Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 028
Guide XI-028

Kyrgyz bakshy, bübü, tabyp and moldo

Kyrgyzstan
A 39 · L 49 · M 1218 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Kyrgyz healing as described in Danuta Penkala-Gawęcka's ethnography (2014, 2017, 2019; Bishkek fieldwork 2011–2013), which draws on the Kyrgyz psychiatrists Duyshenkul Adylov and Elena Molchanova and on the Aigine Cultural Research Center in Bishkek. The Talas study of moldolor by Aitpaeva, Aldakeeva and Egemberdieva (2010) is also used. For the therapist's own work, the guide follows the DSM-5-TR Cultural Formulation Interview (CFI), its supplementary modules, and Kleinman's explanatory-model questions.

What it is. This is not a psychotherapy. It is a living, plural field of Kyrgyz healers who work alongside biomedicine and who are often consulted before it. The guide describes the field so that a psychotherapist can work responsibly alongside it. A psychotherapist does not practise any of these roles. Penkala-Gawęcka's 2017 typology, from Bishkek, lists these healers [source: Penkala-Gawęcka 2017]:

  • Bakshy (bakshï) and bübü: shamans, who work through ritual and contact with spirits. Bübü is sometimes used for a female shaman [source: Penkala-Gawęcka 2014; 2019].
  • Közü achyk ("open-eyed"): clairvoyants.
  • Tabyp (tabïp): healers who diagnose by the pulse and practise traditional Kyrgyz and Islamic healing [source: Penkala-Gawęcka 2017]. Adylov's classification, as cited by Penkala-Gawęcka, describes the tabyp as using "pulse diagnostics" and a hot/cold classification of illness [source: Penkala-Gawęcka 2019, citing Adylov 1999].
  • Moldo (mullahs): healers who heal with Qur'anic recitation [source: Penkala-Gawęcka 2017].
  • Others: bone-setters and herbalists; Adylov also lists the kuuchu and the synchy. Urban healers increasingly add "bio-energy" and imported methods [source: Penkala-Gawęcka 2017; 2019].

The types overlap, and healers often do not name a single specialty [source: Penkala-Gawęcka 2019]. Usage also varies by region. In Penkala-Gawęcka's mainly Kazakh 2014 material, the tabyp/tabip is a "weaker" healer who combines spiritual healing with fortune-telling [source: Penkala-Gawęcka 2014]. Molchanova and colleagues describe a "hybridization" since the mid-1990s: healers now combine traditional ritual with Islamic prayer, herbs, massage and other techniques [source: Molchanova et al. 2018].

How change happens, as the tradition holds it. Illness may be attributed to several causes [source: Penkala-Gawęcka 2017; 2019]:

  • the evil eye (köz tiyüü)
  • fright (korkuu)
  • black magic (porcha)
  • displeasure of ancestor spirits (arbaktar)
  • jinns, or albarsty, a nightmare-like affliction that mostly affects young women.

Healing addresses the cause as the person and the healer understand it. Many Kyrgyz people regard these practices as Islamic, and "most of the healers today associate their healing power with Islam" [source: Penkala-Gawęcka 2014, quoting Duyshembiyeva]. Healing at sacred sites (mazar) is held to be stronger [source: Penkala-Gawęcka 2014; Aitpaeva 2013].

The therapist's own work. Change comes from understanding the client's explanatory model, from separating culturally normative experience from disorder, and from coordinating help the client already trusts. Kyrgyz psychiatrists have described "parallel" or "double" assistance: the doctor relieves symptoms while the healer addresses the cause as the person understands it [source: Penkala-Gawęcka 2017; 2019, citing Molchanova et al. 2009].

2. Framework

The tradition has no published phase model for psychotherapists. The phases below are a [synthesis] that organises the CFI and the collaboration practices the Kyrgyz sources report. There is no source for session counts. The figures given are [synthesis].

Phase A: Engagement and cultural assessment (sessions 1–2).

  • Goal: build trust, then complete the core CFI. Add the informant version when family is central.
  • Context: about 80% of psychotherapy-clinic patients in Bishkek, and nearly all patients on other psychiatric wards, had seen healers before they reached psychiatry [source: Penkala-Gawęcka 2017]. Expect this history, and ask about it without judgement.
  • Move on when: you know the client's name for the problem, the causes they suspect, the help they have sought, and what they expect from you.

Phase B: Explanatory model and help-seeking map (sessions 2–3).

  • Goal: complete the Explanatory Model, Spirituality/Religion and Coping/Help-Seeking modules. Map every healer, moldo, mazar visit and doctor involved, with what each said.
  • Move on when: the client agrees with a shared summary of the problem in their own terms and in clinical terms.

Phase C: Differential understanding (in parallel with A and B).

  • Goal: separate a culturally recognised calling ("shamanic illness"), spirit affliction or fright from psychosis, PTSD, depression or dissociative disorder, using DSM-5-TR and ICD-11 cultural exclusions. Consult a cultural broker where you can.
  • Move on when: there is a working formulation, and urgent risk (psychosis, suicidality, violence, medical danger) has been addressed.

Phase D: Treatment with optional parallel care (weekly; length set by the clinical problem).

  • Goal: deliver the evidence-based treatment for the clinical problem. If the client wishes, coordinate with the healer or moldo the client already sees.
  • Requirements: written consent, an agreed scope for what is shared, and agreement that medical and safety issues go to the prescriber or physician.

Phase E: Integration, family work and follow-up.

  • Goal: help the client make sense of healer and mazar experiences, ease conflict between family members' explanatory models, and plan relapse prevention that fits both frames.

Throughout: safeguarding, and re-running CFI modules when new problems appear. The modules may be repeated during treatment [source: APA CFI Supplementary Modules].

3. Guiding principles

  • The therapist works alongside, never as, a healer. Do not perform, imitate or prescribe any healing, recitation, purification, divination or shrine practice. Your tools are assessment, psychotherapy and coordination. [synthesis]
  • Authority sits within the tradition, not with you. Several sources of legitimacy apply [source: Penkala-Gawęcka 2014; Aitpaeva 2013; Aitpaeva et al. 2010]:
    • A healer's legitimacy rests on community recognition and, as the tradition holds, on being "chosen" by ancestor spirits. It is confirmed by a master healer's blessing (bata). A self-proclaimed healer "is usually regarded with suspicion as a usurper."
    • For Islamic clergy, the Muftiate (Spiritual Administration of Muslims of Kyrgyzstan) and its regional kazyiyats define normative practice.
    • Many village moldolor are unofficial, appointed by villagers.
    • Sacred-site guardians (shaiyk), elders and families govern conduct at mazars.
    • State recognition has been "positive but unstable": healers were brought into Ministry of Health structures in the 1990s, and folk healers left Bishkek's "Beyish" centre when it was reorganised in 2011.
    • Current licensing rules for healers are [uncertain: not verified].
    In practice: ask the client whom they recognise, and never vouch for or rank healers.
  • Disagreement inside the tradition is real; do not take sides. Some official clergy reject bakshy and bübü, and some regard shrine veneration as shirk (associating others with God). Others, including over half of the Talas moldolor studied, see no basic conflict between Islam and kyrgyzchylyk [source: Aitpaeva et al. 2010; Penkala-Gawęcka 2017]. In practice: ask where the client and their family stand.
  • Attribute spiritual concepts; neither confirm nor dismiss them. Say "you understand this as the arbaktar calling you," not "the spirits want…" and not "that's just stress." [synthesis; DSM-5-TR culture chapter]
  • Expect pluralism and prior consultations. People combine biomedicine, healers and Islamic healing because of congruent beliefs, low cost and widespread mistrust of doctors [source: Penkala-Gawęcka 2017]. In practice: treat healer use as information, not non-compliance.
  • Mental-health services are often the "last stop". Survivors of violence in particular reach mental-health care last, if at all [source: Molchanova 2016]. Healers are often "the first and only stop for help-seeking" [source: Molchanova et al. 2018]. In practice: lower the threshold for disclosure, and do not shame earlier choices.
  • Avoid both pathologising and missing illness. Adylov's study of 358 healers found 40 with severe psychotic disorders. Initial psychotic episodes are often first read as "spiritual emergence", which can delay care [source: Penkala-Gawęcka 2019]. In practice: assess carefully on both sides.
  • Kinship shapes illness and help. Clan relations, respect for elders, and gender roles all matter: the position of the young daughter-in-law (kelin), and the norm (esi) that men hide their feelings. Mobile teams in Kyrgyz cities have used family counselling for this reason [source: Penkala-Gawęcka 2019, citing Molchanova 2014a; Molchanova and Agazade 2016]. In practice: involve family when the client wishes, and watch for power imbalances.
  • Do not essentialise "Kyrgyz culture". Penkala-Gawęcka warns, after Kleinman and Benson, that culture can be essentialised, and she notes that appeals to Kyrgyzness can take on a chauvinistic tone [source: Penkala-Gawęcka 2019]. In practice: ask each client; do not assume.
  • Bodily and medical matters go to physicians. Healers' treatments can include herbs, bloodletting, leeches, cauterisation and incisions. Deaths have been reported after healer treatment of serious physical disease [source: 24.kg 2016]. In practice: never advise on herbs or medicines, and route physical concerns to the prescriber or GP.
  • Consent and confidentiality govern all collaboration. Contact a healer or moldo only at the client's request, with specific written consent and an agreed scope. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions. None of them is a Kyrgyz healing practice. The CFI material comes from the official APA forms. Kyrgyz content comes from the ethnographic and psychiatric sources cited. Steps are [synthesis] unless they are tagged otherwise.

4.1 Cultural humility and self-examination

  • Purpose: to notice your own assumptions before they shape assessment. These include assumptions about shamans, Islam, the post-Soviet health system, and healers as either "charlatans" or "wise elders". Kyrgyz doctors themselves are divided on healers. Officials have called some of them "quacks" [source: Penkala-Gawęcka 2014; 2017].
  • Steps:
    1. Before the first session, write down what you believe about spirit healing and Qur'anic healing.
    2. Name your own religious or secular position and how it might show.
    3. Note the language you will work in (Kyrgyz, Russian or another). Note whether you sit inside or outside the client's ethnic and religious community.
    4. Take this reflection to supervision or consultation. Revisit it whenever you feel certainty about a client's spiritual explanation, in either direction.
  • Example language (illustrative): "I'm not from your community, so I may not understand things the way you do. Please correct me when I get something wrong."
  • Watch for:
    • Signs of bias: you hurry to diagnose a calling as psychosis, or you romanticise it. You feel irritation when a client mentions a bübü or moldo.
    • Signs it is working: the client corrects you more freely as sessions go on.

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

  • Purpose: to clarify the problem as the client and their social network see it: its meaning, the help sought, and what they expect from you. The CFI has 16 questions in four domains [source: APA CFI, DSM-5-TR]:
    • cultural definition of the problem
    • cultural perceptions of cause, context and support
    • cultural factors affecting self-coping and past help seeking
    • cultural factors affecting current help seeking.
    APA describes it as usable "by any clinician" in "any care setting" [source: APA DSM-5-TR Section III]. It supports clinical judgement and is not meant to be the only basis for a diagnosis.
  • Steps:
    1. Use it at intake, before the standard history, so the client's own frame comes first.
    2. Work through the four domains in the APA order, in your own conversational words.
    3. For a Kyrgyz client, add specific prompts [synthesis]:
      • their own word for the problem (for example korkuu, porcha, "something from the arbaktar", or a Russian medical term)
      • whether family or a healer has already named it
      • which healers, moldo or mazar they or their family have consulted.
    4. Record answers in the client's words.
    5. Note which supplementary module expands each area. The core form shows this [source: APA CFI].
    6. The form may be reproduced for clinical use. Modifying or translating it needs APA permission [source: APA CFI]. Use an authorised translation, or use an interpreter (4.12).
  • Example language (illustrative): "People sometimes understand their problems in their own way, or the way their family or a healer explains it. How would you describe what's happening to you? What do you call it?"
  • Watch for:
    • Short, "medical-sounding" answers that may reflect expected mistrust of you [source: Penkala-Gawęcka 2017]. Come back to the questions later.
    • Signs it is working: the client starts using their own terms with you.
    • Time required: no APA time is given. About 15–20 minutes for the core CFI is [uncertain: not verified].

4.3 CFI Informant Version and family perspective

  • Purpose: to gather the view of a family member or friend. Kinship and elders often define illness and decide on help [source: Penkala-Gawęcka 2019]. The Informant Version has 17 questions. Q1 covers the informant's relationship to the patient, then the four domains follow [source: APA CFI Informant Version].
  • Steps:
    1. Ask the client's permission, and ask whom they want included: a parent, spouse, mother-in-law or elder.
    2. Interview the informant separately when there may be conflict or coercion.
    3. Compare the family's explanation with the client's. Note who in the family chose the healers.
    4. Never let the informant replace the client's own account. [synthesis]
  • Example language (illustrative): "Your mother has known you all your life. With your permission, I'd like to hear how she understands what's been happening, and who the family has turned to."
  • Watch for:
    • A young kelin who goes quiet when in-laws are present, or a family consensus that overrides the client. In either case, return to individual sessions.
    • Signs it is working: you understand who decides on help in the family.

4.4 Explanatory Model module and Kleinman's questions

  • Purpose: to map the client's own theory of the illness. Kleinman, Eisenberg and Good (1978) give eight questions, paraphrased here [source: Tanenbaum handout; Dinos et al. 2017]:
    1. What do you call the problem?
    2. What caused it?
    3. Why did it start when it did?
    4. What does it do to you, and how does it work?
    5. How severe is it, and will it last a short or a long time?
    6. What treatment should you receive?
    7. What are the chief problems it has caused?
    8. What do you fear most about it?
    The CFI Explanatory Model module expands this area [source: APA Supplementary Modules].
  • Steps:
    1. Ask the eight questions in plain words.
    2. Allow several co-existing causes. Kyrgyz explanations often combine them: evil eye, fright, black magic, ancestor displeasure, jinns, albarsty, and also stress or "nerves" [source: Penkala-Gawęcka 2017].
    3. Ask which healer or doctor gave each explanation.
    4. Write a two-column summary, "how you see it" and "how I see it clinically", and check it with the client.
  • Example language (illustrative): "You said the bübü told you this came from fright. What do you think yourself? Could more than one thing be going on at once?"
  • Watch for:
    • Fear that naming a spiritual cause will get them labelled "crazy". Reassure them that you are asking in order to understand.
    • Signs it is working: the client offers causes they had not mentioned before.

4.5 Spirituality, Religion and Moral Traditions module

  • Purpose: to understand the client's religious identity and practice, and how these bear on the problem. This matters especially where Islamic identity and kyrgyzchylyk are intertwined, or contested within the family [source: APA Supplementary Modules; Aitpaeva et al. 2010].
  • Steps:
    1. Ask about prayer, the mosque, mazar pilgrimage and ancestor remembrance as the client describes them. Do not ask for details of rituals.
    2. Ask whether family members disagree. For example, a relative may see shrine visits or bakshy as forbidden, while the client values them [source: Aitpaeva et al. 2010; Penkala-Gawęcka 2017].
    3. Ask what religious authority the client trusts: an imam, a village moldo, or an elder.
  • Example language (illustrative): "Where does faith fit in your life right now? Is there anyone in your religious community whose advice matters to you about this?"
  • Watch for:
    • Guilt or fear of sin linked to having consulted a healer. Do not adjudicate it. Suggest the client discuss it with the religious authority they trust.
    • Signs it is working: the client can name what religion offers them in coping.

4.6 Coping and Help-Seeking module: mapping healer, moldo and mazar consultations

  • Purpose: to learn, without judgement, every source of help used so far and what each one said. Prior healer contact is the norm among Bishkek psychiatric patients [source: Penkala-Gawęcka 2017]. Healers also often refer patients with serious psychotic symptoms to doctors [source: Penkala-Gawęcka 2019, citing Adylov 2007; Molchanova et al. 2009].
  • Steps:
    1. Build a timeline of each consultation: bakshy, bübü, közü achyk, tabyp, moldo, mazar visits, doctors and psychiatrists.
    2. For each one, ask what it was called, what the client was told, what helped, what did not, and what it cost. Do not ask the client to describe ritual content.
    3. Ask whether any healer advised them to see a doctor.
    4. Ask specifically whether any treatment involved herbs or substances taken by mouth, or procedures on the body. Note these for medical review (4.16).
  • Example language (illustrative): "Many people here see a moldo or a healer before they ever see someone like me. Who have you seen so far, and what did each of them tell you?"
  • Watch for:
    • Minimising, which can come from expecting disapproval.
    • Payments that are large relative to income, and the financial strain they cause. A Bishkek specialist describes some healers earning large sums "without guarantees" [source: 24.kg 2016].
    • Signs it is working: the client volunteers consultations they had first left out.

4.7 Cultural Identity and Patient–Clinician Relationship modules

  • Purpose: to locate the client's identity and to name the trust problems that may affect your work. Identity may span Kyrgyz, Russian-speaking, Uzbek or another ethnicity, a region or clan, urban or rural life, and Muslim practice. Trust problems include mistrust of doctors ("poor professional qualifications and moral values" in common opinion), language barriers, and perceived discrimination [source: APA Supplementary Modules; Penkala-Gawęcka 2017].
  • Steps:
    1. Ask how the client describes themselves.
    2. Ask which language they prefer for emotional topics.
    3. Ask about past experiences with doctors and psychiatric services.
    4. Ask what would make working with you feel safe.
    5. After the 2010 Osh violence, Kyrgyz psychiatrists called for "respect and loyalty towards representatives of other cultures" among visiting specialists [source: Penkala-Gawęcka 2019, citing Molchanova and Agazade 2016]. Ask about inter-ethnic experiences gently.
  • Example language (illustrative): "Some people have had bad experiences with doctors or hospitals. Has anything like that happened to you? What would help you feel you can trust what we do here?"
  • Watch for:
    • Stigma attached to the word "psychiatric". You may need different wording, such as "talking about stress and the heart" [synthesis].
    • Signs it is working: the client openly states preferences or criticisms.

4.8 Working with Kyrgyz idioms of distress (cultural concepts approach)

  • Purpose: to use the client's idioms as DSM-5-TR uses cultural concepts of distress. These are idioms, explanations or perceived causes, and syndromes. They are to be understood, not forced into one diagnosis [source: APA DSM-5-TR Section III].
  • Idioms reported in Kyrgyz settings:
    • korkuu or jürök müshüü (fright)
    • köz tiyüü (evil eye)
    • porcha (black magic)
    • albarsty, a nightmare-like affliction: after Osh, patients with PTSD interpreted their nightmares as visits from it
    • ancestor displeasure (arbaktar), and jinns
    [source: Penkala-Gawęcka 2017; 2019]. None of these appears in the DSM-5-TR glossary of named concepts. That list includes ataque de nervios, dhat, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto and taijin kyofusho [source: UNMC DSM-5-TR slides; uncertain: secondary, list not verified against the DSM-5-TR text]. Comparing korkuu with susto is [synthesis] and is a comparison only.
  • Steps:
    1. Ask what the idiom means to the client, how it began, and what it does to body, mood, sleep and relationships.
    2. Ask what usually helps it in their family or community.
    3. Screen for disorders that commonly sit underneath it, such as PTSD, depression, anxiety or psychosis, with standard instruments, without replacing the idiom.
    4. Use the client's term alongside the clinical one in the formulation.
  • Example language (illustrative): "When you say the albarsty comes at night, tell me what that's like. Many people who have lived through frightening events also have bad nights. Could we look at both together?"
  • Watch for:
    • Translating the idiom away too fast, which loses the alliance.
    • Accepting it with no screening, which misses treatable PTSD or psychosis.
    • Signs it is working: the client uses both vocabularies comfortably.

4.9 Distinguishing a calling, spirit affliction or trance from disorder

  • Purpose: to avoid both pathologising a recognised spiritual process and missing psychosis.
  • The calling as the tradition holds it [source: Penkala-Gawęcka 2014; 2019]:
    • A future healer is held to be chosen by spirits, usually ancestors. The calling often begins with a "shamanic illness": strange dreams, visions, isolation and suffering that does not fit biomedical categories.
    • Experienced healers interpret the signs. Refusing the call is believed to bring punishment on the person or their relatives.
    • Today the illness often appears in middle age, and sufferers are frequently sent to psychiatric clinics first.
  • Steps:
    1. Ask who recognised the experience as a calling (an established healer, family, or the client alone), and whether the community recognises it. Recognition is central to how the tradition defines legitimacy [source: Penkala-Gawęcka 2014].
    2. Apply the cultural exclusions:
      • In DSM, dissociative trance is excluded when it is a normal part of a broadly accepted collective cultural or religious practice. The possession-form identity criterion of DID excludes experiences that are a normal part of a broadly accepted practice [source: PMC9199574]. DSM-5-TR keeps these points in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; whether its exact wording is unchanged is [uncertain: not verified].
      • ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require that the state is involuntary and unwanted and is not part of accepted cultural or religious practice [source: findacode ICD-11 mirror; PMC9199574].
    3. Assess positive markers of disorder whatever the frame: disorganisation; functional decline beyond what the tradition expects; command hallucinations with risk; mania; substance use; inability to step out of the experience; distress the client does not want. [synthesis]
    4. Ask the client and family how they would tell a calling from "ordinary" madness in their tradition.
    5. Consult a cultural broker, and with consent the healer the client trusts (4.13).
    6. Remember that Adylov found severe psychotic disorders among some practising healers, and that first psychotic episodes are often read as spiritual emergence [source: Penkala-Gawęcka 2019].
  • Example language (illustrative): "In your family, how do people tell the difference between someone being called by the arbaktar and someone who is unwell in the mind? What do you notice in yourself that fits one or the other?"
  • Watch for:
    • Escalating risk while the family waits for a spiritual resolution.
    • Signs it is working: you and the client can agree on safety steps that respect both readings.

4.10 Decision support for a client facing a calling

  • Purpose: to help a client think through a calling that others have announced, or that they experience, without pushing them either way. Accepting a calling can mean leaving a job, conflict at home or divorce, and an apprenticeship with a master healer. Some people "tried to avoid taking up the challenge" out of fear [source: Penkala-Gawęcka 2014].
  • Steps:
    1. Explore the client's own wish, the fears on both sides (including the belief that refusing brings punishment), and the practical consequences.
    2. Identify the people with legitimate authority whom the client trusts.
    3. Support their own decision process. Do not refer them to any healer for initiation. [synthesis]
  • Example language (illustrative): "You're being told this is your path, and you're also worried about your work and your marriage. Let's look at what each choice would mean for you, and whose guidance you trust."
  • Watch for:
    • Coercion by others.
    • Exploitation: fees, or control by a self-appointed master. The tradition itself distrusts self-proclaimed healers [source: Penkala-Gawęcka 2014].
    • Signs it is working: the client speaks of the decision as their own.

4.11 Trauma-informed work with survivors of violence who consult healers

  • Purpose: to reach survivors, especially of sexual and gender-based violence, who hide "shame" and go to healers first or only. After the 2010 Osh events, official figures recorded seven rapes, while crisis centres reported over 300 [source: Molchanova 2016; Molchanova et al. 2018]. In one reported case, a bubu suspected rape, named the problem korkuu, and did not charge a fee. The young woman was then treated better by her in-laws [source: Penkala-Gawęcka 2019, citing Molchanova et al. 2017].
  • Steps:
    1. Ask about frightening events in general terms first, and offer a same-gender clinician where possible.
    2. Accept a culturally acceptable label, such as korkuu or albarsty nightmares, as a respectful entry point. Screen for PTSD and current danger.
    3. Keep disclosure confidential from family unless the client chooses otherwise.
    4. Follow local reporting law and safety planning.
    5. If the client's healer is a source of support, consider parallel care with consent (4.13). [synthesis]
  • Example language (illustrative): "Sometimes after a very frightening experience, people feel korkuu and don't want anyone to know what happened. You don't have to tell me details. Can I ask a few questions about sleep and fear?"
  • Watch for:
    • The setting: post-traumatic presentations in Kyrgyz settings are described as complex and clinically variable [source: Molchanova et al. 2018].
    • Dissociation and overwhelm during questioning. Slow down (see section 5).
    • Signs it is working: the client discloses more over time and returns to sessions.

4.12 Interpreters, cultural brokers and local mediators

  • Purpose: to bridge language and culture. After Osh, Kyrgyz psychiatrists proposed "local mediators" and "effective communication between traditional healers and mental health professionals" [source: Penkala-Gawęcka 2019, citing Molchanova and Agazade 2016].
  • Steps:
    1. Use a trained interpreter in the client's preferred language, not a family member.
    2. Brief the interpreter on confidentiality and on not softening spiritual content.
    3. Where available, consult a cultural broker trusted by the client's community. Use client consent, and share only what is needed.
    4. Debrief afterwards on any terms that did not translate. [synthesis]
  • Example language (illustrative): "I'd like an interpreter to help us, so nothing important gets lost. They keep everything private. Is there a language you'd prefer, or anyone you would not want in that role?"
  • Watch for:
    • An interpreter from the client's small community, which raises privacy fears.
    • The interpreter's own views about healers or religion colouring the translation.

4.13 Parallel care and collaboration with a healer or moldo (only if the client wishes)

  • Purpose: to coordinate the "double assistance" model that Kyrgyz psychiatrists describe. The clinician treats symptoms, and the healer addresses the perceived cause. The model is suggested especially for non-psychotic clients with a traditional worldview [source: Penkala-Gawęcka 2017; 2019, citing Molchanova et al. 2009]. Molchanova and colleagues wrote that psychiatry "might greatly benefit from cooperation with traditional healing" [source: Penkala-Gawęcka 2019]. Collaboration evidence also comes from other regions. 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. Ask whether the client wants their healer or moldo involved at all. Many will prefer to keep the two separate.
    2. Obtain specific written consent: what may be shared, with whom, and how long the consent lasts.
    3. Contact the practitioner the client already trusts. Do not select or recommend a healer yourself.
    4. Agree roles with the practitioner [synthesis]:
      • You will not interfere with their work, and they will not ask the client to stop psychiatric medication.
      • Physical or medical problems go to a physician.
      • Each of you will tell the other, with consent, about any risk.
    5. Agree how the practitioner can refer back if symptoms worsen. Healers often refer patients with serious psychotic symptoms to doctors already [source: Penkala-Gawęcka 2019].
    6. Document the arrangement and review it regularly.
  • Example language (illustrative): "You've told me the moldo's prayers give you strength. I won't get in the way of that. If you'd like, and only if you'd like, I could speak with him so we're not pulling you in different directions."
  • Watch for:
    • Advice to stop medication, fees that exploit the client, or delay of urgent care. If these appear, discuss them with the client and revisit consent.
    • The client's discomfort with you knowing the healer.
    • Signs it is working: the client no longer feels caught between helpers.

4.14 Family and kinship work

  • Purpose: to address illness within family and clan structures. Kyrgyz mobile mental-health teams (psychiatrist, psychologist, nurse, social worker) working since 2006 in several cities explore family and clan relations and offer family counselling. The NGOs "Mental Health and Society" and "Family and Society" have been involved [source: Penkala-Gawęcka 2019, citing Molchanova 2014a].
  • Steps:
    1. Map who holds influence (elders, parents-in-law, spouse).
    2. Hear each person's explanatory model.
    3. Name disagreements about healers and religion without ruling on them.
    4. Agree practical support for the client.
    5. Pay particular attention to neglect of a young kelin, and to the male norm (esi) of hiding feelings [source: Penkala-Gawęcka 2019].
  • Example language (illustrative): "Everyone here wants Aibek to get better. Some of you trust the tabyp and some trust the clinic. Can we agree on what each of you will do this month?"
  • Watch for:
    • Blame of the client, or family pressure to accept or refuse a calling.
    • Signs it is working: family members stop undermining each other's chosen help.

4.15 Integrating healer and mazar experiences

  • Purpose: to help the client make meaning of a healing session, shrine pilgrimage or spiritual experience, and connect it to therapy goals. Mazars are held to bring healing power closer [source: Penkala-Gawęcka 2014; Aitpaeva 2013].
  • Steps:
    1. Invite the client to share only what they wish about how it felt and what it meant. Do not ask for the content of the ritual.
    2. Explore what changed in mood, hope, relationships or sense of purpose.
    3. Link those changes to their goals.
    4. Also explore distress the experience caused, such as fear, guilt, or conflict with relatives. [synthesis]
  • Example language (illustrative): "You went to the mazar with your aunt last week. What, if anything, felt different afterwards? How does that connect with what we're working on?"
  • Watch for:
    • Increased fear after being told of black magic (porcha) or a curse. Address the anxiety directly, without disputing the belief.
    • Signs it is working: the experience becomes a resource the client can draw on.

4.16 Medical safety and routing to the prescriber

  • Purpose: to keep physical risk with physicians. Reported healer treatments include herbs, bloodletting, leeches, cauterisation, incisions and caustic substances. Kyrgyz media report deaths of a child and an adult after healer treatment of serious physical disease. In the adult's case, criminal proceedings opened only after press coverage [source: 24.kg 2016]. Healers are also consulted for terminal cancer [source: Penkala-Gawęcka 2017]. No healing practice described here is a treatment for physical disease.
  • Steps:
    1. Ask neutrally about anything taken by mouth or done to the body.
    2. Never advise starting, stopping or changing any medicine or herb.
    3. With consent, inform the prescriber or GP, and encourage the client to tell them directly.
    4. Urgent physical symptoms go to medical care the same day. [synthesis]
  • Example language (illustrative): "I'm not the right person to judge herbs or medicines. Would you be willing to tell your doctor what the tabyp gave you, so they can check it fits safely with your other treatment?"
  • Watch for:
    • Delay of urgent care, and a belief that payment guarantees quick results. A Bishkek health official describes this belief [source: 24.kg 2016].
    • Signs it is working: medical review happens.

4.17 Safeguarding

  • Purpose: to act when a practice, or abuse presented as a practice, causes harm. Examples include restraint, beating, starvation, sexual abuse, coercion of a child or vulnerable adult, delay of urgent medical care, and financial exploitation. [synthesis based on standard safeguarding duties]
  • Steps:
    1. Distinguish the tradition from harm done under its name. The tradition itself distrusts self-proclaimed healers [source: Penkala-Gawęcka 2014].
    2. Assess immediate danger.
    3. Follow your jurisdiction's child and adult protection and reporting procedures.
    4. Involve family members who are protective.
    5. Document carefully, and consult supervision.
    6. Do not name minors in records shared outside the service.
  • Example language (illustrative): "I respect that your family wanted help from the healer. What you're describing put your daughter in danger, and I have a duty to make sure she's safe. Let's talk about what happens next."
  • Watch for:
    • Disengagement after a report. Keep contact open, and explain your duty without contempt for the tradition.

4.18 Clients living outside Kyrgyzstan: Immigrants and Refugees module

  • Purpose: for Kyrgyz clients abroad, to assess migration history, legal and economic stress, and access to healers or moldo from home. Some may keep contact with healers remotely, which is [uncertain: not verified] [source: APA Supplementary Modules].
  • Steps:
    1. Use the module's areas: background, migration, current life, and expectations of the future.
    2. Ask whether family at home is consulting healers on the client's behalf.
    3. Ask how isolation from mazars and elders affects them. [synthesis]
  • Example language (illustrative): "Since you came here, who do you turn to when things go wrong? Is your family back home doing anything to help you, with a healer or at a mazar?"
  • Watch for:
    • Precarious legal status, which may make the client hide distress.
    • Signs it is working: the client names supports in both places.

5. Handling problems

Most guidance here is [synthesis]. Points tied to Kyrgyz sources are cited.

  • The client will not discuss healers ("I don't believe in that") but family does. Do not push. Note it, and return to it through the family module or the help-seeking timeline. Expect concealment: mistrust of doctors is common, and puristic Islamic trends oppose both Kyrgyz healing and rural mullahs' healing, so some clients feel shame about consulting [source: Penkala-Gawęcka 2017]. Example (illustrative): "Some families see healers and some don't. Either way is fine here. I only ask so I understand everything that's helping or worrying you."
  • Stuck between two explanations. Some clients fear that accepting therapy means betraying the arbaktar or the moldo, or that accepting a calling means betraying the clinic. Use the parallel-care frame: two kinds of help for two aspects of one problem [source: Penkala-Gawęcka 2017; 2019]. Ask what the trusted healer or religious authority would say about also seeing you. [synthesis]
  • Resistance after a previous psychiatric experience. First episodes are often seen by healers before psychiatry, and public resentment of psychiatrists is described [source: Penkala-Gawęcka 2019]. Name the mistrust openly, give the client choices about pace and topics, and explain confidentiality limits clearly. [synthesis]
  • Overwhelm or dissociation in session. This can come when discussing spirits, violence or a calling. Pause, ground the client in the present (feet, breath, the room), shorten the session, and return to safety before content. Never induce or encourage trance states in therapy. [synthesis]
  • Non-adherence to psychiatric medication because a healer or relative advised stopping it. Do not advise on medicines. Explore the client's reasons, invite them to tell the prescriber, and with consent tell the prescriber yourself. If the client wishes, raise the issue with the healer during collaboration. [synthesis]
  • Rupture after the client feels judged (for example, if you seemed to doubt the evil eye or porcha). Acknowledge it directly, restate that you are not judging their beliefs, and ask what would repair trust. [synthesis]
  • Rising psychosis or suicide risk while the family waits for a spiritual resolution. Use standard risk assessment. Explain that safety care does not replace what the healer or moldo offers. Involve protective family, and, with consent, the healer who may already refer serious psychosis to doctors [source: Penkala-Gawęcka 2019]. Use emergency services if risk is imminent. [synthesis]
  • The client asks you to recommend a healer, or to join a healing session or mazar visit. Decline warmly. Explain that you work alongside the tradition and that the choice of healer belongs to the client, their family and their community. Legitimacy within the tradition rests on community recognition and a master's blessing [source: Penkala-Gawęcka 2014]. Avoid pointing clients to self-proclaimed or commercial healers. [synthesis]
  • You suspect exploitation by a healer (large fees, sexual contact, isolation from family, demands to stop medication). Separate the practitioner from the tradition. Tradition itself treats some such figures with suspicion, and Kyrgyz officials and specialists have raised concerns about fraud [source: Penkala-Gawęcka 2014; 24.kg 2016]. Assess safeguarding duties (4.17).
  • Conflict over the client's religious choices within the family (for example, a relative who sees bakshy or shrine visits as forbidden). These positions are found among Kyrgyz moldolor themselves [source: Aitpaeva et al. 2010]. Use family sessions to make room for coexistence, and suggest the family consult the religious authority they trust on doctrinal questions. [synthesis]
  • Your own discomfort or over-identification. Use supervision. Notice whether you are trying to "save" the client from tradition, or to become their spiritual guide. [synthesis]
  • Not addressed in the sources:
    • specific psychotherapy outcomes when parallel care is used in Kyrgyzstan
    • current Kyrgyz licensing rules for healers
    • Muftiate guidance on Qur'anic healing
    All three are [uncertain: not verified].

Sources

Kyrgyz healing, ethnography and Kyrgyz psychiatry

Cultural assessment

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