Balinese balian

1. Introduction

Version followed: balian as Balinese scholars and the Bali provincial regulation on traditional health services describe them (Pergub Bali No. 55/2019; Suatama 2019; Fahyan and Farhah 2024), with outsider ethnography as context (Connor, Asch and Asch 1986). The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and Outline for Cultural Formulation.

What it is. A balian is a Balinese traditional healer. This is a living healing tradition of Balinese Hindu communities. It is not a psychotherapy, and the psychotherapist does not practise it. Balinese authors describe several kinds of balian. The names and spellings vary between sources [source: Suatama 2019; Fahyan and Farhah 2024]:

Balian ketakson (often called a trance healer or spirit medium): heals through trance, in which a deity is believed to enter the healer's body. Fahyan and Farhah say this kind specialises in illness linked to spiritual disturbance or supernatural beings.
Balian kapican (Fahyan and Farhah spell it kepicak): works with objects the healer is believed to have received as gifts from the unseen realm (pica).
Balian usada: works from the lontar usada, palm-leaf manuscripts of Balinese traditional medicine, together with knowledge handed down in the family.
Balian campuhan or campuran: combines these approaches. Fahyan and Farhah include healers who also consult doctors or use biomedical techniques. Suatama notes that a modern health practitioner may also practise as a balian usada.
Fahyan and Farhah also describe a holistic balian who works with ritual, meditation and energy cleansing.

"Balian taksu". In Suatama's account taksu is not a separate type of balian. It means charisma or spiritual power, which is said to come from meditation, prayer and consultation with senior balian. Fahyan and Farhah do not use the term at all; the trance-healer category is ketakson in both sources. "Balian taksu" as a category is [uncertain: not verified].

How Balinese sources explain illness. Balinese Hindus are described as recognising two kinds of cause. Sekala causes are visible and physical. Niskala causes are invisible and spiritual. Suatama also contrasts pangiwa (harmful or destructive magic, including leak) with panengen (protective knowledge), and says a balian must stand on the panengen side. These are Balinese concepts, held as the tradition holds them [source: Suatama 2019].

Core idea for the psychotherapist. Many Balinese clients, and their families, understand mental distress partly or wholly in niskala terms, and many consult a balian before, or alongside, a doctor. In the Bangli psychiatric hospital study, informants tended to attribute mental illness to non-physical causes and often went to a balian first. Stigma kept some people away from hospital, and one patient said they would see a doctor if the balian's treatment did not help [source: Fahyan and Farhah 2024]. The psychotherapist works alongside this. Change in your part of the work comes from understanding the client's explanatory model, assessing carefully without pathologising or missing illness, and coordinating care that the client and family will accept. That may include the balian when the client wishes, and always includes safeguarding [synthesis].

2. Framework

Who holds authority.

Within the tradition: Suatama describes a balian's standing as coming from inheritance, study of the lontar usada, and spiritual power built through meditation, prayer and consultation with senior balian. The trance healer's authority is attributed to the deity believed to act through them. Calling and initiation are not described here [source: Suatama 2019].
Provincial regulation (Bali): Pergub Bali No. 55/2019 governs "Pelayanan Kesehatan Tradisional Bali", health services rooted in the healing traditions of the Balinese people. It names the empirical Balinese traditional healer pengusada, whose knowledge comes through inheritance or non-formal study with a teacher (aguron-guron). A pengusada must hold a registration certificate (STPT). Competency certificates come from Gotra Pengusada, the Balinese traditional healers' association, which also sets ethical rules with the provincial government. Practitioners must join a professional association. The provincial health unit supervises, and the public can make written complaints [source: Pergub Bali 55/2019, arts. 1, 10, 15, 16, 42–44].
Limits the regulation sets: no advertising; pengusada may not use medical equipment; regulated services may not involve mystical or klenik practices or invoke unseen beings; remedies may not contain synthetic drug ingredients, narcotics or psychotropics; integrated traditional-plus-conventional services may be offered only in hospitals and community health centres (puskesmas) [source: Pergub Bali 55/2019, arts. 9, 12, 21–26, 32]. Whether trance healers (ketakson) fall inside or outside this regulated framework is [uncertain: not verified]. The term "balian" itself does not appear in the regulation.
Mental-health services: psychiatric care in Bali includes the Bangli psychiatric hospital (RSJ Bangli) [source: Fahyan and Farhah 2024] and community programmes such as the Suryani Institute for Mental Health [source: Ashoka]. Indonesia has national health insurance (BPJS), but specialists cluster in cities and many people with severe mental illness do not get continuous care [source: DFG project 460656552].

Phases of the psychotherapist's work [synthesis; built on the CFI's own guidance on use; source: APA CFI and Supplementary Modules]:

Phase	Goal	Typical format	Move on when
1. Preparation	Examine your own assumptions about spirit, trance and magic; learn the client's local services and language needs	Before first contact; supervision	You can name your likely biases and know where to refer
2. Cultural assessment	Core CFI, explanatory model (sekala/niskala), healer consultation, family role	Sessions 1–2, about one session; informant version with family if the client agrees	You can state the client's own account of the problem, cause and preferred help
3. Differential assessment	Separate culturally normative experience (e.g. kerauhan in ceremony) from disorder; screen risk, psychosis, medical causes	Sessions 1–3; consult a cultural broker	Diagnosis, or a decision that there is none, is reasoned and documented
4. Shared plan	Agree what you do, what the doctor does, and what the client and family may do with a balian	One session, family often present	Client and family endorse the plan
5. Parallel care and integration	Your own treatment; coordination; making sense of healing experiences	Weekly or as the modality requires; CFI modules repeated as needed	Goals met, or the plan is revised
Throughout	Safeguarding (restraint or pasung, coercion, delayed medical care, abuse)	Every contact	Not applicable

The CFI supplementary modules can be used at the first evaluation, later in care, or repeatedly during treatment [source: APA Supplementary Modules]. No source sets a session count for culturally responsive work with Balinese clients [uncertain: not verified].

3. Guiding principles

You work alongside the tradition, not in it. Never offer, imitate or arrange a balian's healing yourself; your role is assessment, therapy, coordination and safeguarding [synthesis].
Hold niskala explanations as the client holds them. Do not argue for or against spirits, pangiwa or divine presence; ask what the explanation means for the client [source: Suatama 2019; synthesis].
Ask about the balian early and without judgement. Many clients see a balian first and may not say so unless asked [source: Fahyan and Farhah 2024].
Treat both sekala and niskala care as possibly valid to the client. The one patient's stated plan (balian first, doctor if no improvement) shows that both can sit side by side; plan with that sequence in view [source: Fahyan and Farhah 2024; synthesis].
Trance in ceremony is often normative. Kerauhan at Hindu ceremonies is common, is often understood as divine presence, and many who experience it regard it as a gift; do not treat it as a symptom by default [source: Wisnawa and Fridari 2021].
Do not miss illness either. DSM and ICD-11 exclude trance or possession that is part of broadly accepted cultural or religious practice; distress, impairment and involuntary, unwanted episodes outside that context still call for full assessment [source: PMC9199574; findacode ICD-11 6B62].
The CFI supports judgement; it does not decide diagnosis [source: APA CFI].
Family is often the decision unit. In the DFG project description, families, biomedical practitioners and traditional healers negotiate what an illness means; include family with consent [source: DFG project 460656552].
Stigma is a barrier to care. Shame keeps some Balinese patients from hospital; reduce it in how you speak and where you meet [source: Fahyan and Farhah 2024].
Collaboration only when the client wishes and with consent. Share nothing with a healer without explicit permission [synthesis].
Respect what the tradition keeps to itself. Do not ask for, record or pass on details of trance sessions, lontar contents, mantra, offerings or the objects of a balian kapican [synthesis].
Safeguarding overrides deference. Shackling and confinement (pasung) have been banned in Indonesia since 1977 and still occur; restraint, coercion or delayed medical care are never acceptable as "tradition" [source: HRW 2016; HRW 2018].
Never advise on medicines or herbal remedies. Questions about stopping, starting or combining medicines with balian remedies go to the prescriber [synthesis].
Use the client's own words. Say balian, kerauhan, niskala as the client does; avoid derogatory outsider labels [synthesis].

4. Intervention inventory

These are the psychotherapist's own interventions. None of them is a balian practice. Balian healing, trance sessions, lontar knowledge and healing objects belong to the tradition and are not described here.

4.1 Cultural humility and self-examination

Purpose: to notice your own beliefs about spirits, trance, magic and "folk" healing before they shape assessment. Use it before the first session and whenever you feel certain or dismissive [synthesis].
Steps: (1) write down your first reaction to a client who says an illness has a niskala cause; (2) name where that reaction comes from (training, religion, tourism images of Bali); (3) list what you do not know about this client's village, caste, family temple and religious obligations; (4) take it to supervision or a cultural consultant; (5) during sessions, flag your own certainty as a sign to ask another question [synthesis].
Example language (illustrative): "I'm not Balinese, so I may get things wrong. Please correct me when I do."
Watch for: reducing everything to "belief" or, the opposite, romanticising the balian. It is working when you can hold the client's explanation and your clinical concerns at the same time without one cancelling the other [synthesis].

4.2 Core Cultural Formulation Interview (CFI)

Purpose: to clarify the problem from the client's and their network's perspective: what it means, possible sources of help, and what they expect from services. Use it at intake with any client, and especially when niskala causes or healer use are mentioned [source: APA CFI].
Steps: work through the CFI's 16 questions in its four domains, in your own words where needed but keeping each topic: (1) the cultural definition of the problem; (2) cultural perceptions of cause, context and support, including stressors, supports and the role of cultural identity; (3) self-coping and past help seeking, including barriers; (4) current help seeking: preferences and the clinician–patient relationship, including perceived racism and language barriers. The form shows which supplementary module expands each topic. APA allows clinicians to reproduce the CFI for use with their patients; modifying or translating it needs APA permission [source: APA CFI]. The time needed is [uncertain: not verified].
Example language (illustrative): "People explain problems like this in different ways. How would you describe what is happening, in your own words?" · "Have you, or your family, asked anyone outside medicine for help with this?"
Watch for: answers in Balinese terms (sekala, niskala, kerauhan, a family temple obligation). Record them in the client's words. It is working when you can write the client's account of problem, cause and preferred help in two or three sentences they would agree with [source: APA CFI; synthesis].

4.3 CFI supplementary modules

Purpose: in-depth assessment of a topic the core CFI opens up. Use as an add-on or alone, at first evaluation, later, or repeatedly [source: APA Supplementary Modules].
Steps: choose the module that fits. Of the 12, those most often relevant here are: Explanatory Model (sekala/niskala causes); Spirituality, Religion and Moral Traditions (temple obligations, ceremonies, kerauhan); Coping and Help-Seeking (balian, doctor, puskesmas); Social Network and Caregivers (family decisions); Cultural Identity; Patient–Clinician Relationship; Immigrants and Refugees for Balinese living abroad; School-Age Children and Adolescents and Older Adults by age. The Caregivers module is given to the caregiver, not the client. Use the Informant Version (17 questions) with a family member or friend, with the client's consent [source: APA Supplementary Modules; APA Informant Version].
Example language (illustrative): "You mentioned the ceremony at your family temple. Could we spend some time on how your religious life connects with what you are going through?"
Watch for: module fatigue; spread modules across sessions. It is working when the module changes your plan, for example by showing who in the family decides on care [synthesis].

4.4 Exploring the explanatory model (Kleinman)

Purpose: to learn the client's own theory of the illness, so the plan makes sense to them. Use it early and when the client rejects a diagnosis or a referral [source: Kleinman, Eisenberg and Good 1978, via Tanenbaum handout].
Steps: cover, in your own words, Kleinman's eight topics: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they should get; the main problems it has caused; what they fear most. Then ask specifically whether the cause is seen as sekala, niskala or both, and whether a balian has named a cause. Summarise back [source: Tanenbaum handout; Suatama 2019; synthesis].
Example language (illustrative): "Some people feel an illness has a visible cause, some feel there is something unseen as well. How do you and your family see it?"
Watch for: a family view that differs from the client's. Do not ask the client to choose between explanations. It is working when the client adds detail without being prompted and accepts a summary that includes both their explanation and your concerns [synthesis].

4.5 Asking about balian consultation without judgement

Purpose: to know what other care the client is receiving, what they were told, and whether anything conflicts with safety or treatment. Use it at intake and after any visit to a healer [source: Fahyan and Farhah 2024; synthesis].
Steps: (1) normalise the question; (2) ask whether the client or family has seen a balian, and what kind (usada, ketakson, kapican, mixed) if they wish to say; (3) ask what cause was named and what the client was advised to do, not how the healing was done; (4) ask whether any remedy was given, so the prescriber can be told; (5) ask how the client felt about it; (6) ask whether they want you to know about or work with that healer; (7) record only what is needed clinically [synthesis].
Example language (illustrative): "Many families in Bali see a balian as well as a doctor. Has your family done that? I'm not asking about what happened in the healing itself, just what it meant for you and anything I should know."
Watch for: guardedness, which may reflect expected disapproval; remedies that the prescriber needs to know about; advice to stop medicines; restraint at home. It is working when the client brings healer visits up unprompted [synthesis].

4.6 Cultural concepts of distress and Balinese idioms

Purpose: to recognise when the client expresses distress through a cultural idiom, explanation or syndrome, as DSM-5-TR defines cultural concepts of distress. Use it when the presentation is described in cultural terms [source: APA DSM-5-TR Section III].
Steps: (1) note the client's terms (for example niskala illness, pangiwa, being disturbed by unseen beings); (2) ask what the term means to them, how others in their community would see it, and what is usually done about it; (3) treat it as information about meaning and help seeking, not as a diagnosis; (4) still assess for any DSM disorder. DSM-5-TR lists cultural concepts such as ataque de nervios, dhat syndrome, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto and taijin kyofusho [source: UNMC slides citing APA 2022; exact DSM-5-TR list uncertain]. No Balinese concept is in that list; Balinese idioms must be learned from the client and community [synthesis].
Example language (illustrative): "When you say it is a niskala illness, what does that mean for you? What would people in your village usually do?"
Watch for: stigmatising or generalising language; DSM-5-TR revised its examples to avoid it [source: APA DSM-5-TR Section III]. It is working when the idiom helps you plan rather than labelling the client [synthesis].

4.7 Distinguishing normative trance and possession from disorder

Purpose: to avoid pathologising kerauhan and other accepted religious experience while not missing a dissociative, psychotic or medical condition. Use it whenever trance or possession is described [synthesis].
Steps: (1) establish context: did it happen during a temple ceremony or other accepted collective practice? [source: Wisnawa and Fridari 2021]; (2) ask how the client and their community interpret it (divine presence, a gift, or something harmful) [source: Wisnawa and Fridari 2021]; (3) check the diagnostic exclusions: DSM dissociative trance does not apply when the trance is a normal part of broadly accepted collective cultural or religious practice, and DID's possession form requires that the disturbance is not a normal part of such practice [source: PMC9199574]; ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require that the state is involuntary and unwanted and outside accepted practice, with distress or impairment [source: findacode ICD-11 6B62; PMC9199574]; (4) ask about episodes outside ceremony, loss of control, amnesia, injury, distress, and impact on work and family; (5) screen for psychosis, substance use, epilepsy and other medical causes and refer for medical assessment where indicated; (6) consult a Balinese cultural broker or religious figure the client trusts, with consent [synthesis].
Example language (illustrative): "When this happens at the temple, how do people around you understand it?" · "Has it ever happened somewhere it was not expected, or felt unwanted?"
Watch for: Suryani and Jensen's book on trance and possession in Bali compares them with Western dissociation, possession disorder and suicide [source: Suryani and Jensen, catalogue record]; its specific criteria are [uncertain: not verified]. It is working when your formulation names both the cultural meaning and any disorder, and the client recognises it as fair [synthesis].

4.8 Assessing psychosis when niskala causes are given

Purpose: severe mental illness is often first understood in niskala terms and first taken to a balian; delay to psychiatric care can be long [source: Fahyan and Farhah 2024; DFG project 460656552].
Steps: (1) assess for psychotic symptoms using standard methods, separating shared community beliefs from the client's own unusual beliefs; (2) ask family and community members whether the beliefs or behaviour are typical in their setting; (3) do not count culturally held beliefs as delusions on their own; the DSM-5-TR note on this point is [uncertain: not verified]; (4) assess risk; (5) arrange psychiatric review where psychosis, mania or high risk is present, presenting it as additional help that need not replace the balian [synthesis].
Example language (illustrative): "Your family sees an unseen cause, and the balian may help with that. A doctor may also be able to help you sleep and feel calmer. Could we try both?"
Watch for: confusion of normal religious idiom with delusion; family pressure for or against treatment; restraint at home. It is working when the client accepts assessment without having to give up their explanation [synthesis].

4.9 Working with the family

Purpose: in Bali the meaning of an illness and the choice of care are often worked out by families together with doctors and healers [source: DFG project 460656552]. Use it whenever family members are involved in decisions, with the client's consent.
Steps: (1) ask the client who should be involved and what may be shared; (2) use the CFI Informant Version or Caregivers module with relatives [source: APA Informant Version; APA Supplementary Modules]; (3) map each person's explanation and preferred help; (4) find the shared goal (for example, the client sleeping, working and taking part in ceremony again); (5) agree roles: family, doctor, therapist and, if wished, balian; (6) talk about stigma and shame openly [source: Fahyan and Farhah 2024; synthesis].
Example language (illustrative): "Everyone here wants Made to get well. Let's write down what each of you thinks would help, and see where those ideas fit together."
Watch for: one relative speaking for the client; disagreement between generations over balian and hospital; signs of confinement. It is working when the family agrees on next steps and the client's own voice is heard [synthesis].

4.10 Collaboration and referral with a balian or registered pengusada

Purpose: to coordinate care when the client wishes to see, or already sees, a traditional healer. Suryani describes a referral system linking traditional healers and psychiatrists, and Fahyan and Farhah recommend collaboration between balian and doctors or psychologists [source: Ashoka; Fahyan and Farhah 2024]. Suryani and Jensen (1991) wrote on integrating psychiatrist, traditional healer and culture in clinical practice in Bali; its methods are [uncertain: not verified].
Steps: (1) confirm the client wants collaboration; this is never a condition of your care; (2) get specific, written consent naming the healer and what may be shared; (3) let the client or family choose the healer through their own community pathways; you do not recommend or arrange ceremonies; (4) for the regulated sector, note that pengusada are registered (STPT), certified through Gotra Pengusada and supervised by the provincial health unit, and that integrated services run in hospitals and puskesmas [source: Pergub Bali 55/2019]; (5) agree, through the client, how both kinds of care will run alongside each other and what each party will watch for (risk, worsening, medicine adherence); (6) never share notes, diagnoses or risk information beyond what the client agreed; (7) review the arrangement regularly [synthesis].
Example language (illustrative): "If it would help, and only if you want it, I could talk with the balian your family trusts, so we are not working against each other. What would you be comfortable with me sharing?"
Watch for: advice to stop medicines or avoid hospital; any confinement or coercion; the client feeling pressured by either side. It is working when the client feels the two kinds of care support each other [synthesis].

4.11 Coordinating with medical and psychiatric services; medicines and remedies

Purpose: to make sure medical causes and treatable mental illness are not missed and that remedies and medicines are known to the prescriber. Use it whenever there are physical symptoms, severe illness, or any remedy alongside medication [synthesis].
Steps: (1) know the local options: puskesmas, general hospitals, RSJ Bangli, community programmes such as the Suryani Institute, and BPJS coverage [source: Fahyan and Farhah 2024; Ashoka; DFG project 460656552]; (2) refer for medical review of new physical symptoms, seizures or confusion; (3) if the client takes any traditional remedy, ask them to tell the prescriber; do not comment on its use, dose or safety yourself; (4) never advise starting, stopping or changing a medicine; route every such question to the prescriber; (5) the Bali regulation forbids synthetic drug ingredients, narcotics and psychotropics in traditional remedies, and the drug and food agency oversees herbal medicines [source: Pergub Bali 55/2019, arts. 32, 45].
Example language (illustrative): "That's a question for your doctor. Would you like us to write down what you are taking, so you can show them?"
Watch for: the client stopping medicines quietly; physical symptoms explained only as niskala. It is working when the prescriber knows everything the client takes [synthesis].

4.12 Interpreters and cultural brokers

Purpose: many Balinese clients may prefer Balinese or Indonesian for emotional and religious matters; Balinese terms such as sekala, niskala and kerauhan do not translate neatly [synthesis].
Steps: (1) ask which language the client prefers for these topics; (2) use a professional interpreter, not family, for assessment; (3) brief the interpreter on keeping religious terms in the original; (4) with consent, consult a Balinese cultural broker (a colleague, community or religious figure the client trusts) on whether an experience is typical; (5) protect confidentiality in small communities where the broker may know the family [synthesis].
Example language (illustrative): "Would it be easier to talk about this in Balinese or Indonesian? I can arrange an interpreter."
Watch for: the interpreter softening or explaining away religious content; the client holding back because the broker is known to them. It is working when the client speaks more freely [synthesis].

4.13 Integrating healing and ceremonial experiences

Purpose: to help the client make sense of a balian consultation, kerauhan or ceremony within their life and treatment, without interpreting it for them [synthesis].
Steps: (1) invite the client to say what the experience meant, in their own words; (2) do not ask for ritual details; (3) connect what they took from it to their goals (for example, relief, restored family duties, renewed hope); (4) explore any distress, fear or conflict it raised; (5) note any change in symptoms or risk [synthesis].
Example language (illustrative): "What did you take away from that visit? Has anything changed for you since?"
Watch for: fear after a named niskala cause (for example pangiwa); conflict with family; shame if healing "did not work". It is working when the experience becomes part of the client's own story of recovery [synthesis].

4.14 Safeguarding: restraint, coercion, delayed care and abuse

Purpose: to protect clients from harm in any setting. Shackling or confinement (pasung) was banned in Indonesia in 1977, but government figures still counted about 12,800 people in pasung in July 2018 [source: HRW 2018]. In healing centres elsewhere in Indonesia HRW documented chaining, forced treatment, seclusion, and physical and sexual violence [source: HRW 2016]. These reports do not concern Bali specifically. Suryani's institute runs a community programme in Bali for people restrained or confined for years [source: Ashoka].
Steps: (1) at every contact, ask whether anyone at home or in a healing setting has been tied, locked up, beaten, deprived of food or forced into treatment; (2) ask about touch in any healing that made the client uncomfortable, and whether they could stop it; (3) ask whether medical care has been delayed; (4) for children and dependent adults follow your local child-protection and adult-safeguarding procedures; never name minors in notes shared outside your service; (5) in Indonesia, involve the puskesmas or community mental health programmes in releasing and supporting people in pasung, and engage the family, since some rescued people are shackled again without community support [source: HRW 2018; Ashoka]; (6) document and report according to your jurisdiction [synthesis].
Example language (illustrative): "Sometimes families feel they have no choice but to keep someone at home or tie them up when they are very unwell. Has anything like that happened?"
Watch for: abuse presented as tradition, and tradition misread as abuse; consult before concluding. It is working when the client is safe and the family has another option [synthesis].

4.15 Reducing stigma and shame around services

Purpose: shame about hospital visits keeps some Balinese patients from psychiatric care [source: Fahyan and Farhah 2024].
Steps: (1) ask what the client fears others will think; (2) offer discreet settings (puskesmas, telehealth, home visits where available); (3) frame help in terms the client accepts, for example restoring balance or family duties; (4) separate their worth from the illness [synthesis].
Example language (illustrative): "Seeing me does not mean you have given up on other help. Many people use both."
Watch for: missed sessions after a family member learns of therapy. It is working when attendance holds steady [synthesis].

4.16 Visitors and expatriates who consult balian

Purpose: non-Balinese clients may have consulted a balian as a visitor. This item is [synthesis]; no source addresses it.
Steps: (1) ask what the client was seeking and what happened for them emotionally; (2) explore expectations and any distress, without judging the tradition; (3) do not encourage seeking ceremonies outside the community's own pathways; (4) assess for exploitation or unsafe practice and offer your own treatment for the underlying problem.
Example language (illustrative): "What were you hoping that visit would help with? Let's look at how we can work on that here too."
Watch for: turning a living tradition into a commodity in the client's or your own language; ongoing distress. It is working when the client's own goals are back at the centre.

4.17 Writing the cultural formulation

Purpose: to bring the cultural assessment into the record and the plan, using the DSM-5-TR Outline for Cultural Formulation [source: APA DSM-5-TR Section III].
Steps: (1) cultural identity; (2) cultural concepts of distress and explanations (sekala/niskala); (3) psychosocial stressors and supports, including family, banjar or village, and temple obligations; (4) cultural features of the relationship between client and clinician; (5) overall assessment and plan, including healer use and safeguarding [source: APA DSM-5-TR Section III; synthesis]. The exact Outline headings are [uncertain: not verified].
Example language (illustrative): "Let me read back what I have written about how you see the problem, so you can tell me if I've got it right."
Watch for: labels the client would find stigmatising. It is working when the client agrees the record is fair [synthesis].

5. Handling problems

All guidance in this section is [synthesis] unless a source is given.

Client will not say whether they see a balian. Expected disapproval is the usual reason. Normalise the question ("many families do both"), say you will not judge, and come back to it later. Do not push.
Client or family rejects psychiatric explanation. Do not debate. Go back to the explanatory model (4.4), find shared goals, and offer medical help as extra help rather than a replacement. Fahyan and Farhah's informant who planned to see a doctor "if no improvement" shows a sequence you can work with: agree what "no improvement" would look like and when to review [source: Fahyan and Farhah 2024].
Balian advises stopping medication. Do not criticise the healer. Tell the client you cannot advise on medicines and help them talk to the prescriber promptly. If they consent, raise it through the agreed collaboration (4.10). Assess risk if medicines stop.
Client is frightened after being told of a niskala cause (for example harmful magic). Hold the explanation as theirs. Work on the fear, sleep and safety in their terms. Ask what in their tradition offers protection, and whether they want to involve someone they trust, without suggesting any ritual yourself [source: Suatama 2019 on pangiwa and panengen].
Unclear whether trance is normative or a disorder. Delay diagnosis, collect context (4.7), and consult a cultural broker and colleague. ICD-11 and DSM exclusions turn on whether episodes are involuntary, unwanted and outside accepted practice, with distress or impairment [source: findacode ICD-11 6B62; PMC9199574].
Overwhelm during assessment. Spread CFI modules over several sessions [source: APA Supplementary Modules], slow down, and return to grounding and present concerns.
Rupture over perceived disrespect. Name it, apologise for the specific thing, and ask how to do better. The CFI's clinician–patient relationship topic and module give a structure for this [source: APA CFI; APA Supplementary Modules].
Family conflict over care (balian vs hospital). Meet with the family (4.9), map each view, look for a combined plan, and keep the client's consent at the centre.
Non-attendance. Often linked to ceremonial obligations, family decisions or shame. Plan around the ceremonial calendar with the client, offer flexible times, and check for stigma (4.15).
Pasung or coercion discovered. Treat as safeguarding (4.14). Act through local services and community programmes, and work with the family on alternatives, since without support people may be restrained again [source: HRW 2018; Ashoka].
Client asks you to take part in or arrange a ceremony. Decline warmly. Explain that this belongs to their community and its healers, and offer to support them in your own role.
You feel drawn to judge or romanticise the tradition. Take it to supervision (4.1).
Regulatory uncertainty. Whether a particular healer is a registered pengusada can be checked with the healer or the regional health office, since registration (STPT) and Gotra Pengusada certification apply to the regulated sector [source: Pergub Bali 55/2019]. How this applies to trance healers is [uncertain: not verified].

Sources

Web sources:

Books and articles cited:

Connor L, Asch P, Asch T (1986). Jero Tapakan, Balinese Healer: An Ethnographic Film Monograph. Cambridge: Cambridge University Press.
Connor L, Samuel G, eds. (2001). Healing Powers and Modernity: Shamanism, Science and Traditional Medicine in Asian Societies. Westport, CT: Bergin and Garvey.
Connor LH (1995). Acquiring invisible strength: a Balinese discourse of harm and well-being. Indonesia Circle 23(66):124–153.
Films by Asch, Asch and Connor: Jero on Jero: A Balinese Trance Seance Observed (1981); Jero Tapakan: Stories from the Life of a Balinese Healer (1983); The Medium is the Masseuse (1983).
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.
Suryani LK, Jensen GD (1991). Psychiatrist, traditional healer and culture integrated in clinical practice in Bali. Medical Anthropology 13:301–314.
Suryani LK, Jensen GD. Trance and Possession in Bali: A Window on Western Multiple Personality, Possession Disorder, and Suicide. Oxford University Press (year [uncertain: not verified]).

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