Then ceremonies (Tày, Nùng, Thái)

1. Introduction

Version followed: the tradition as described in UNESCO's 2019 inscription "Practices of Then by Tày, Nùng and Thái ethnic groups in Viet Nam" (Decision 14.COM 10.b.42, file 01379) and Vietnamese press and scholarly sources; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules as published by the American Psychiatric Association (APA).

What Then is, as its bearers' heritage file and scholars describe it. Then (thực hành Then) is a ritual practice that UNESCO describes as "an essential ritual practice in the spiritual life" of the Tày, Nùng and Thái peoples of Viet Nam. It expresses their understanding of people, the natural world and the cosmos. Ceremonies are led by a Then master (thầy Then; male Ông Then or female Bà Then). They are held for peace, for healing from illness, for good crops and for the new year, in the household of the person requesting the ceremony, outdoors, or at the master's own altar. Some masters lead about 200 ceremonies a year. Knowledge passes orally, within the rituals, from masters to descendants and students. [source: UNESCO RL page; Báo Quốc tế 2019] Viet Nam's national press lists 11 provinces where Then is practised: Bắc Giang, Bắc Kạn, Cao Bằng, Hà Giang, Lạng Sơn, Quảng Ninh, Thái Nguyên and Tuyên Quang in the northeast, and Điện Biên, Lai Châu and Lào Cai in the northwest. [source: VOV 2019; Báo Văn hóa 2022] Related Tày Then traditions continue across the border in Longzhou, Guangxi, China. [source: Holm 2019]

How healing is understood within the tradition (attributed). Then practitioners are understood as intermediaries between people and the spirit world, communicating with deities on behalf of a household or community. [source: VOV 2019; Đỗ Duy Hưng 2025] Scholarship describes several aims of healing and protective ceremonies: protecting a person's soul and vitality and restoring a soul that has gone astray (vía lạc), as described for the Bà Chúa Then temple worship in Lạng Sơn [source: Đỗ Duy Hưng 2025]; relieving misfortune (giải hạn), linked to Tày beliefs about destiny [source: Phạm Thị Thu Hà 2010]; and dealing with illness understood as an astral impediment, worked out from almanac consultation, as Holm reports from fieldwork in Cao Bằng and Guangxi [source: Holm 2019]. Vietnamese scholars cited by Norton call Then masters shamans. Norton notes that masters are also possessed in some ceremonies. [source: Norton 2016] These are the tradition's own and its scholars' accounts. This guide neither asserts nor dismisses them.

Who holds authority. Authority over ceremony, healing and the recognition of new masters rests with Then masters and the Tày, Nùng and Thái communities they serve. The largest ceremony type, Lẩu Then cấp sắc, is the multi-day rite that recognises a new master. It is named here only. [source: Norton 2016, citing Nguyễn Thị Yên] Holm reports that apprentices of either sex learn from both a male and a female master teacher, and that people prefer Then whose parents and grandparents were also Then. [source: Holm 2019] Heritage safeguarding involves the state: the Ministry of Culture, Sports and Tourism guided the community and provincial dossier, and the 11 provinces have committed to safeguarding. This is heritage management, not ritual authority. [source: Báo Quốc tế 2019; Báo Văn hóa 2022] UNESCO's inscription decision records that the practice stays alive because individuals, families and communities invite Then masters to perform ceremonies; that Viet Nam has funded safeguarding of ethnic communities' heritage, Then included, through national culture programmes since 2001; and that the proposed measures (guidelines and policies, research, inventorying and documentation, teaching Then singing and tính lute playing in schools, publications, and encouraging young people to take up the practice) were planned with the communities and artists, who gave written and recorded consent to the nomination. [source: UNESCO Decision 14.COM 10.b.42]

What the psychotherapist does. The psychotherapist does not perform, simulate or prescribe Then, and does not refer clients to ceremonies outside the community's own pathways. The therapist's work is culturally responsive assessment and therapy alongside the tradition. This means eliciting the client's own explanatory model, distinguishing culturally normative experience from disorder, coordinating with a Then master only when the client asks, and keeping medical care and safety in view. How change happens in this work: the client's problem is understood in the client's own terms, the treatment plan is negotiated to fit those terms, and the client's healing resources (family, community, Then) are respected, not set against psychotherapy. [source: APA CFI; synthesis]

2. Framework

This is a framework for culturally responsive psychotherapy with clients from Then-practising communities (in Viet Nam, in cross-border areas or in the diaspora). It is not a protocol for Then itself. Phases and session counts are [synthesis]. The assessment content follows the APA CFI. [source: APA CFI; APA supplementary modules]

Phase 0: preparation (before contact).

Goal: know your own assumptions about spirit healing, "superstition" and ethnic minorities. Learn the basic heritage facts above, and arrange a language-matched interpreter or cultural broker if needed.
Move on when: you can describe Then without either endorsing or dismissing it, and language access is in place.

Phase 1: cultural assessment (sessions 1–2, about 50–90 minutes in all) [synthesis on timing].

Goal: core CFI (16 questions across four domains), with the Informant Version with family if the client agrees. Add modules as needed: Explanatory Model; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Social Network; and Immigrants and Refugees for migrants. [source: APA CFI; APA supplementary modules] APA gives no time for the core CFI; reports of about 15–20 minutes are [uncertain].
Move on when: you can state the client's name for the problem, the client's view of its cause, what has been tried (including any Then ceremony), and what the client hopes for from you.

Phase 2: formulation and differential (sessions 2–3).

Goal: write a cultural formulation. Decide whether the experiences reported (for example, possession, being spoken to by spirits, soul loss) are culturally normative or meet criteria for a disorder, using DSM-5-TR and ICD-11 exclusion clauses and a cultural broker's input. Screen for medical causes and risk.
Move on when: the formulation is shared with the client in their own terms and a plan is agreed.

Phase 3: negotiated treatment (typically 6–20 sessions, set by the presenting disorder) [synthesis].

Goal: deliver evidence-based therapy for the identified problem, adapted to the client's explanatory model. Coordinate with a Then master or family only when the client wishes. Integrate meaning from any ceremony the client attends within their community.
Review the plan every 4–6 sessions; return to Phase 2 if new experiences or risk emerge.

Phase 4: review and ending.

Goal: review outcomes in both the client's terms and standard measures. Agree on how the client will use family, community and services afterwards.
End when: the goals agreed in Phase 2 are met or the client chooses to end.

The CFI modules can be used at intake, later in care, or repeatedly during treatment. [source: APA supplementary modules]

3. Guiding principles

Authority rests with the community. Then masters and Tày, Nùng and Thái communities decide who is a master and what a ceremony requires. Practical meaning: never judge whether a ceremony was "done right" or whether a master is genuine; if this matters to the client, they ask within their community. [source: Holm 2019; Norton 2016]
Alongside, never instead of, the tradition. Practical meaning: you offer psychotherapy; you do not offer, imitate or recommend Then ceremonies. [synthesis]
Attribute, do not adjudicate. Practical meaning: speak of "what you understand happened to your vía" rather than "your soul was lost" or "that is just a belief". [synthesis]
The client's model leads the plan. The CFI exists to clarify the problem from the perspective of the client and their social network: its meaning, sources of help and expectations of services. Practical meaning: ask before you explain. [source: APA CFI]
The CFI informs, it does not diagnose. Practical meaning: use CFI material to shape diagnosis and treatment, not as the sole basis for a diagnosis. [source: APA CFI]
Avoid both errors: pathologising the normative and missing illness. DSM-5 and ICD-11 exclude trance and possession that are part of broadly accepted cultural or religious practice. Practical meaning: a Then master's ceremonial possession is not a symptom; involuntary, unwanted, distressing states outside that context may be. [source: PMC9199574; findacode ICD-11 6B62]
Heritage on stage is not the whole tradition. Then singing and the tính lute are widely staged as ethnic heritage at festivals and taught in schools, and scholars debate whether staged Then is secular folk art. Practical meaning: do not assume a client who enjoys hát Then holds or rejects the ritual beliefs; ask. [source: Norton 2016; Báo Văn hóa 2022]
Power and minority status matter. Norton links representations of Then to nationalist discourse and unequal relations between the Việt (Kinh) majority and minority peoples. Practical meaning: a Kinh or foreign therapist should name the difference and invite correction. [source: Norton 2016; synthesis]
Health and safety come first, without blame. Viet Nam's Law on Belief and Religion (No. 02/2016/QH14, in force 1 January 2018) protects belief practices. It prohibits using them to infringe body, health or life and prohibits exploiting them for profit, and it also prohibits insulting belief. Practical meaning: respect the practice and act on harm. [source: Law 02/2016/QH14]
Medicines go through the prescriber. Practical meaning: never advise starting, stopping or changing a medicine because of a ceremony or a belief; refer the question to the prescriber. [synthesis]
Consent and confidentiality for any contact. Practical meaning: no contact with a Then master or family without the client's specific consent, scope and limits agreed. [synthesis]

[source for section: UNESCO RL page; Norton 2016; Holm 2019; APA CFI; Law 02/2016/QH14]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a Then procedure, and none involves taking part in a ceremony. Steps and example language are [synthesis] unless a source is tagged. All example wording is illustrative.

4.1 Cultural humility and self-examination

Purpose: to stop your own framing ("superstition", "folk art", "exotic shamanism", or uncritical romanticism) from shaping the assessment. Use it before the first session and whenever you feel certainty about what the client's experience "really" is. [synthesis]
Steps: (1) Write down what you believe about spirit healing and about the Tày, Nùng and Thái peoples, and where those beliefs came from. (2) Note your position relative to the client: Kinh majority, foreign or diaspora clinician, urban or rural, and state-employed or private. Norton's point about majority–minority inequality applies here. [source: Norton 2016] (3) Identify what you do not know, such as the client's language, province and whether the family has a Then lineage. (4) Plan to ask rather than infer. (5) After sessions, review any moment you explained the client's experience to them.
Example language (illustrative): "I'm not from your community, and I don't want to assume I understand what Then means to your family. Please correct me whenever I get it wrong."
Watch for: the client becoming guarded or over-formal (they may expect contempt); you translating their words into diagnostic terms too fast. It is working when the client volunteers their own terms (vía, hạn, names of spirits or deities) without prompting.

4.2 Core Cultural Formulation Interview (DSM-5-TR)

Purpose: to clarify the problem from the client's and their network's perspective: its meaning, causes, supports, past and current help seeking, and expectations of you. Use at intake for every client, by any clinician in any setting. [source: APA CFI; APA Section III]
Steps: (1) Introduce the interview as a way to understand the problem in the client's own words. (2) Work through the four APA domains in order. Domain 1 is the cultural definition of the problem (Q1–3). Domain 2 is cultural perceptions of cause, context and support (Q4–10), covering causes, stressors and supports, and the role of cultural identity. Domain 3 is self-coping and past help seeking (Q11–13), covering coping, past help and barriers. Domain 4 is current help seeking (Q14–16), covering preferences and the clinician–patient relationship, including perceived racism and language barriers. [source: APA CFI] (3) In Domain 3, ask specifically about any ceremony (cultural healing or protection) the family has arranged. (4) Use the client's words in your notes. (5) Mark which subtopics need a supplementary module. The core form shows which module expands each subtopic. [source: APA supplementary modules] The APA form may be reproduced by clinicians for use with their patients; modifying or translating it needs APA permission. [source: APA CFI]
Example language (illustrative): "People describe problems like this in many ways. How would you describe what has been happening, to yourself or to your family?" / "Has your family done anything, at home or with someone in the community, to help with this?"
Watch for: answers given in the clinician's vocabulary ("stress", "depression") that may hide a second, private explanation; check gently later. Watch also for silence in Domain 4 about discrimination. It is working when you can state the client's name for the problem and their preferred help.

4.3 CFI Informant Version with family members

Purpose: to hear how family, who often arrange ceremonies and care, understand the problem. Use when family are involved in decisions or care, with the client's consent. [source: APA CFI Informant]
Steps: (1) Ask the client whom to include and what may be shared. (2) Use the Informant Version (17 questions; it opens with the informant's relationship to the client, then follows the four domains). It is labelled DSM-5, 2013. [source: APA CFI Informant] (3) Interview the informant separately if the client prefers. (4) Compare the family's account with the client's; note agreements and differences without ranking them.
Example language (illustrative): "Your mother has been very involved. Would it help if I asked her how she sees what is happening? You can decide what I may tell her."
Watch for: the family account overriding the client's; a family member (or the client) pressing for or against a ceremony. It is working when differences are named openly and the client still feels in charge.

4.4 CFI supplementary modules

Purpose: in-depth assessment where the core CFI shows a need. There are 12 modules. Those most relevant here are Explanatory Model; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Social Network; Patient–Clinician Relationship; Immigrants and Refugees; Older Adults; School-Age Children and Adolescents; and Caregivers. [source: APA supplementary modules]
Steps: (1) Choose modules from the core CFI flags. (2) Use them as add-ons or as standalone tools, at the first evaluation, later or repeatedly. [source: APA supplementary modules] (3) For a Then-practising family, typically start with Spirituality, Religion and Moral Traditions (role of Then and ancestors in daily life, and whether this is a source of strength or strain) and Explanatory Model. Use Cultural Identity for language, ethnicity, migration and majority–minority experience. [synthesis on selection] (4) Paraphrase module questions in plain speech; do not read them mechanically.
Example language (illustrative): "Are there spiritual or religious practices in your family that matter to you? How do they help, or make things harder, at the moment?"
Watch for: fatigue from too many modules in one session; spread them out. It is working when the module brings out material that changes the plan, such as an ongoing ceremony, a family dispute about it, or a sense of obligation.

4.5 Kleinman's explanatory-model questions

Purpose: a short, portable way to elicit the client's model, from Kleinman, Eisenberg and Good (1978). Use when time is short, at review points, or with family. [source: Tanenbaum handout; Dinos et al. 2017]
Steps: Ask, in your own words and in an order that flows, about: (1) what the client calls the problem; (2) what caused it; (3) why it started when it did; (4) what it does to them and how it works; (5) how severe it is and whether it will be short or long; (6) what treatment they think they should receive; (7) the main problems it has caused; (8) what they fear most about it. [source: Tanenbaum handout] Record the answers verbatim where possible, including words such as vía (soul or vital spirit), hạn (misfortune, often tied to destiny), or a spirit or deity named by the client. [source: Đỗ Duy Hưng 2025; Phạm Thị Thu Hà 2010]
Example language (illustrative): "What do you think started this, and why now?" / "What are you most afraid this could lead to?"
Watch for: plural models held at once (for example, overwork and a misfortune year and "nerves"); these are common and need not be resolved. It is working when the client's fears are spoken (for example, that the problem will spread to children, or that a ceremony was not enough).

4.6 Asking about consultation with a Then master, without judgement

Purpose: to learn what the client has already done and plans to do, so that care is coordinated and nothing is hidden. Use in Domain 3 of the CFI and at every review. [source: APA CFI domain 3; synthesis]
Steps: (1) Normalise: many families use more than one source of help. (2) Ask whether a Then master or another community specialist has been consulted, and what they said the problem was. Do not ask what was done in the ceremony, what was sung, or what objects were used. (3) Ask how the client felt afterwards and what is expected next (for example, a further ceremony). (4) Ask whether the client wants you to know more, or to keep the two separate. (5) Note any instruction the client believes they must follow, and check for anything with health implications (for example, stopping treatment) so it can go to the right professional.
Example language (illustrative): "Some families ask a thầy Then for help when someone is unwell. Has your family done that? I'm asking so I can work alongside it, not to judge it."
Watch for: fear that disclosure will be treated as backwardness or reported; reassure about confidentiality and its limits. It is working when the client discusses ceremonies as readily as clinic visits.

4.7 Cultural concepts of distress: idioms, explanations and syndromes

Purpose: to recognise when the client's distress is expressed through idioms or causal explanations from their tradition. DSM-5-TR defines cultural concepts of distress as including "idioms, explanations or perceived causes, and syndromes". [source: APA Section III]
Steps: (1) Know that the DSM-5-TR glossary examples (for example, ataque de nervios, khyâl cap, kufungisisa, maladi dyab, shenjing shuairuo, susto) do not include a Tày, Nùng or Thái entry. [source: UNMC slides] [uncertain: exact DSM-5-TR glossary list not verified against the manual] (2) Treat soul loss (vía lạc) and misfortune (hạn) as explanations or perceived causes in the client's model, not as diagnoses. [source: Đỗ Duy Hưng 2025; Phạm Thị Thu Hà 2010; synthesis on use] (3) Ask what the idiom implies: what the client should do, who should help, and how long it lasts. (4) Assess symptoms separately with standard tools, and link the two in the formulation ("experienced as…; also meets criteria for…" or "does not meet criteria"). (5) Never equate an idiom with a single DSM disorder.
Example language (illustrative): "When you say your vía has not settled, what does that feel like day to day? What would show you it had come back?"
Watch for: you substituting a Kinh or Chinese idiom (for example, shenjing shuairuo) for the client's own; Tày, Nùng and Thái terms differ by language and locality [uncertain: not verified]. It is working when the client's own outcome markers become goals in the plan.

4.8 Distinguishing culturally normative experience from disorder

Purpose: to avoid diagnosing ceremonial possession, trance or spirit communication as illness, while not missing psychosis, dissociative disorder, mood disorder or medical illness. Use whenever the client reports possession, trance, spirit voices, soul loss or a sense of being chosen by spirits.
Steps: (1) Establish context. Did the experience occur within a ceremony, in a recognised role (for example, as a Then master or apprentice), and is it accepted as such by the client's community? Norton reports that Then masters are possessed in some ceremonies. [source: Norton 2016] (2) Apply the manual exclusions. In DSM-5, the possession form of dissociative identity disorder requires that the disturbance is "not a normal part of a broadly accepted cultural or religious practice". Dissociative trance (other specified dissociative disorder) does not apply when the trance is "a normal part of a broadly accepted collective cultural or religious practice". DSM-5-TR keeps these exclusions in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; whether it keeps identical wording is [uncertain]. [source: PMC9199574] ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice; 6B62 also requires recurrence or a single episode lasting several days, and distress or impairment. [source: findacode ICD-11 6B62; PMC9199574] (3) Assess what is outside the cultural frame: onset outside ceremony, loss of control the community itself regards as abnormal, functional decline, other psychotic features (disorganisation, broad persecutory beliefs), mood symptoms, substance use, and medical causes such as fever, epilepsy, head injury or delirium. [synthesis] (4) Ask the client and family whether they regard the experience as normal or as a problem. (5) If unsure, consult a cultural broker from the client's community (with consent). Defer diagnosis, monitor, and get a medical review where indicated. A DSM-5-TR culture note on not counting culturally sanctioned experiences as psychotic symptoms is [uncertain: not verified].
Example language (illustrative): "In your community, would people see what happened to you as part of Then, or as something going wrong? What do you think yourself?"
Watch for: your own surprise or discomfort driving the differential; family disagreement (one member sees a spiritual calling, another illness). Accounts of becoming a Then master through a calling illness are not described in the sources used here [uncertain: not verified]; do not assume such a pattern. It is working when the formulation states both the cultural meaning and the clinical findings, and the client recognises both.

4.9 Interpreters and cultural brokers

Purpose: to give the client language access and contextual knowledge. Tày, Nùng and Thái are distinct languages; Then is sung in the ethnic language. [source: UNESCO RL page] Use when the client's preferred language for distress differs from yours, or when cultural meaning is unclear.
Steps: (1) Ask which language the client prefers for talking about feelings and about spiritual matters (they may differ). (2) Prefer a trained interpreter not from the client's immediate social network; discuss confidentiality and how to render terms such as vía without translating them away. (3) A cultural broker (a community member, scholar or experienced clinician from the community) advises you on meaning, with the client's consent and without identifying details unless agreed. (4) Brief and debrief the interpreter or broker. (5) Remember that the broker's view is one perspective, not the community's authority on ceremony.
Example language (illustrative): "Some words don't translate well. When a word matters to you, please say it in your own language and we'll talk about what it means."
Watch for: an interpreter who interprets for the client or softens spiritual content out of embarrassment. It is working when the client uses their own terms freely.

4.10 Collaboration and coordination with a Then master, when the client wishes

Purpose: to align care when the client and family are using both Then and psychotherapy and want them to fit together. Use only at the client's request. WHO's Traditional Medicine Strategy 2014–2023 promotes safe integration of traditional and complementary medicine, including practitioners, into health systems. [source: WHO strategy page] No formal Viet Nam programme linking Then masters with mental health services is documented in the sources cited here [uncertain: not verified].
Steps: (1) Ask what the client wants: information only, a joint understanding, or no contact. (2) Obtain written consent specifying who, what may be shared and for how long. (3) Let the client or family make the approach in the usual community way; you do not seek out a master. (4) If contact happens, keep to roles. Explain what psychotherapy offers and ask what the master understands the problem to be and what the family has been advised. Do not ask for, record or assess ceremony content. (5) Agree practical points such as timing of sessions around ceremonies, and that urgent medical or safety concerns are referred to the right services. (6) Record the agreement; revisit it at review. Trials of collaborative care between traditional or faith healers and primary care exist elsewhere and are not Then-specific. 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].
Example language (illustrative): "If you'd like, I could talk with the thầy Then your family consults, so that we're not pulling in different directions. Only if you want that, and you decide what I share."
Watch for: the client feeling you are testing or competing with the master; pressure from either side to abandon the other form of help. It is working when the client reports less conflict between the two and continues both, or chooses one freely.

4.11 Keeping medical and psychiatric care in view

Purpose: to make sure ceremonies and psychotherapy do not delay assessment of medical illness, serious mental illness or risk. Use at intake and whenever symptoms escalate.
Steps: (1) Screen for medical red flags (fever, confusion, seizures, head injury, rapid weight loss, new neurological signs) and refer for medical assessment. (2) Assess suicide and self-harm risk by standard practice; plan safety with the client and family, including lethal-means counselling (safe storage and removal). (3) If the client takes prescribed medicine, do not advise on it. If they ask whether to stop it during or after a ceremony, route the question to the prescriber. (4) Frame medical care as in addition to, not instead of, what the family is doing. [synthesis for all steps]
Example language (illustrative): "What your family is doing for you matters. I'd also like a doctor to check the fever and the confusion, so we know nothing physical is being missed. Both can happen."
Watch for: the family postponing care until after a ceremony when symptoms are urgent; the client hiding medicine changes. It is working when medical review happens promptly and the family does not feel their practice was overridden.

4.12 Integrating ceremony experiences into therapy

Purpose: to help the client make sense of a ceremony they took part in within their community (for example, for peace, healing or relief of misfortune) and link its meaning to therapy goals. [source for ceremony aims: UNESCO RL page; Phạm Thị Thu Hà 2010] Use in sessions after a ceremony, if the client raises it.
Steps: (1) Invite, do not require, discussion. (2) Ask about the client's experience and meaning (relief, hope, family unity, obligation, doubt), not about procedure. (3) Link meanings to goals: for example, felt support from family becomes a coping resource; a sense that misfortune has been addressed becomes a moment to rebuild routine. (4) If the client feels worse, more frightened or under obligation, explore this without blaming the ceremony or the master, and reassess risk. (5) Note changes against the client's own outcome markers.
Example language (illustrative): "You mentioned the ceremony last week. If you'd like to talk about it, what was it like for you, and has anything shifted since?"
Watch for: symptom relief attributed solely to the ceremony, leading to sudden withdrawal from treatment; respect it, and agree a check-in. It is working when the client can hold the ceremony and therapy in one coherent story.

4.13 Safeguarding where a practice harms

Purpose: to act on harm without stigmatising the tradition. Viet Nam's Law on Belief and Religion prohibits using belief practice to infringe body, health, life or property, and exploiting it for profit. [source: Law 02/2016/QH14] No source used here documents a pattern of harm specific to Then [uncertain: not verified]; this item covers general vigilance.
Steps: (1) Listen for coercion, financial exploitation (for example, escalating payments demanded with threats), physical harm, sexual contact, confinement or withholding of food, and delay of urgent medical care, whoever the perpetrator is. (2) Distinguish the tradition from individual misconduct. (3) For a child or an adult at risk, follow local safeguarding and reporting law; consult a supervisor. (4) Document facts, not judgements about belief. (5) Keep the therapeutic relationship where safe.
Example language (illustrative): "What you describe, being asked for more money with threats about your child's health, worries me. That's not about your tradition; it's about someone pressuring you. Can we look at what protection is available?"
Watch for: your own bias making ordinary practice look sinister, or deference making real harm look cultural. It is working when the client feels protected, not judged.

4.14 Working with family and community

Purpose: to engage the people who often decide on help and provide care. Ceremonies are typically held in the household of those who request them. [source: UNESCO RL page] In a Huế urban (largely Kinh) sample, family care was a leading response to mental illness, and families sought medical help mainly in severe cases. Applying this to Tày, Nùng and Thái communities is [uncertain]. [source: van der Ham et al. 2011]
Steps: (1) Map the family and community network (Social Network module). (2) With consent, hold a family session to share the formulation in terms all can accept. (3) Clarify roles: who arranges ceremonies, who attends appointments, who supports daily routine. (4) Address stigma and shame directly. (5) Agree a plan for crises.
Example language (illustrative): "Each of you is trying to help in your own way. Can we put the ways together so she gets the most support?"
Watch for: elders' views silencing younger members (or the reverse); confidentiality breaches through the network. It is working when the family plan includes both community and clinical help without conflict.

4.15 Identity, heritage and minority experience

Purpose: to address how ethnicity, majority–minority relations, migration and the staging of Then as heritage shape the client's experience. Use when cultural identity is part of the distress or of the therapeutic relationship. [source: Norton 2016; APA supplementary modules]
Steps: (1) Use the Cultural Identity module (language, ethnicity, generation, migration). (2) Ask how the client relates to Then: lived religious practice, family obligation, heritage pride, festival performance, or distance. Then is both staged at festivals and taught in schools, and practised in ceremonies. [source: Norton 2016; Báo Văn hóa 2022] (3) Explore experiences of being seen as "backward" or exoticised, and any discrimination in services (CFI Domain 4). (4) For diaspora or cross-border clients (including Tày communities in Guangxi), ask about loss of access to community practitioners. [source for cross-border: Holm 2019; synthesis]
Example language (illustrative): "For some people Then is family faith, for some it's heritage on stage, for some it's both or neither. Where are you with it?"
Watch for: ambivalence, such as pride in heritage alongside embarrassment about ritual belief; do not resolve it for the client. It is working when the client can speak about identity without defending it.

4.16 When the client is a Then master, apprentice or from a Then lineage

Purpose: to support a client whose distress relates to a ritual role, lineage expectations or apprenticeship, without entering the tradition's authority. Holm reports a preference for masters from Then families and apprenticeship to male and female teachers. [source: Holm 2019]
Steps: (1) Treat the role as legitimate. (2) Separate questions of ritual competence or calling (for the community and their teachers) from psychological ones such as burden, conflict, workload (some masters lead about 200 ceremonies a year [source: UNESCO RL page]), family pressure and exhaustion. (3) Apply 4.8 carefully: ceremonial possession in role is normative. (4) Respect confidentiality about ritual knowledge; never ask the client to disclose it.
Example language (illustrative): "I won't ask you about the ceremonies themselves; that's your teachers' domain. I'm here for how all of this is affecting you."
Watch for: the client's fear that therapy will be used to discredit their role. It is working when the client brings personal concerns freely while keeping ritual matters private.

5. Handling problems

The Then sources describe the tradition, not psychotherapy; all responses below are [synthesis] unless tagged, applying the CFI and the principles in section 3.

The client gives only "modern" explanations, then hints at another. Clients may present in the clinician's vocabulary and keep a spiritual explanation private. Response: return to CFI Domain 2 later in care with a normalising question ("Some families also see other reasons. Is there anything like that for you?"). Accept a "no". In the Huế survey, traditional explanations came up much less often than modern ones, which may reflect both real views and reluctance to disclose. [source: van der Ham et al. 2011; synthesis]
Stuck: the client says only a ceremony can help, and therapy is pointless. Response: do not argue. Ask what the ceremony is expected to change and what the client will notice. Offer therapy for what remains, such as sleep, worry, family strain or work, alongside the ceremony. Keep the door open for return.
Resistance born of expected contempt. Minority clients may expect a Kinh, urban or foreign therapist to see Then as backward. [source: Norton 2016 on majority–minority relations; synthesis] Response: name the difference early (4.1), ask CFI Domain 4 questions about past experiences of services, and repair openly if you misstep.
Overwhelm during assessment. Reports of possession, frightening dreams or spirit contact may bring fear. Response: slow down, ground in the present, shorten modules, and return to safety and supports. Do not probe ritual detail. Reassess risk.
Non-adherence: missed sessions around ceremonies or festivals, or stopping after a ceremony. Response: plan around the ceremonial calendar with the client. Agree in advance a check-in after any ceremony. If they stop, send a respectful message leaving the door open.
Medication stopped after a ceremony. Response: do not advise on medicine. Explore the meaning, assess risk, and arrange a prompt review with the prescriber with the client's consent.
Family split: one side wants Then, another wants hospital, or a young person rejects Then. Response: family session (4.14), with each view stated in the speaker's terms. Look for a plan that includes both where safe; when there is urgent risk, safety decides, explained respectfully.
Diagnostic uncertainty: is this possession in role, or psychosis? Response: apply 4.8. Defer the label, monitor, consult a cultural broker and a psychiatrist, and look for features outside the cultural frame. Remember ICD-11 and DSM exclusions for accepted cultural practice. [source: PMC9199574; findacode ICD-11 6B62]
The client asks you to take part, attend a ceremony, or recommend a master. Response: decline warmly. Explain that ceremonies belong to the community and its masters, and that your role is psychotherapy. Suggest the client consult within their family and community in the usual way.
The client asks you whether the spirits are real or whether the ceremony worked. Response: neither affirm nor dismiss. Reflect what the client believes and what they noticed, and stay with the meaning and effects in their life.
Rupture: you used a dismissive word ("superstition", "just belief") or mispronounced or misused a term. Response: name it, apologise, ask how it landed, and invite correction. Then is protected heritage and belief practice in Viet Nam, and the law prohibits insulting belief. [source: Law 02/2016/QH14; UNESCO RL page]
Suspected exploitation or coercion by someone presenting as a master. Response: see 4.13. Separate the person from the tradition, follow safeguarding law, and avoid generalising to Then.
Client is a diaspora or cross-border Tày, Nùng or Thái person cut off from community practitioners. Response: explore grief and loss of access. Ask whether the client has legitimate links with family or community at home. Do not suggest substitutes or online ceremonies, and do not improvise ritual in therapy.
Heritage staging stirs conflict (for example, distress at seeing Then performed as entertainment, or pressure to perform). [source: Norton 2016 on staged Then] Response: explore the meaning of sacred and staged forms for the client, and validate mixed feelings.
Therapist discomfort or fascination. Response: supervision; avoid curiosity-driven questions about ritual detail that serve you, not the client.

Sources

Web sources:

Cited works:

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).
Nguyễn Thị Yên, classification of Then types, as cited in Norton 2016 [uncertain: not verified].
Gureje O et al. (2020 ). COSIMPO c luster randomised trial of c ollaborative care between traditional and faith healers and primary health care workers for psychosis in Nigeria and Ghana, The Lancet (abstract, PubMed 32861306); journal per Centre for Global Mental Health.

UNESCO nomination file 01379 (nomination form and inventory documents): the safeguarding summary in this guide rests on the Committee's Decision 14.COM 10.b.42, not on the nomination form itself [uncertain: form not summarised].

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