Vietnamese lên đồng mediumship (Đạo Mẫu)

1. Introduction

Version followed: the tradition as described in UNESCO's 2016 inscription of "Practices related to the Viet beliefs in the Mother Goddesses of Three Realms" (Decision 11.COM 10.b.37), as Vietnam's Ministry of Culture, Sports and Tourism (MCST) and its Department of Cultural Heritage (Cục Di sản văn hóa) frame it in guidance reported by the Vietnamese press (2018–2024), and as described in ethnography by Nguyễn Thị Hiền (2007, 2008), Karen Fjelstad (2014) and Barley Norton (2009). For the clinician's own work, the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules are followed.

What it is. Đạo Mẫu (the Mother Goddess religion; officially Tín ngưỡng thờ Mẫu Tam phủ, worship of the Mother Goddesses of Three Realms) is a living Viet religious practice. UNESCO describes worship of Mother Goddesses linked with heaven, water, and mountains and forests, alongside other spirits regarded as legendary heroes, through daily worship, temple festivals and rituals such as the spirit possession ritual. Its bearers are members of the public, temple guardians, ritual priests, spirit mediums, assistants and musicians, who pass knowledge on orally. Lên đồng (also hầu đồng) is that possession ritual: within the tradition, mediums (thanh đồng, ông đồng, bà đồng) are understood to embody a sequence of spirits, accompanied by chầu văn music performed by ritual musicians (cung văn) [source: UNESCO ICH page; Norton 2009 publisher page; Báo Pháp Luật 2016 interview with Ngô Đức Thịnh].

Not a therapy the psychotherapist performs. Lên đồng is a religious practice held by its own community, with its own authority (master mediums, temple keepers, musicians) and, in Vietnam, state heritage oversight. A psychotherapist does not conduct, recommend or imitate any part of it. This guide covers what the tradition and its scholars describe, who holds authority, and the psychotherapist's own culturally responsive work with clients for whom Đạo Mẫu matters.

How the tradition understands wellbeing and change (attributed). UNESCO states that worshippers seek spiritual fulfilment and everyday wishes such as good health and success. In Nguyễn Thị Hiền's ethnography from northern Vietnam, people distinguish "yang" illness, with physical causes treated by doctors, from "yin" illness, held to have supernatural causes and diagnosed by diviners or mediums. Some illness and misfortune are read as signs of a spirit calling (căn, "spirit root"; a strong calling is described as a "heavy" root, nặng căn). Within this model, accepting the calling through initiation and periodic rituals is held to restore health; Nguyễn reports the view that every medium can heal, at least themselves [source: Nguyễn Thị Hiền 2008, Asian Ethnology]. Mediums interviewed by Nguyễn mainly took up the practice because they saw it as their destiny and expected health and auspiciousness [source: Nguyễn Thị Hiền 2007, JSEAS abstract]. Folklorist Ngô Đức Thịnh compared the heightened state of the ritual to "trị liệu tâm lý" (psychological therapy) [source: Báo Pháp Luật 2016]. These are descriptions of the tradition's own understanding and scholars' readings, not claims of clinical efficacy; no independent evidence of therapeutic effect is cited here [uncertain: not verified].

For the psychotherapist, change happens when the client's own explanatory model, religious commitments and help-seeking are understood and respected, culturally normative experience is distinguished from disorder, and any psychotherapy, medical care and religious practice the client chooses are coordinated rather than set against each other [synthesis; source: APA CFI].

2. Framework

This is a framework for the psychotherapist's work alongside the tradition, not a phase model of lên đồng. Phases, session counts and transition criteria are [synthesis] built on the DSM-5-TR CFI; no Đạo Mẫu body publishes a clinical protocol.

Context the therapist needs (sources as stated).

History of suppression. Lên đồng was condemned under French colonial rule and banned by the Vietnamese Communist Party in the late 1950s; anti-superstition campaigns publicly disparaged mediums, and practice continued quietly. It became more visible after the Đổi Mới reforms of 1986 and revived from the early 1990s; a 2004 ordinance recognised spirit veneration as a folk belief activity, and it was inscribed by UNESCO in 2016 [source: Norton 2009 publisher page; Nguyễn Thị Hiền 2008; UNESCO]. Older clients or their families may have learned to hide practice or to call it "superstition" (mê tín dị đoan).
Who holds authority. Within the community: master mediums (đồng thầy), who, in Nguyễn's account, diagnose a calling, exorcise and initiate novices; temple keepers (thủ nhang) and temple or relic-site management boards; musicians (cung văn). Recognised senior practitioners are honoured by the state as artisans (nghệ nhân). In Vietnam, MCST and its Department of Cultural Heritage, provincial culture departments and bodies such as the Thăng Long–Hà Nội Heritage Association set heritage guidance and run training [source: Nguyễn Thị Hiền 2008; Nhân Dân 2022; Tuổi Trẻ 2024]. A healer's authority also rests on whether the person accepts their account of the illness: Nguyễn describes a case in which a patient rejected a medium's diagnosis [source: Nguyễn Thị Hiền 2008].
State guidance. MCST Document No. 618/BVHTTDL-DSVH (12 February 2018) called for rectifying hầu đồng practice; heritage officials have recommended holding it only at Mother Goddess temples or relic sites, not as street or tourist performance, and discouraging heavy use of votive gold paper and costly offerings [source: Nhân Dân 2022]. In October 2024 the Department of Cultural Heritage asked Bắc Ninh province to correct a staged hầu đồng performance as untrue to the heritage's nature and practice space, citing the Law on Cultural Heritage and Articles 4–5 of Decree 39 (respect for the sacredness of rites and spaces; no distortion of customs, taboos or secrets) [source: Tuổi Trẻ 2024].
Community concerns. Senior practitioners and officials report commercialisation, people declaring themselves đồng thầy after a few years where at least 12 years of practice was previously expected, and some people using the "nhà Thánh" to extract large payments that ruin families (tán gia bại sản) [source: Nhân Dân 2022]. Ngô Đức Thịnh contrasted earlier mediums held to "có căn" (have a calling) with people who join as a trend (đồng đua), and described rising costs of costumes and blessed gifts [source: Báo Pháp Luật 2016].
Diaspora. Đạo Mẫu is practised among overseas Vietnamese, notably in Silicon Valley and Orange County, California, with second-generation, US-socialised mediums and tensions with practitioners in Vietnam [source: Pokorny 2011 review of Fjelstad & Nguyễn 2011; USC Transnational Religion page].

Phases of the psychotherapist's work [synthesis].

Phase	Goal	Typical sessions and format	Move on when
0. Preparation	Examine own assumptions about possession, "superstition" and religion; learn the context above; arrange an interpreter if needed	Before first contact; supervision or consultation	You can describe the tradition without either endorsing or dismissing it
1. Cultural assessment	Core CFI; explanatory model; Spirituality, Religion and Moral Traditions and other modules as indicated; informant version with family if the client agrees	Sessions 1–2, individual, plus family session if wanted. Time for the core CFI is not stated on the APA form [uncertain: not verified]	The client's own account of the problem, its cause, its relation to spirits or căn, and their preferred help is clear
2. Differential formulation	Separate culturally normative ritual possession and religious experience from dissociative, psychotic, mood or other disorders; identify risk	Sessions 2–3; consult a cultural broker or, with consent, a community member	Formulation written in both the client's terms and diagnostic terms, with uncertainty stated
3. Shared plan	Agree goals; decide with the client whether and how psychotherapy, medical or psychiatric care and their religious life connect; consent for any contact with temple figures	Session 3–4	Client has chosen the plan and knows they may change it
4. Ongoing work and integration	Treat agreed problems; help the client make meaning of experiences and decisions (for example, about a calling or initiation); monitor risk, costs and coercion	Weekly or as agreed; repeat CFI modules when circumstances change (APA permits repeated use)	Goals met, or the client chooses to continue only with community support
Safeguarding (any phase)	Respond to coercion, financial exploitation, harm to minors or delayed urgent care	Immediately	Safety plan and reporting complete

[source: APA CFI and Supplementary Modules; synthesis for phasing]

3. Guiding principles

Alongside, not inside. You work with the client's religious life, never perform, prescribe or simulate lên đồng or any of its rites. Practical meaning: refer questions about the spirits, căn or ritual to the client's master medium or temple, not to yourself [synthesis].
Name authority accurately. Authority lies with master mediums, temple keepers and the community, and for heritage matters with MCST and provincial authorities [source: Nhân Dân 2022; Nguyễn 2008]. Practical meaning: ask the client whose guidance they follow; do not treat any one medium as speaking for the whole tradition.
Attribute, don't adjudicate. Spirits, yin illness and căn are described as the client and tradition hold them, neither affirmed as fact nor dismissed [synthesis]. Practical meaning: use phrases such as "in your understanding" or "as your temple sees it".
Use the client's words. Practical meaning: record the client's terms (căn, nặng căn, yin illness, a particular spirit) alongside any diagnostic language [source: APA CFI, cultural definition of the problem].
Possession in accepted practice is not a disorder. ICD-11 possession trance disorder (6B63) and trance disorder (6B62) require the state to be involuntary and unwanted and not part of accepted cultural or religious practice; DSM-5 dissociative trance and the possession form of dissociative identity disorder exclude broadly accepted collective cultural or religious practice [source: ICD-11 text via findacode; PMC9199574, quoting DSM-5]. DSM-5-TR keeps these exclusions in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; its exact wording is [uncertain: not verified]. Practical meaning: never diagnose from participation in lên đồng alone; assess distress, impairment and whether the experience is wanted and fits the community's norms.
Avoid both errors. Practical meaning: do not pathologise a calling or ritual trance, and do not miss psychosis, mania, depression, trauma or medical illness because it is framed as yin illness [synthesis].
Both explanations can coexist. Fjelstad, an anthropologist who became a medium, concluded that "both secular and sacred explanations and treatments were relevant" to her illness [source: Fjelstad 2014]. Practical meaning: offer psychotherapy and medical care as additions, not replacements.
Client choice governs collaboration. Practical meaning: contact a master medium, temple keeper or family member only when the client asks, with written consent stating what may be shared [synthesis; source: CFI help-seeking domain].
Respect stigma and history. Practical meaning: expect concealment born of past bans and "superstition" labels; make it safe to disclose without implying approval or disapproval [source: Nguyễn 2008; Norton 2009 page].
No advice on religious decisions. Practical meaning: help the client think through initiation, offerings or temple commitments in terms of their own values and resources; do not urge them towards or away from the tradition [synthesis].
Watch for exploitation without blaming the tradition. Community leaders themselves criticise financial pressure and unqualified self-declared masters [source: Nhân Dân 2022; Báo Pháp Luật 2016]. Practical meaning: explore costs and pressure as you would in any setting, and distinguish abuse by an individual from the practice.
Gender and sexuality with care. Ngô Đức Thịnh says some young gay men may find their "thế giới nữ tính" (feminine world) in hầu đồng [source: Báo Pháp Luật 2016]; UNESCO notes the practice's role in appreciating women [source: UNESCO]. Practical meaning: let the client define what the practice means for their gender or sexual identity; do not assume.
Medicines go to the prescriber. Practical meaning: never advise starting, stopping or changing a medicine; refer any such question to the prescriber [synthesis].
Language access. Practical meaning: use a trained interpreter, not a family member, for assessment, and check that religious terms are rendered without ridicule [synthesis].

4. Intervention inventory

Every item below is the psychotherapist's own work. None is part of lên đồng, and none involves ritual, music, offerings, initiation or divination. CFI content is paraphrased; the APA forms may be reproduced by clinicians for use with their patients, but modification or translation needs APA permission [source: APA CFI PDF]. Example language is illustrative.

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout the work, to notice your own reactions (fascination, scepticism, the "superstition" frame, exoticising) so they do not shape assessment [synthesis].
Steps: (1) Write down what you believe possession, spirits and mediums are, and where those beliefs came from. (2) Note your position: outsider, Vietnamese but secular, Catholic, Buddhist, and so on; Fjelstad's account shows how researcher position shapes what is seen [source: Fjelstad 2014; Jähnichen 2010 review of Norton]. (3) Read the context in section 2, including the history of bans. (4) Take one case to supervision or peer consultation with a colleague familiar with Vietnamese religious life. (5) Revisit after any session where you felt judgement or excitement.
Example language (illustrative, to yourself or a supervisor): "When she said the Mother had called her, my first thought was 'delusion'. What did I actually observe?"
Watch for: reflexive pathologising; the opposite error of romanticising and overlooking real distress; curiosity about ritual detail that serves you rather than the client. Working if: your notes describe the client's experience in their terms and your clinical judgements separately.

4.2 Core Cultural Formulation Interview

Purpose / when: First or second session with any client for whom Đạo Mẫu, spirits or căn are part of the picture, or when the explanation of distress is unclear. APA describes it as usable by any clinician in any setting; it supports understanding and is not a sole basis for diagnosis [source: APA CFI PDF; APA DSM-5-TR Section III].
Steps: (1) Explain that you ask everyone about their own understanding. (2) Work through the four APA domains in your own words: cultural definition of the problem; perceived causes, stressors, supports and the role of cultural identity; self-coping and past help seeking, including barriers; and current help-seeking preferences and the clinician–patient relationship. (3) In past help seeking, ask openly about temples, mediums, fortune-tellers, pagodas, churches, doctors and traditional medicine. (4) In the relationship question, ask whether the client worries that you will think them superstitious or ill. (5) Note which supplementary modules to add.
Example language (illustrative): "People explain problems like this in many ways: medical, family, spiritual. How do you and your family explain what has been happening?" / "Have you gone anywhere else for help, such as a temple or a medium, a doctor, a pagoda? Whatever you tell me, I'm asking so I can fit in with what already helps."
Watch for: brief, guarded answers (fear of the "mê tín" label or of being reported); answers in family members' voices; mismatch between what the client says and what family say. Working if: the client volunteers their own terms (căn, a particular spirit, yin illness) and preferences.

4.3 Spirituality, Religion and Moral Traditions module

Purpose / when: When religious identity or practice is central, or when the client is a medium, temple keeper, disciple or family member of one [source: APA Supplementary Modules].
Steps: (1) Ask about the client's religious identities (Đạo Mẫu often sits alongside Buddhism and ancestor veneration; let the client describe the mix [synthesis]). (2) Ask about the role of the tradition in daily life and in their problem. (3) Ask how practice helps and whether any part of it is a source of stress (cost, obligations, conflict with family or another religion). (4) Ask whether religious figures are involved in decisions about the problem. (5) Record relationships (their temple, master medium), not ritual content.
Example language (illustrative): "What place does the Mother Goddess religion have in your life? Does it help with what you're going through, make it harder, or both?"
Watch for: the client explaining ritual detail at length; listen, but do not probe for what the community keeps private, and do not record rites. Working if: you understand what the practice gives the client and where it strains them.

4.4 Explanatory model (Kleinman questions and CFI Explanatory Model module)

Purpose / when: To elicit the client's account of the problem in detail, especially when illness is understood as yin illness or a sign of a calling [source: Kleinman et al. 1978 via Tanenbaum handout; APA Supplementary Modules; Nguyễn 2008].
Steps: Ask, in paraphrase: what they call the problem; what caused it; why it started when it did; what it does to them and how; how severe it is and whether it will be short or long; what treatment they think they should have; the main problems it has caused; what they fear most. Then ask what others (family, master medium, doctor) say, and where these views agree or conflict. Summarise back in the client's words.
Example language (illustrative): "You said the master told you this is căn, not an ordinary illness. What do you think? What would it mean for you if that's right, and if it isn't?" / "What are you most afraid will happen?"
Watch for: fear that refusing a calling will bring misfortune, which Nguyễn reports as part of the model [source: Nguyễn 2008]; ambivalence between explanations; pressure from others' models. Working if: the client can state their own view separately from others' and you can name the decisions in front of them.

4.5 Informant version and family work

Purpose / when: When family are involved in the problem or in help seeking, or disagree about it (Nguyễn describes a medium whose in-laws disbelieved her illness [source: Nguyễn 2008]). The CFI Informant Version is for a family member or friend; the Caregivers module is for caregivers [source: APA Informant Version; Supplementary Modules].
Steps: (1) Obtain the client's consent for who joins and what may be discussed. (2) Use the informant questions in your own words: their relationship with the client, then the same four domains. (3) Map each person's explanation (spiritual, medical, moral, family). (4) Identify where they agree (wanting the client well) and the decisions under dispute (initiation, hospital, cost). (5) Return the decisions to the client.
Example language (illustrative): "Everyone here wants Lan to get better. Can each of you say what you think is going on, and what you hope will help?"
Watch for: one member dominating; the client deferring; disclosures of debt or coercion; generational and diaspora splits (younger relatives rejecting the practice as superstition, older relatives hiding it). Working if: the family can hold more than one explanation and the client's choice is respected.

4.6 Asking about consultation with mediums and temples without judgement

Purpose / when: At intake and whenever new symptoms or decisions arise; also uses the CFI Coping and Help-Seeking module [source: APA Supplementary Modules].
Steps: (1) Normalise the question. (2) Ask who they consult (master medium, temple keeper, diviner, other healers), how often, and what was advised. (3) Ask what helped and what did not. (4) Ask about any costs or obligations. (5) Ask whether they want those helpers to know about therapy, and vice versa. (6) Record facts without evaluative terms.
Example language (illustrative): "Many people I see also go to a temple or a medium. If you do, it helps me to know what they've said, so we're not pulling you in different directions."
Watch for: advice to stop medical or psychiatric treatment (route the client to their prescriber; do not counter-advise on medicines yourself); demands for large payments; the client fearing your disapproval. Working if: the client discusses both kinds of help freely in session.

4.7 Differential assessment: normative possession and calling vs disorder

Purpose / when: When a client reports possession experiences, a spirit calling, voices or visions, personality change attributed to spirits, or when family or a medium describe the problem as yin illness.
Steps: (1) Establish context: does the experience occur within lên đồng at a temple, as the community expects, or spontaneously and elsewhere? (2) Ask whether it is wanted or unwanted, and controllable. ICD-11 6B63 possession trance disorder involves replacement of identity by an external possessing identity that is involuntary and unwanted; 6B62 trance disorder involves narrowed awareness without an alternate identity; both exclude accepted cultural or religious practice and require significant distress or impairment [source: ICD-11 via findacode; PMC9199574]. DSM-5 dissociative identity disorder allows identity disruption described as possession but excludes broadly accepted cultural or religious practice; dissociative trance (other specified dissociative disorder) excludes normal collective practice [source: PMC9199574, quoting DSM-5]. DSM-5-TR keeps this in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; continuity of the exact wording is [uncertain: not verified]. (3) Ask whether the client's own community regards the experience as normal: what does their master medium or temple say? (4) Screen independently of the spiritual frame for psychotic symptoms outside ritual, mood elevation or depression, suicidality, trauma and dissociation outside ritual, substance use and medical causes; arrange medical review of new neurological or physical symptoms. (5) Compare onset and course with the client's account (for instance, Nguyễn records signs such as unexplained personality change and a "false illness", ốm giả vờ, read as yin illness [source: Nguyễn 2008]). (6) Write a formulation that states both readings and your uncertainty.
Example language (illustrative): "When the spirits come during ceremonies at the temple, does that feel right and expected to you? Are there other times, outside the temple, when things happen that frighten you or that you can't control?"
Watch for: experiences outside ritual that the client finds unwanted; functional decline; the community itself regarding the person as unwell; command content urging harm; sleep loss and mood elevation. Nguyễn reports that within the tradition insanity can be read as yin illness and gives cases where ritual was credited after hospital treatment failed [source: Nguyễn 2008]; hold that account with respect while ensuring psychiatric assessment is available. Working if: you can explain to the client which experiences you see as part of their religious life and which concern you, and why.

4.8 Working with idioms and cultural concepts of distress

Purpose / when: When the client uses terms such as căn, nặng căn, yin illness or being called by a particular spirit. DSM-5-TR defines cultural concepts of distress as including idioms, explanations or perceived causes, and syndromes [source: APA DSM-5-TR Section III]. The DSM-5-TR glossary examples listed in secondary sources do not include a Vietnamese possession-calling entry [source: UNMC slides; uncertain: not verified against the manual].
Steps: (1) Treat these terms as the client's explanations or idioms, not as diagnoses. (2) Ask what the term means to them and to their community, and what follows from it (obligations, initiation, rituals, family roles). (3) Use the term back in the client's words where they wish. (4) Keep diagnostic coding separate and only where criteria are met. (5) Avoid translating it into a Western label in front of the client unless asked.
Example language (illustrative): "When you say you have a heavy căn, what does that mean for you? What do people expect of someone with a heavy căn?"
Watch for: the idiom carrying fear of punishment or misfortune if obligations are not met; the idiom being used by others to pressure the client. Working if: the client feels understood and can talk about distress in their own terms.

4.9 Interpreters and cultural brokers

Purpose / when: When the client prefers Vietnamese, or when religious terms, northern/southern regional usage or diaspora dynamics are unclear [synthesis].
Steps: (1) Use a trained interpreter; brief them that religious terms should be rendered neutrally. (2) Check the interpreter's own attitudes (some may regard hầu đồng as superstition). (3) Where formulation is uncertain, consult, with consent and minimal identifying detail, a cultural broker such as a Vietnamese clinician, a scholar of Vietnamese religion, or a community member the client suggests. (4) Do not use children as interpreters.
Example language (illustrative, briefing an interpreter): "Please translate her words about the Mother and the spirits exactly, without softening or adding comment."
Watch for: interpreter and client from the same small community (confidentiality), interpreter correcting or laughing. Working if: the client's account in session matches what they later say in their own language.

4.10 Collaboration with a master medium or temple, when the client wishes

Purpose / when: When the client wants their master medium, temple keeper or temple community to know about therapy, or wants you to understand their guidance. No formal healthcare referral pathway with Đạo Mẫu practitioners is described in the sources used here [uncertain: not verified]. Broader evidence on collaboration between mental health services and traditional or faith healers concerns other traditions. The COSIMPO cluster randomised trial in Nigeria and Ghana (Gureje et al., The Lancet 2020) found that collaborative care between traditional or faith healers and primary health care workers reduced psychotic symptoms (PANSS) and harmful practices more than usual care [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839].
Steps: (1) Let the client decide whether, whom and why. (2) Obtain written, specific consent: who, what may be shared, for how long, and the right to withdraw. (3) Agree with the client the aim (for example, coordinating timing around a ceremony, or the master knowing the client is also receiving psychiatric care). (4) Approach respectfully, as one helper to another; ask what they think would help; do not ask about rites. (5) Do not attend or take part in ceremonies; do not ask the medium to diagnose. (6) Debrief the client afterwards. (7) Remember authority is plural; a medium speaks for their own temple, not the tradition.
Example language (illustrative): to the client, "Would it help if your teacher at the temple knew you are seeing me? You decide what, if anything, I share." To a medium (with consent), "Mrs H. asked me to speak with you because your guidance matters to her. I'm supporting her with sleep and worry, and I want to make sure what we do fits with what you're doing together."
Watch for: advice that conflicts with urgent medical care; requests for payment routed through you; any sign that contact puts the client at risk socially. Working if: the client reports less conflict between the kinds of help they receive.

4.11 Coordinating with medical and psychiatric care

Purpose / when: When symptoms may be physical or psychiatric, when the client takes medicines, or when yin illness and yang illness explanations compete [source: Nguyễn 2008; synthesis].
Steps: (1) Ask what doctors have said and what treatment the client has. (2) Encourage medical review for new physical or neurological symptoms. (3) With consent, liaise with the GP or psychiatrist about cultural context so that ritual participation is not misread. (4) Refer every question about starting, stopping or changing medicines to the prescriber. (5) Frame care as both/and, using the client's own account where possible (Fjelstad combined oncology with spiritual help [source: Fjelstad 2014]).
Example language (illustrative): "Your temple is helping with the spiritual side. Would you also be willing to let a doctor check the physical side, so nothing is missed?"
Watch for: stopping medicine on spiritual advice (route to the prescriber promptly); clinicians dismissing the client's religion and the client disengaging. Working if: the client stays engaged with both.

4.12 Integrating experiences and decisions about a calling

Purpose / when: When a client is processing ritual experiences, an illness read as a calling, or a decision about initiation (trình đồng mở phủ, named here only as the community's term; its content belongs to the community) [source: Nhân Dân 2022; Nguyễn 2008].
Steps: (1) Invite the client to describe what the experience meant to them, without asking for ritual content. (2) Explore effects on mood, relationships, identity, sexuality and gender, work and money. (3) For a pending decision, help the client lay out their values, the views of family and master medium, resources and fears; Fjelstad describes a heavy calling and her own conditional decision [source: Fjelstad 2014]. (4) Respect a decision either way; the choice is the client's. (5) Help integrate the experience into ongoing therapy goals.
Example language (illustrative): "You've told me what the master and your mother think. If you set their voices aside for a moment, what do you want?" / "What would it cost you, in money, time and relationships, and what would it give you?"
Watch for: fear-driven decisions (fear of misfortune if refused); unaffordable costs; relief and renewed social support (Fjelstad describes the temple community's support as crucial [source: Fjelstad 2014]). Working if: the client describes the decision as their own.

4.13 Identity, migration, stigma and the history of suppression

Purpose / when: For clients whose distress involves concealment, shame, family religious conflict, migration, or racism in services. Uses the CFI Cultural Identity, Immigrants and Refugees, Older Adults or School-Age Children and Adolescents modules as relevant [source: APA Supplementary Modules].
Steps: (1) Ask how open the client can be about their practice, with whom, and why. (2) Acknowledge, if relevant, that the practice was banned and called superstition for decades before heritage recognition [source: Norton 2009 page; Nguyễn 2008; UNESCO]. (3) For diaspora clients, explore ties to temples in Vietnam and in the new country, and generational differences [source: Pokorny 2011]. (4) Explore experiences of being dismissed or ridiculed by services. (5) For gender and sexual identity, let the client describe what the practice means to them [source: Báo Pháp Luật 2016; UNESCO].
Example language (illustrative): "Some people have grown up being told that what their family does at the temple is backward. Has that been part of your experience?"
Watch for: internalised shame; splitting between "modern" and "traditional" selves; prior negative experiences of mental health care. Working if: the client discloses more over time and reports feeling respected.

4.14 Exploring costs, obligations and pressure

Purpose / when: When the client mentions large offerings, costumes, payments to a master or temple, debts, or pressure to undergo initiation or open a shrine. Community leaders and officials themselves report practices that ruin families financially and self-declared masters with little experience [source: Nhân Dân 2022; Báo Pháp Luật 2016].
Steps: (1) Ask neutrally about money and time spent and whether they are manageable. (2) Ask who decides amounts and what is said if the client cannot pay. (3) Separate the client's religious commitment from any individual's pressure. (4) If the client wishes, help them find other community voices (another temple, a senior practitioner) for a second view. (5) Escalate to safeguarding if coercion or exploitation of a vulnerable person is present (4.15).
Example language (illustrative): "Sometimes devotion and money get tangled. How do the costs feel to you? Is anyone telling you something bad will happen if you don't pay?"
Watch for: threats of spiritual harm tied to payment; debts hidden from family; a vulnerable adult making large payments. Working if: the client makes religious commitments within their means and by choice.

4.15 Safeguarding

Purpose / when: When there is coercion, financial abuse of a vulnerable adult, sexual exploitation, harm to a child, or delay of urgent medical or psychiatric care [synthesis; source on financial exploitation: Nhân Dân 2022]. None of the sources used here document physical abuse within lên đồng; do not presume it [uncertain: not verified].
Steps: (1) Assess immediate risk (suicide, self-harm, harm to others, untreated serious illness). (2) Follow your local adult and child safeguarding procedures and duty-to-report law. (3) For minors, safeguarding takes precedence; involve parents or carers unless that increases risk; assess the child's assent and understanding. (4) Distinguish harm by an individual from the tradition; a community authority (another senior practitioner or the temple's management board) may also be an ally, if the client consents. (5) Document facts, not judgements about the religion.
Example language (illustrative): "I respect your faith and I'm not asking you to give it up. What I'm worried about is that you've stopped eating and sleeping, and I need to make sure you're safe."
Watch for: retaliation against the client; the client withdrawing from therapy for fear of interference with their religion. Working if: the client remains engaged and safe.

4.16 Review and repeat assessment

Purpose / when: At major transitions (after a ceremony the client chose, a family conflict, migration, a change of temple) or every few months. APA allows supplementary modules to be repeated during treatment [source: APA Supplementary Modules].
Steps: (1) Revisit the explanatory model and help seeking. (2) Recheck risk and functioning (Level of Functioning module where useful). (3) Update the formulation and plan with the client.
Example language (illustrative): "It's been a few months. Has your understanding of what's going on changed, or what helps?"
Watch for: shifts in explanation that track pressure rather than the client's own view. Working if: the formulation stays recognisable to the client.

5. Handling problems

Most of this section is [synthesis]; sources are named where they bear on the point.

Client won't talk about the practice. Likely causes: past bans and stigma, fear of being labelled superstitious or mentally ill [source: Nguyễn 2008; Norton 2009 page]. Response: say you ask everyone about spiritual and religious help; make clear nothing is needed beyond what the client wants to share; never press for ritual details.
Client wants you to confirm or deny that spirits caused the illness. Response: say you are not an authority on the spirits, that their master medium or temple is, and that your role is to help with what they are going through. "I can't tell you what the spirits want. I can help with the panic and the sleep, alongside whatever your temple advises." (illustrative)
Client asks you to attend or join a ceremony. Response: thank them, decline participation, and explore what it would mean to them; if attending purely as an observer at the client's invitation is considered, discuss boundaries in supervision first [synthesis].
Competing explanations in the family. Response: map each view (4.5); focus on shared goals; return decisions to the client; avoid siding with the "medical" or "spiritual" camp.
Possible psychosis framed as yin illness. Response: complete 4.7; explain your concern in the client's terms; offer psychiatric assessment as an addition to religious help; if risk is high, follow emergency procedures. Nguyễn reports that within the tradition insanity can be treated as yin illness [source: Nguyễn 2008]; do not argue the model, address safety.
Overwhelm after ritual experiences. Response: grounding and stabilisation within your usual practice; explore whether the experience was expected in the community's terms; involve the client's temple support if they wish; reassess for dissociation outside ritual (4.7).
Pressure to undergo initiation or pay large sums. Response: 4.14; help the client consider other community voices; safeguarding if a vulnerable person is being exploited [source: Nhân Dân 2022].
Advice from a medium to stop medicines or avoid hospital. Response: do not counter-advise on medicines; urge the client to speak with the prescriber promptly; with consent, liaise with the prescriber; where the client wishes, seek a joint understanding with the medium (4.10).
Non-attendance around festival periods or ceremonies. Response: plan sessions around the client's religious calendar; treat absences as scheduling, not resistance.
Rupture: client feels judged. Response: name it, apologise for any dismissive word, ask what felt wrong, and restate respect; check whether a colleague, interpreter or note language contributed.
Therapist's own discomfort or fascination. Response: supervision (4.1); keep curiosity in service of the client; never collect ritual content.
Diaspora tensions. Response: explore links between temples abroad and in Vietnam and between generations [source: Pokorny 2011]; avoid assuming any one temple's norms are standard.
Gender or sexuality disclosures linked to the practice. Response: let the client lead; avoid both stereotyping (for example, that male mediums are gay) and erasing what the practice may offer them [source: Báo Pháp Luật 2016].
Client wants to leave the practice and fears consequences. Response: explore fears, supports and the meaning of leaving; the client may want to consult another senior practitioner; respect the choice either way; assess risk if fear is severe.

Sources

Tradition, authority and scholarship

Books cited

Norton, B. (2009). Songs for the Spirits: Music and Mediums in Modern Vietnam. University of Illinois Press (publisher page only).
Fjelstad, K. & Nguyễn Thị Hiền (2011). Spirits without Borders: Vietnamese Spirit Mediums in a Transnational Age. Palgrave Macmillan (via review).
Fjelstad, K. & Nguyễn Thị Hiền (eds). Possessed by the Spirits: Mediumship in Contemporary Vietnamese Communities. Cornell Southeast Asia Program [uncertain: year and edition not verified].
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 (pages per Dinos et al. 2017).

Clinical assessment

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