Watch for: Over-identifying with the healer role; collecting exotic detail the client did not offer; treating Nepal as one culture. Working if you can describe the client's framing without evaluative words [synthesis].

4.2 CFI core interview

  • Purpose / when: Sessions 1–2 with any client whose problem may be framed in spiritual, Nepali or mixed terms; repeat parts when the framing changes [source: APA CFI].
  • Steps: (1) Introduce the interview as a chance to understand the problem in the client's own way (the CFI opens with such a statement). (2) Cultural definition of the problem: the client's own words, how they describe it to family, what troubles them most. (3) Causes, as the client and as family and community see them; stressors and supports; salient aspects of identity. (4) Self-coping and past help-seeking, explicitly including traditional and spiritual help and how useful each was; barriers such as cost, stigma, language. (5) Current preferences and what the network suggests. (6) Concerns about you or the clinic, including bias or language. Follow the italic interviewer guidance in the APA form; paraphrase into Nepali through a trained interpreter; obtain APA permission before modifying or translating the published form [source: APA CFI].
  • Example language (illustrative): "Sometimes people describe a problem in their own words, which can be different from how doctors describe it. How would you describe what is happening?" / "Who else have you gone to for help, such as a dhami-jhankri, a lama, an astrologer, a doctor? What did each say, and did it help?"
  • Watch for: Short, guarded answers about healers or witchcraft; Pham (2019) noted participants were reluctant to discuss witchcraft with a foreign researcher. Do not push; return later. The CFI is not the sole basis for a diagnosis [source: APA CFI; Pham 2019]. Working when the client corrects or adds to your summary.

4.3 CFI supplementary modules

  • Purpose / when: To deepen specific areas. The APA lists 12 modules: Explanatory Model; Level of Functioning; Social Network; Older Adults; Psychosocial Stressors; Spirituality, Religion, and Moral Traditions; Immigrants and Refugees; Cultural Identity; Caregivers; Coping and Help-Seeking; School-Age Children and Adolescents; Patient-Clinician Relationship [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
  • Steps: (1) Choose modules from the core answers: Explanatory Model when spiritual causation is named; Spirituality, Religion, and Moral Traditions when deities, ancestral deity, karma or healers are central; Coping and Help Seeking for complex care paths; Caregivers and Social Network when family coordinates care; Immigrants and Refugees for diaspora and resettled clients; School-Age Children and Adolescents for minors. (2) Use one or two per session. (3) Record answers in the client's terms [synthesis on selection; module list: source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
  • Example language (illustrative): "You said your family thinks your clan deity may be displeased. Can you tell me more about what that means in your family, and what they think should happen?"
  • Watch for: Interview fatigue; turning modules into a checklist. Working when the formulation contains the client's own causal story [synthesis].

4.4 Eliciting the Nepali explanatory model

  • Purpose / when: Throughout assessment; essential when the client names supernatural, astrological, bodily or social causes [synthesis].
  • Steps: (1) Listen for domains Nepali respondents use for distress: heart-mind, brain-mind, body, spirit and social status [source: Kohrt and Hruschka 2010]. (2) Listen for causes reported in Nepal research, as the client names them: ghost possession (bhut lagnu), a spiritual illness called lagan, a supernatural problem caused by others (bigar), damaging love spells (mohoni), astrological misalignment (grahadasha), and malevolent forces capturing the soul's essence [source: Pham 2019]; karma from one's own past life or family members' sins [source: Kohrt and Hruschka 2010]; displeasure of an ancestral deity [source: Kohrt 2014]. Soul loss is also documented in ethnography of Yolmo Sherpa healing [source: Desjarlais 1993, chapter titles; content uncertain: not verified]. A Nepali term for soul or spirit loss commonly cited in the literature was not confirmed in the sources used [uncertain: not verified]. (3) Ask what follows from each cause: who can help, what would show improvement, what the family fears. (4) Summarise back using the client's words.
  • Example language (illustrative): "When you say the problem is in your man [heart-mind], and your father says it is a bhut, how do those two fit together for you?"
  • Watch for: Imposing a single cause; translating every term into a diagnosis. Working when the client offers more detail and uses their own terms freely [synthesis].

4.5 Mapping the care pathway and asking about healers without judgement

  • Purpose / when: Early, and at each review; healers, drug retailers and community health assistants commonly refer onward according to patients' expectations [source: Pham 2019].
  • Steps: (1) Draw with the client a timeline of every helper consulted, in order (this reflects the hierarchy of resort: source Kohrt and Harper 2008). (2) For each: what was said, what was done in general terms (do not ask for ritual detail), cost, what helped, what did not, any harm. (3) Ask about current and planned consultations. (4) Ask what the client wants you to know or not know. (5) Ask about costs; Pham (2019) reports a healer charging about 6,000 rupees and a hospital workup about 10,000 [source: Pham 2019].
  • Example language (illustrative): "Many families see a dhami-jhankri and a doctor, sometimes at the same time. Nothing you tell me about that will change how I treat you. Who have you seen so far?"
  • Watch for: Shame or fear of criticism (villagers often saw doctors and healers as competing: source Pham 2019); financial strain; displaced medical care. Working when the client discloses current healer visits without prompting [synthesis].

4.6 Choosing less stigmatising language of distress

  • Purpose / when: In feedback, psychoeducation and family sessions [source basis: Kohrt and Hruschka 2010; Kohrt and Harper 2008].
  • Steps: (1) Note whether the client locates the problem in heart-mind or brain-mind; heart-mind distress was socially acceptable to seek help for, while brain-mind idioms added stigma [source: Kohrt and Hruschka 2010]. (2) Where accurate, frame difficulties and treatment in heart-mind or stress terms. (3) Avoid labels the family hears as madness unless needed and explained. (4) Reframe in less stigmatising ways, as Kohrt and Harper (2008) recommend for stigma reduction [source].
  • Example language (illustrative): "What you describe sounds like a heavy burden on your heart-mind after everything that happened. That is something people can get help with."
  • Watch for: Minimising a serious disorder to avoid stigma. Working when the family stays engaged after feedback [synthesis].

4.7 Distinguishing normative experience from disorder

  • Purpose / when: When a client reports possession, trance, a calling to become a healer, spirit encounters, or unusual perceptions [synthesis].
  • Steps: (1) Establish whether the experience is recognised in the client's community: a healer's possession by helping spirits and a calling after fainting, trance or dreams are described as part of becoming a jhakri [source: Paudel 2025]; Paudel also suggests abduction narratives can give a socially acceptable way to explain distress or trauma [source: Paudel 2025]. (2) Ask whether family, community or a recognised healer regards it as expected or as an affliction. (3) Assess separately: duration, distress, functioning, control, sleep, mood, substance use, medical causes, risk. (4) Consult a cultural broker or Nepali clinician. (5) Formulate both: what the experience means culturally and whether a treatable disorder is also present. DSM-5 states that dissociative identity disruption "may be described in some cultures as an experience of possession", and its dissociative trance example excludes trance that is "a normal part of a broadly accepted collective cultural or religious practice" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. DSM-5-TR keeps these points in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; that it keeps the exact wording is [uncertain].
  • Example language (illustrative): "In your community, is this the kind of experience that comes to someone who is being called, or is it seen as something that has gone wrong? What do your elders say?"
  • Watch for: Psychotic features (disorganisation, loss of function, experiences the community itself sees as abnormal); dissociation after trauma; intoxication. Working when cultural brokers and clinical assessment converge [synthesis].

4.8 Interpreters and cultural brokers

  • Purpose / when: Any client with limited English or whose key concepts are Nepali or another Himalayan language (Tamang, Magar, Gurung, Limbu and others) [synthesis].
  • Steps: (1) Use a trained interpreter, not family, for assessment. (2) Brief the interpreter on confidentiality and on not editing spiritual content. (3) Check the interpreter's caste, ethnicity and community ties with the client's consent. (4) Separately, a cultural broker (a Nepali clinician or community member) may advise on meanings, with the client's permission and minimal identifying detail. (5) Ask the client which language they think about their problem in [synthesis; CFI barrier item on language-concordant services: source APA CFI].
  • Example language (illustrative): "Please translate exactly what I say and exactly what she says, including anything about gods or spirits, even if it seems unusual."
  • Watch for: Interpreters softening or omitting healer and witchcraft talk; social-status concerns in small communities. Working when the client's words come through with Nepali terms intact [synthesis].

4.9 Collaboration and referral with healers the client chooses

  • Purpose / when: When the client wishes, and only with consent. Pham (2019) recommends a bio-psycho-social-spiritual collaborative model and referral networks; Ghimire et al. (2025) report most Jumla healers interviewed did not oppose biomedical care and some referred clients to hospitals or psychiatrists [source].
  • Steps: (1) Ask whether the client wants you to coordinate with their healer at all. (2) If yes, agree in writing exactly what may be shared, with whom, and how consent can be withdrawn. (3) Contact is about coordination: timing, warning signs, when to send the client to emergency or medical care, how each of you will avoid contradicting the other in front of the client. (4) Never request or comment on ritual content. (5) Agree a two-way referral route for crises. (6) Document [synthesis on steps].
  • Example language (illustrative): "Would it help if I spoke with the dhami-jhankri you trust, only about how we can both support you and what to do if things get worse? You decide what I can say."
  • Watch for: Pressure on the client from either side; a healer who discourages urgent care; your own temptation to evaluate the ritual. Working when the client experiences the two as complementary [synthesis].

4.10 Working with the family as care coordinators

  • Purpose / when: When family members decide which helpers to consult; in Pham's case study the family coordinated care across a drug retailer, an astrologer and three dhami-jhankri [source: Pham 2019].
  • Steps: (1) With the client's consent, invite key family members (CFI Caregivers and Social Network modules). (2) Ask each person's explanation and preferred helpers. (3) Name agreement and disagreement neutrally. (4) Agree a shared plan that includes what therapy offers, what the healer offers, and danger signs that mean urgent medical care. (5) Protect the client's voice, especially for young people, women and those of lower social standing within the family [synthesis].
  • Example language (illustrative): "Everyone here wants her to get well. Let's write down what each of you thinks will help, and agree which signs mean we go to the hospital the same day."
  • Watch for: The client silenced; blame on one member (for example as a source of bigar or witchcraft, see 4.15). Working when family supports attendance and the client speaks freely [synthesis].

4.11 Building the common factors healers are rated highly on

  • Purpose / when: Throughout; healers perceived as successful scored high on alliance, empathy, promoting expectations of recovery and using cultural models of distress [source: Pham, Koirala and Kohrt 2020]. Pham (2019) used the ENACT scale to rate such factors [source].
  • Steps: (1) Validate the client's emotions explicitly. (2) Give a clear, culturally framed rationale for what you will do. (3) State realistic hope for recovery. (4) Use the client's idioms in your rationale. (5) Check the alliance each session (CFI clinician-patient relationship item) [synthesis; CFI item: source APA CFI].
  • Example language (illustrative): "Your fear makes sense after what happened. Here is how our sessions can help your heart-mind settle, alongside what your family is doing."
  • Watch for: Hope without a rationale; rationale only in biomedical terms. Working when attendance is steady and the client repeats the rationale in their own words [synthesis].

4.12 Integrating healing experiences into therapy

  • Purpose / when: After a client has consulted a healer and wants to make sense of it, or when a ritual brought relief that faded. In Kohrt's case of a former child soldier, a healer's ritual (man baadhne, glossed as binding the heart-mind) temporarily eased distress [source: Kohrt 2014].
  • Steps: (1) Invite the client to describe what the experience meant, not how it was done. (2) Ask what changed afterwards and what remains. (3) Link meanings to therapy goals (for example a sense of protection, reconciliation with an ancestral deity, family support). (4) Where relief faded, explore remaining stressors and symptoms without implying the ritual failed. (5) Respect the client's plan for further rituals; the treatment decision about rituals is theirs [synthesis].
  • Example language (illustrative): "After that visit you said you felt lighter for a while. What was it that felt different, and what has come back?"
  • Watch for: Asking for ritual detail; framing the healer as rival; distress returning in a pattern suggesting depression or PTSD needing focused treatment. Working when the client can hold both experiences without conflict [synthesis].

4.13 Addressing karma, blame, shame and social standing

  • Purpose / when: When the client or family attributes misfortune to sins in a past life or of family members, or fears loss of social status. Kohrt and Hruschka found survivors felt blamed for negative events seen as karma, and some families avoided care because revealing this karma was stigmatising [source: Kohrt and Hruschka 2010].
  • Steps: (1) Name the burden of blame without debating karma. (2) Separate responsibility for events from the client's worth. (3) Explore who knows and what the client fears socially. (4) Offer confidential, discreet care arrangements. (5) Use self-compassion or trauma-focused work in the client's terms when indicated [synthesis].
  • Example language (illustrative): "Whatever the reasons in your family's view, you have been carrying this alone. What would it mean for you to get help without others knowing?"
  • Watch for: Self-blame feeding depression or suicidality; family concealment delaying care. Working when shame lessens and help-seeking widens [synthesis].

4.14 Trauma, conflict-affected and returnee clients

  • Purpose / when: Clients affected by Nepal's civil war, disasters or migration, including former combatants. Kohrt (2014) describes a former child soldier who believed wartime acts (touching the dead, eating with other castes) offended his ancestral deity, and a girl returnee who was urged by women elders to perform an atonement fast but chose instead to focus on starting a business [source: Kohrt 2014].
  • Steps: (1) Assess trauma exposure and symptoms. (2) Ask about spiritual and caste-pollution concerns tied to the events. (3) Ask what the client wants: some seek rituals, some decline them; support either choice. (4) Address practical reintegration (livelihood, family) alongside symptoms. (5) Offer trauma-focused treatment where indicated, with a culturally framed rationale [synthesis on steps].
  • Example language (illustrative): "Some people want a ritual when they come home, some don't. What feels right for you, and what does your family expect?"
  • Watch for: Pressure from elders against the client's wishes; gendered expectations; retraumatisation by premature detail. Working when the client sets the pace and functioning improves [synthesis].

4.15 Safeguarding: physical harm, delayed care and witchcraft accusations

  • Purpose / when: Whenever a practice or accusation risks harm. Reported harms in Nepal include patients hit with books, brooms and stones during healing, being given animal blood to drink, a hospitalised relative discharged to see a healer, delay of care that a villager felt nearly cost lives, and a visibly intoxicated healer [source: Pham 2019]. Women accused of witchcraft have been beaten, smeared with soot, force-fed excreta, expelled and killed; Nepal Police data cited for 2018–20 counted 98 victims, 94 of them women and four minors; Section 168 of the Criminal Code provides up to five years' jail and a fine up to Rs 50,000 [source: Himalayan Times 2020]. Perpetrators were family, neighbours and healers [source: Himalayan Times 2020].
  • Steps: (1) Ask directly, without accusing the tradition, whether anything in any treatment has hurt the client or frightened them. (2) Assess risk to the client and to anyone accused (often older, single or disabled women: source Himalayan Times 2020). (3) For children and adults at risk, follow your jurisdiction's safeguarding and reporting duties; in Nepal, police and gender-based violence services are routes [synthesis on routes]. (4) Where urgent medical care is being delayed, state the medical concern plainly and help arrange care. (5) Document facts, not judgements about beliefs. (6) Never name minors in records shared outside the service [synthesis].
  • Example language (illustrative): "I respect that your family is seeking help from many people. I also need to ask: has anyone hit you, kept food from you, or kept you from the doctor as part of treatment?"
  • Watch for: A family member labelled boksi (witch) or as a source of bigar; children blamed for misfortune; minimisation from fear of community reprisal. Working when risk is reduced and the client is safe [synthesis].

4.16 The medical and medication interface

  • Purpose / when: Always. Healers in Jumla linked symptoms such as headache, dizziness, neck stiffness, forgetfulness and fainting to mental illness, and named alcohol and cannabis use among youth as a major contributor [source: Ghimire et al. 2025].
  • Steps: (1) Screen for medical causes of somatic and neurological complaints and refer for medical review. (2) Screen for alcohol and drug use. (3) Ask whether the client takes any prescribed medicine or any healer's or ayurvedic remedy; record it and pass it to the prescriber. (4) Never advise starting, stopping or changing a medicine or remedy. (5) Coordinate with psychiatry for severe disorders (psychosis, bipolar disorder, severe depression) [synthesis].
  • Example language (illustrative): "Please tell your doctor about everything you are taking, including anything from a healer. They can check it is safe together."
  • Watch for: Fainting or seizure-like episodes needing neurological review; stopping medicine after a ritual. Working when the prescriber has a full picture [synthesis].

4.17 Risk and suicide assessment in cultural terms

  • Purpose / when: Every client, and especially when healing has not brought "satisfaction in the soul"; one participant linked unmet inner satisfaction (atma santushti) to suicide [source: Pham 2019]; Jumla healers reported suicidal clients [source: Ghimire et al. 2025].
  • Steps: (1) Ask about suicidal thoughts directly, in the client's idiom and in plain words. (2) Assess intent, plan, history, protective factors including family and faith. (3) Use lethal-means counselling (safe storage and removal) per current standard practice. (4) Agree a safety plan that names family, healer (if the client wishes) and emergency services. (5) Follow up closely [synthesis].
  • Example language (illustrative): "When nothing brings peace to the soul, some people think about ending their life. Have you had thoughts like that?"
  • Watch for: Hopelessness after failed treatments; shame. Working when the safety plan is used [synthesis].

4.18 Diaspora and resettled Nepali-speaking clients

  • Purpose / when: Clients in Nepali diaspora or resettled communities, who may have limited access to healers and may consult relatives by phone or community figures locally [synthesis].
  • Steps: (1) Use the CFI Immigrants and Refugees and Cultural Identity modules [source: APA CFI]. (2) Ask how the client is maintaining spiritual and family supports at a distance. (3) Ask whether local community organisations or recognised healers are part of their life; do not recommend practitioners yourself. (4) Address migration stressors, racism and service barriers [synthesis].
  • Example language (illustrative): "Back home, who would your family have gone to for this? What is possible for you here?"
  • Watch for: Isolation; commercial workshops marketed to outsiders as Nepali shamanism are not the same as a client's community healers [synthesis]. Working when the client has a support network they endorse.

4.19 Client-defined outcome review

  • Purpose / when: Every 4–6 sessions and at ending; Pham (2019) recommends treating patients as partners whose sense of "better" matters [source].
  • Steps: (1) Ask what "better" means to the client and family (sleep, work, harmony, peace in the soul). (2) Rate it simply each review. (3) Combine with a standard symptom measure if useful. (4) Adjust the plan [synthesis].
  • Example language (illustrative): "When you are well again, what will you and your family notice first?"
  • Watch for: Clinician goals replacing the client's. Working when both measures improve [synthesis].

5. Handling problems

Most guidance here is [synthesis]; sources are named where they support a point.

  • Client or family stuck between "doctor" and "dhami-jhankri". Villagers often see the two as competing ("If people believe more in the dhami-jhankri then the doctor will be ineffective": source Pham 2019). Response: say explicitly that you do not ask anyone to choose; map what each helper offers; agree danger signs that mean medical care. Revisit at each review [synthesis].
  • Client reluctant to discuss spirits or witchcraft. Participants were reluctant to discuss witchcraft with a foreign researcher [source: Pham 2019]. Response: normalise ("many families consider this"), offer a Nepali-speaking clinician or interpreter of the client's choosing, and return to it later; never press [synthesis].
  • Relief after a ritual fades, client discouraged. Response: validate the relief that came; review current stressors and symptoms; frame therapy as an additional support, not a replacement (see 4.12) [synthesis; temporary relief documented: source Kohrt 2014].
  • Non-attendance during healing periods or festivals. Response: plan sessions around them in advance; treat gaps as part of a plural care path, not resistance; agree a check-in by phone [synthesis].
  • Overwhelm or dissociation when discussing possession or trauma. Response: slow down, ground in present surroundings, shift to practical topics, return with the client's consent; assess for trauma-related dissociation and refer for specialist assessment if severe [synthesis].
  • Rupture when the client feels you doubted their beliefs. Response: acknowledge directly (CFI item on concerns about the clinician: source APA CFI); restate that you do not judge their explanation; ask what would help trust; consider a Nepali co-worker [synthesis].
  • Family pressing for a ritual the client does not want. Response: support the client's choice, as in Kohrt's account of a returnee who declined an atonement fast [source: Kohrt 2014]; hold a family session if the client wishes; check for coercion and gendered pressure [synthesis].
  • Client asks you to recommend or join a healing ceremony. Response: decline kindly; explain that healing within the tradition belongs to healers recognised by their community; support the client in using their own family and community routes [synthesis].
  • Healer advises stopping medicine or delaying hospital care. Response: do not argue the belief; state the medical risk plainly; with consent, coordinate with prescriber and, if the client wishes, the healer; if a delay is life-threatening, act on urgent-care and safeguarding duties [synthesis; delay harms documented: source Pham 2019].
  • Signs of physical harm or abuse in healing. Response: safeguarding takes precedence (see 4.15); document; report as your jurisdiction requires; offer medical care [synthesis; harms documented: source Pham 2019].
  • A family member is accused of witchcraft. Response: assess immediate danger to the accused; involve police or protection services per local law (Nepal: Criminal Code section 168, as reported); support the client to separate distress from blame [source for law and patterns: Himalayan Times 2020; response synthesis].
  • Child or adolescent involved. Response: use the CFI School-Age Children and Adolescents module; obtain assent and parental consent; screen for harm in any treatment; follow child safeguarding procedures; never name minors in shared material [synthesis; module: source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
  • Severe mental illness framed only as possession. Response: respect the framing while explaining what medical treatment can add; arrange psychiatric assessment; use heart-mind language to reduce stigma; involve family. In Nepal, specialist services are expanding to district level; for example Ramechhap Hospital began a regular psychiatrist service in 2026 [source: Kantipur 2026; rest synthesis].
  • Cost and exploitation. Healing and hospital costs can strain families [source: Pham 2019]; some villagers said bad dhami-jhankri treat "only for income" [source: Pham 2019]. Response: ask about cost and debt; help the family weigh options without disparaging the tradition [synthesis].
  • The client is themselves a healer. Response: treat as any client; respect their role and lineage; explore how their distress affects their healing work (in Kohrt's account a former soldier lost his healing abilities: source Kohrt 2014); do not consult them professionally about other clients [synthesis].
  • Your own uncertainty or fascination. Response: supervision; consult cultural brokers; keep the focus on the client's goals [synthesis].

Sources

Web sources:

Books 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].
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