Sangoma and inyanga (Southern Africa)

1. Introduction

Version followed: South Africa's statutory framework (Traditional Health Practitioners Act 22 of 2007, and the draft Traditional Health Practitioners Regulations, 2024), with attributed ethnography and clinical research from KwaZulu-Natal (isiZulu-speaking) and Xhosa-speaking communities. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). Practices differ between language groups, regions and lineages. Nothing here applies unchanged to Eswatini, Lesotho, Botswana, Zimbabwe or Mozambique.

This is a living healing tradition, not a psychotherapy. A psychotherapist does not practise it. Southern African traditional health practitioners (THPs) include diviners, usually called sangoma (isiZulu isangoma, plural izangoma; isiXhosa igqirha, plural amagqirha), and herbalists, usually called inyanga (plural izinyanga). Diviners are understood to be called by the ancestors. Herbalists work mainly with remedies. [source: Zabow 2007; Mzimkulu & Simbayi 2006; The Conversation, THP regulation] [uncertain: not verified: the isiZulu singular and plural forms and the sangoma/inyanga glosses]. South African law now names these roles: a "diviner" and a "herbalist" are each a person who engages in traditional health practice and is registered in that category. [source: THPA s1]

In the tradition's own account, illness or misfortune may be read as a call from the ancestors to become a healer. The person then goes through ukuthwasa, an apprenticeship with an established practitioner. Xhosa sources call the initiatory illness intwaso. [source: Zabow 2007; Rhodes University thesis, Three perspectives on ukuthwasa; van der Zeijst et al. 2022] These are the community's own understandings. This guide neither states them as fact nor dismisses them.

For the therapist, change comes through culturally responsive care. That means understanding the client's explanatory model, telling a culturally recognised calling apart from illness that needs treatment, and supporting the client's own choices across both systems. Collaboration is with registered practitioners whom the client and their community recognise. Research from KwaZulu-Natal suggests that for some people, the calling and training work as a culturally sanctioned healing process. The experiences involved might be classed as psychotic, but they often eased once the person was accepted into a valued role. [source: van der Zeijst et al. 2021; van der Zeijst et al. 2022]

2. Framework

2a. The tradition's own structure (context only; who holds authority)

• Calling and training. The tradition holds that diviners are called by the ancestral spirits. The calling may come with symptoms that resemble mental illness, including unusual perceptual experiences. Training (ukuthwasa) takes place under an established THP. Some participants regard accepting the calling as the only effective cure. [source: van der Zeijst et al. 2021; The Conversation] Initiation and divination methods are not described here. They belong to the practitioners and lineages who hold them.
• Who holds authority. Authority sits with the trainer and lineage, the family (including, in the tradition's terms, the ancestors), and healer bodies such as the Traditional Healers Organisation. The Conversation reports that this body has over 29,000 members. [source: The Conversation] The statutory regulator is the Interim Traditional Health Practitioners Council of South Africa, set up under s4 of the Act. The Act exists to establish this Council, to provide for the registration, training and practice of THPs, and to "serve and protect the interests of members of the public" who use THPs. Section 2 came into force on 1 October 2018 (Proclamation 29 of 2018). [source: THPA s1, s2]
• Statutory categories. The Act's definitions cover diviner, herbalist, traditional birth attendant, traditional surgeon, student and traditional tutor. A traditional tutor is a registered practitioner accredited by the Council to teach. [source: THPA s1] Under the draft regulations of 21 June 2024 (Government Gazette 50840, Notice 4986, published for comment):
  • Divination and herbalism students must be at least 18.
  • Training lasts at least 12 months.
  • Students keep a logbook signed by the tutor or institution.
  • Existing practitioners can register on documentary proof or on community recognition.
  These are proposals, not law in force. In May 2026 Parliament's Portfolio Committee on Health reported that the regulations needed to operationalise the Act had still not been promulgated, that registration of practitioners had not begun and no national register exists, and that the Council has remained an interim body since 2014, with an amendment bill in process to make it permanent. [source: Parliament of South Africa, Portfolio Committee on Health statements, 26 and 28 May 2026] Before relying on any provision above, check the current Government Gazette or ask the Interim Council. [source: Draft THP Regulations 2024]
• What the law prohibits. Under s49 it is an offence for anyone who is not a registered THP or student to:
  • practise for gain;
  • diagnose, treat or advise for gain;
  • use titles such as "healer" or "doctor".
  It is also an offence to diagnose, treat or offer to cure "cancer, HIV and AIDS or any other prescribed terminal disease", or to promote remedies for them. The penalty is a fine or up to 12 months' imprisonment. [source: THPA s49]

2b. The psychotherapist's own phases [synthesis, built on the CFI and the collaboration literature]

No source sets session counts. The phases below are a working structure. Format: individual sessions, with family or informant sessions where the client agrees. Use an interpreter where needed.

1. Engagement and cultural assessment (sessions 1–2). Goal: a safe, non-judgemental frame. Use the core CFI, and add supplementary modules as needed. [source: APA CFI] Move on once you can state the problem in the client's own terms, their explanatory model, and what help they have already sought (including from izangoma, izinyanga, churches or prophets).
2. Formulation and differential consideration (sessions 2–4, overlapping with phase 1). Goal: tell apart (a) a calling or other culturally recognised experience that the client and their community see as normative, (b) a mental or physical disorder needing treatment, and (c) both together. Move on once immediate risks are assessed, medical causes have been considered with the prescriber or GP, and you and the client have a shared working understanding, including any disagreement.
3. Shared plan, with collaboration if the client wishes (from session 3–5). Goal: a plan that respects the client's chosen pathways. This may include consented contact with a registered THP the client already trusts, and must be clear about what each party does. Move on once roles, consent and confidentiality limits are agreed in writing.
4. Parallel care and integration (ongoing). Goal: support the client through the tradition's process (such as ukuthwasa) or alongside it. Monitor mental state, functioning, adherence to any prescribed treatment, and safety. Help the client make meaning of their experiences in their own framework. Review at set points, for example every 4–6 sessions.
5. Review and ending. Goal: consolidate gains. Agree how the client can return. Hand over clearly to the THP, the GP or psychiatric services as relevant.

Return to phase 2 whenever new risk, a marked deterioration or a new physical symptom appears.

3. Guiding principles

• Write and act alongside the tradition, never within it. You do not divine, diagnose a calling or prescribe remedies. You leave every judgement within the tradition to its practitioners. [source: THPA s1, s49] [synthesis]
• Describe concepts as the client holds them. Ancestors, calling, witchcraft and possession are recorded as the client's and community's understandings. In practice, say "you understand this as…", never "this is" or "this is just". [source: Zabow 2007; Mzimkulu & Simbayi 2006]
• Expect dual use. Most service users in a rural KwaZulu-Natal sub-district held traditional explanations and used both systems. In practice, ask about both in every assessment. [source: Campbell-Hall et al. 2010]
• Do not equate local categories with diagnoses. Ufufunyana/amafufunyana overlaps with schizophrenia in symptoms but differs in its causal account. Patients use such terms flexibly, as explanatory categories. In practice, keep the client's term and your diagnosis side by side in the record. [source: Ngubane & De Gama 2024; Zabow 2007]
• Avoid both errors: pathologising and missing illness. DSM-5-TR excludes trance and possession that are part of a broadly accepted cultural or religious practice. ICD-11 possession trance disorder requires the state to be involuntary and unwanted. In practice, ask whether the community recognises the experience, whether it is wanted, and whether it is causing distress or impairment. [source: DSM-5 / DSM-5-TR via PMC9199574 and Lewis 2023; ICD-11 6B62, 6B63]
• Know the course data, and keep watching. In 42 apprentice THPs followed for 3 years, psychotic disorders fell from 7 (17%) to 4 (10%), and 98% said ukuthwasa had helped. Some still had a disorder. In practice, do not assume either benignity or illness. Re-assess over time. [source: van der Zeijst et al. 2022]
• Client choice governs collaboration. Contact a healer only at the client's request, with written consent, and with clear confidentiality limits. In practice, the client decides whether, whom and what is shared. [source: APA CFI, help-seeking domain] [synthesis]
• Respect and two-way exchange. Healers report feeling under-appreciated by Western-trained practitioners, and referral has mostly flowed one way, from THPs to clinics. In practice, treat a healer as a colleague with a different expertise, and share what therapy can offer. [source: Campbell-Hall et al. 2010; Ngubane & De Gama 2024; Zabow 2007]
• Legitimacy and the law. Under the Act, registration with the Council is the statutory marker. Community recognition is the cultural one. As of May 2026 registration had not begun and there was no national register, so registration cannot yet be checked. [source: Parliament of South Africa, May 2026] In practice, ask the client which practitioner they trust. Once registration opens, prefer registered practitioners for any referral, and treat claims to cure cancer or HIV as a legal and safety red flag. [source: THPA s49; Draft THP Regulations 2024]
• Never advise on medicines or remedies. Mixing herbal products with antiretrovirals may change drug levels, and switching between systems was linked to poor adherence. In practice, ask, record, and route to the prescriber. [source: Dheda 2017; Campbell-Hall et al. 2010]
• Do not ask for what is held back. Initiation and divination knowledge belongs to lineages. In practice, let the client share what they choose, and never probe for ritual detail. [synthesis]
• Name history and racism. Patients and families report negative experiences and misunderstandings with services. In practice, invite the client to talk about mistrust, and use the CFI's clinician–patient relationship question. [source: Zabow 2007; APA CFI Q16]

4. Intervention inventory

All the interventions below are the psychotherapist's own work. None of them is a traditional healing practice.

4.1 Cultural humility and self-examination

• Purpose / when: Before and during work with any client who draws on izangoma, izinyanga or ancestral understandings. Use it especially when you notice scepticism, fascination or anxiety in yourself. [source: Campbell-Hall et al. 2010, on the lower willingness of Western-trained staff to collaborate] [synthesis]
• Steps:
  1. Note your own assumptions about ancestors, witchcraft and healers, and where they came from (training, religion, media).
  2. Note the power you hold: diagnosis, records, and possibly a role in involuntary care.
  3. Learn the basic local categories from published sources, not from the client's time. Examples: diviner and herbalist roles, ukuthwasa, ufufunyana. [source: Zabow 2007]
  4. Take cases to supervision or consultation with a colleague who shares the client's cultural background.
• Example language (illustrative): "I was trained mainly in one way of understanding distress. You may see it differently, and I would like to learn how you and your family see it."
• Watch for:
  • Using exotic or dismissive language.
  • Treating the client as a cultural teacher instead of a patient.
  • Relief at handing everything to a healer, or the reverse.
  It is working when the client corrects you freely and brings up healer contact without being asked.

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

• Purpose / when: At first assessment, to understand the problem from the client's and their network's view, including meaning, sources of help and expectations. It has 16 questions in four domains: cultural definition of the problem; perceptions of cause, context and support; self-coping and past help-seeking; and current help-seeking. APA states it can be used by any clinician in any setting. Clinicians may reproduce it for use with their patients. Changing or translating it needs APA permission. It is not meant to be the only basis for a diagnosis. [source: APA CFI; APA DSM-5-TR Section III] Time needed: the APA forms give no figure. Field-trial clinicians found that later interviews took less time. [source: Lewis-Fernández et al. 2017] [uncertain: no minutes figure verified]
• Steps:
  1. Explain the purpose.
  2. Work through the four domains in your own conversational order, using the official form as a guide.
  3. Ask specifically about what the family calls the problem (Domain 1) and about cultural identity (Domain 2). This includes language, clan, church affiliation and urban or rural ties.
  4. Under past help-seeking (Domain 3), ask about diviners, herbalists, faith healers or prophets, clinics and hospitals.
  5. Close with Domain 4: preferences, and the relationship with you.
  6. Summarise in the client's words and check you have understood.
• Example language (illustrative): "People often describe a problem in their own way, or in the way their family or community does. How would you describe what has been happening?" Later: "Sometimes people see an inyanga or a sangoma, a church, or a clinic, or several at once. Who have you seen, and what did they say?"
• Watch for:
  • Brief or guarded answers about healers, which may signal fear of judgement. Normalise dual use (see 4.6).
  • Answers that only repeat clinic language.
  It is working when the client gives an account that includes cause, help-seeking and fears in their own terms.

4.3 CFI supplementary modules and Informant Version

• Purpose / when: To go deeper where the core CFI shows it matters. There are 12 modules, which can be used as add-ons or on their own, at intake, later, or repeatedly. The most relevant here are:
  • Explanatory Model
  • Spirituality, Religion, and Moral Traditions
  • Coping and Help-Seeking
  • Cultural Identity
  • Social Network
  • Immigrants and Refugees (for clients in the diaspora or from neighbouring countries)
  • Caregivers (given to the caregiver)
  The Informant Version (17 questions) is for a family member or friend. [source: APA CFI Supplementary Modules; APA CFI Informant Version]
• Steps:
  1. Pick the module that matches the gap. For example, use Spirituality when a calling is raised, and Social Network when family pressure about the calling is central.
  2. Get the client's consent before using the Informant Version, and agree with them what may be discussed.
  3. See the informant separately or together, as the client prefers.
  4. Compare the accounts without arbitrating between them.
• Example language (illustrative): To a relative: "Your daughter has agreed that I can hear how the family understands what is happening. What do you call it, and what do the elders say should happen next?"
• Watch for:
  • Conflict between family members' views. For example, one sees a calling, another sees madness, and a church elder rejects ancestral explanations.
  • The client deferring to the informant.
  It is working when you can map who believes what and who decides.

4.4 Eliciting the explanatory model (Kleinman)

• Purpose / when: Throughout assessment and whenever the plan stalls. Kleinman, Eisenberg and Good (1978) set out eight questions. Paraphrased: what the problem is called, its cause, why it started when it did, what it does and how it works, how severe it is and how long it will last, what treatment is needed, the chief problems it has caused, and what is feared most. [source: Tanenbaum handout; Dinos et al. 2017]
• Steps:
  1. Ask the questions in your own words, over one or more sessions.
  2. Record the client's categories verbatim. Examples: a calling from the ancestors, ufufunyana, being bewitched, "nerves", God's will. [source: Zabow 2007; Ngubane & De Gama 2024]
  3. Expect several causes at once, such as indigenous, psychosocial, physical and religious. [source: Zabow 2007]
  4. Note which treatments the client thinks fit which cause.
  5. Reflect the model back to the client.
• Example language (illustrative): "What do you think caused this? … Why do you think it began this year? … What are you most afraid it could mean, or lead to?"
• Watch for:
  • Fear of bewitchment, which psychiatric services rarely address and which may drive disengagement. [source: Zabow 2007]
  • Shame or a sense of being punished, for example believing the ancestors are angry because a calling was ignored. [source: Ngubane & De Gama 2024; Mzimkulu & Simbayi 2006]
  It is working when the client sees their own model reflected accurately and the plan can be framed to fit it.

4.5 Working with cultural concepts of distress and local idioms

• Purpose / when: When the client uses a named local illness or idiom. Regional examples:
  • Ufufunyana/amafufunyana, described as possession by evil spirits.
  • Ukuphambana, described as madness.
  • Intwaso or a calling.
  • Kufungisisa, a Shona idiom listed among DSM-5-TR cultural concepts of distress.
  [source: Zabow 2007; Ngubane & De Gama 2024; UNMC DSM-5-TR slides] DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: APA DSM-5-TR Section III] The DSM-5 glossary lists kufungisisa with the gloss "thinking too much". [source: Cummings 2015, FPR] The exact DSM-5-TR wording is [uncertain].
• Steps:
  1. Ask what the term means to this client and family. Meanings are not rigid.
  2. Ask what usually helps with it and who treats it.
  3. Do not convert it into a diagnosis. Note it alongside any DSM or ICD formulation, and use the Outline for Cultural Formulation in your report.
  4. Use the term in session if the client wishes.
• Example language (illustrative): "You said your aunt called this ufufunyana. What does that word mean in your family, and what do people usually do about it?"
• Watch for:
  • Assuming one meaning across language groups. [source: Zabow 2007]
  • A label used to blame or exclude a family member.
  It is working when the term helps rather than blocks shared planning.

4.6 Asking about healer consultation and parallel treatment without judgement

• Purpose / when: At intake and at each review. Dual use is common, and moving between treatments has been linked to poorer adherence. [source: Campbell-Hall et al. 2010]
• Steps:
  1. Normalise dual use.
  2. Ask whom they have seen: a diviner, herbalist, faith healer or prophet, family elders, a clinic.
  3. Ask what each one advised. This covers the explanation, any instruction to stop or avoid treatments, any remedies taken, and costs.
  4. Do not ask for the ritual content of any consultation.
  5. Record remedies by name only if the client gives one. Pass this to the prescriber or GP with consent. Do not comment on safety yourself.
  6. Ask how the practitioner is recognised (lineage, trainer, healer organisation, community). Registration with the Council could not yet be checked as of May 2026, because registration had not begun. [source: Parliament of South Africa, May 2026]
• Example language (illustrative): "Many people here use both a healer and the clinic. That is fine to tell me. Has anyone advised you about your tablets, or given you something to take?"
• Watch for:
  • Being told to stop prescribed treatment.
  • Herbal or slimming products taken alongside antiretrovirals. These may change drug levels, so route them to the prescriber. [source: Dheda 2017]
  • Large payments or exploitation.
  • Any claim to cure HIV or cancer, which is an offence under s49. [source: THPA s49]
  It is working when disclosure keeps going across sessions.

4.7 Distinguishing a reported ancestral calling or possession from psychotic, mood or other disorder

• Purpose / when: When the client, family or a healer describes a calling, ukuthwasa, or possession, or when perceptual experiences are reported. This is the central clinical task. Psychotic and mood-related experiences are common in people with a calling. Some apprentices still met criteria for a psychotic disorder 3 years later, but most improved. [source: van der Zeijst et al. 2022; Ngubane & De Gama 2024]
• Steps:
  1. Assess risk first: suicidality, harm to others, self-neglect, and inability to eat, drink or sleep.
  2. Rule out physical and substance causes with the GP or psychiatrist. Ngubane & De Gama (2024) record a THP's view that some presentations attributed to a calling followed stopping HIV treatment.
  3. Use the Spirituality and Explanatory Model modules to learn whether the family and recognised healers treat the experience as a calling, and whether the client wants it.
  4. Apply the manuals as written:
     • DSM-5-TR: dissociative identity disorder (DID) presentations may be described as possession, but are excluded where they are part of a broadly accepted cultural or religious practice. Dissociative trance is likewise excluded when it is a normal part of collective cultural or religious practice.
     • ICD-11: 6B62 trance disorder and 6B63 possession trance disorder both require the state to be involuntary and unwanted, not part of accepted practice, and causing significant distress or impairment.
     [source: PMC9199574; Lewis 2023; findacode ICD-11] [uncertain: exact DSM-5-TR wording]
  5. Seek a cultural broker, or, with consent, the views of the client's recognised healer (see 4.9, 4.10).
  6. Formulate plainly. Is this (a) normative within the client's community, (b) a disorder, or (c) both?
  7. Re-assess over time instead of deciding once.
• Example language (illustrative): "Your family sees this as a calling. I take that seriously. I also want to make sure nothing else is making you unwell, such as your body, sleep or medicines, because both can be true at once. Can we look at that together?"
• Watch for these markers that call for active treatment alongside any tradition pathway [synthesis]:
  • escalating risk;
  • severe loss of function;
  • a state the client experiences as unwanted;
  • disagreement among recognised healers or the family about whether this is a calling;
  • no improvement as the training proceeds.
  Be equally careful about labelling as psychosis an experience that the client and community recognise, that is wanted, and that comes without impairment. It is working when the formulation is shared and risk is managed.

4.8 Interpreters and language

• Purpose / when: Whenever the client's first language (isiZulu, isiXhosa, Sesotho, Setswana, siSwati and others) differs from yours. Concepts such as ancestral calling or ufufunyana lose meaning in translation. [source: Mzimkulu & Simbayi 2006, who interviewed healers in isiXhosa and translated the transcripts] [synthesis]
• Steps:
  1. Use a trained interpreter, not a family member, for assessment and risk.
  2. Brief the interpreter on confidentiality, and ask them to keep local terms in the original language, with a gloss.
  3. Check whether the interpreter's own religious views (for example, a church that rejects ancestral practice) may colour how they translate.
  4. Debrief after the session.
• Example language (illustrative): To the interpreter: "Please keep the client's own word for the illness, then tell me what it means, rather than translating it as 'mental illness'."
• Watch for:
  • Interpreter editorialising.
  • The client holding back with a community member present. Offer a different interpreter.
  It is working when the client's terms appear in your notes accurately.

4.9 Consulting cultural brokers

• Purpose / when: When the formulation depends on whether an experience is normative in the client's community, or when the family's and the clinic's accounts clash. [synthesis, consistent with the call for culture-centred orientation of Western practitioners, Campbell-Hall et al. 2010]
• Steps:
  1. With the client's consent, identify a broker. This could be a colleague from the same community, a community health worker, or a recognised elder.
  2. Share only what the client permits.
  3. Ask general questions, for example how people locally tell a calling from other illness, rather than asking for a verdict on the client.
  4. Bring what you learn back to the client.
• Example language (illustrative): "Without naming anyone, how would people in your community usually tell whether a young person's dreams and illness are a calling, or something the clinic should see?"
• Watch for:
  • Brokers with a stake in the outcome.
  • Treating one broker's view as representing a whole language group.
  It is working when the broker's input sharpens the questions you ask the client.

4.10 Collaboration and referral with a registered traditional health practitioner (client-led)

• Purpose / when: When the client wants their healer and their therapist to work together, or asks for a referral. Recommendations from South African research include:
  • acquainting THPs with Western approaches;
  • orienting Western practitioners toward culture-centred care;
  • district forums to negotiate "respectful collaborative relationships".
  [source: Campbell-Hall et al. 2010] The most robust trial evidence for collaboration comes from West Africa. In the COSIMPO trial in Nigeria and Ghana (Gureje et al. 2020, The Lancet), collaborative shared care between traditional and faith healers and primary care for psychosis reduced symptoms more than usual care. Harmful practices also fell. [source: COSIMPO, PubMed 32861306] Do not assume these results transfer directly to South Africa.
• Steps:
  1. Get the client's written consent naming the practitioner, the purpose and the information to be shared.
  2. Ask the client how the practitioner is recognised by the community. Registration is the statutory marker under the Act [source: THPA s1, s49], but as of May 2026 registration had not begun and there was no national register [source: Parliament of South Africa, May 2026]. Once registration opens, prefer registered practitioners for formal referral.
  3. Make first contact with respect for the practitioner's expertise. Explain your role and limits.
  4. Agree on each party's role. The healer works within the tradition. You provide therapy, risk monitoring and liaison with medical care. Agree how urgent concerns will be communicated in both directions.
  5. Do not ask the healer to change their practice, and do not take part in or attend ceremonies.
  6. Record what was agreed.
• Example language (illustrative): To the healer, with consent: "[Client] has asked me to be in touch. I work with how she is feeling and coping, and with the clinic if medicines are needed. I would value hearing how you understand her situation, as far as you are able to share, and agreeing how we keep each other informed if she becomes very unwell."
• Watch for:
  • Conflicting advice about prescribed medicines. Route this to the prescriber, and take it up with the client.
  • Confidentiality spreading through community networks.
  • Practitioners who claim to cure HIV or cancer, or who practise for gain while unregistered. These are offences under s49. [source: THPA s49]
  It is working when there is two-way contact, the client stays engaged with both, and no one is pushed to choose.

4.11 Medicines, remedies and the prescriber

• Purpose / when: Whenever remedies from an inyanga or other source are used alongside prescribed medicines. Herbal mixtures may induce or inhibit drug-metabolising enzymes and transporters, which can lower or raise antiretroviral levels. [source: Dheda 2017] Switching between systems has been linked to poorer adherence. [source: Campbell-Hall et al. 2010]
• Steps:
  1. Ask whether any remedies, teas, steaming, purging or other treatments are being used, without asking for preparation details.
  2. With consent, tell the prescriber or GP.
  3. Never advise starting, stopping or changing any medicine or remedy.
  4. Explore what taking each one means to the client, for example loyalty to ancestors or to the clinic.
• Example language (illustrative): "I am not the right person to say what to take. Your doctor needs to know everything you are using so they can keep you safe. Would you be willing for me to let them know, or would you prefer to tell them yourself?"
• Watch for:
  • Physical symptoms such as vomiting, jaundice or confusion. Seek urgent medical review.
  • Viral-load concerns.
  • Covert stopping of medication.
  It is working when the prescriber is informed and the client feels free to tell both systems.

4.12 Supporting a client before, during and after ukuthwasa (integration)

• Purpose / when: When a client has accepted a calling, is in training, or has completed it. In KwaZulu-Natal research, possible benefits of the training included reframing distressing experiences as valued, reducing stigma, and strengthening social standing and identity. [source: van der Zeijst et al. 2022; van der Zeijst et al. 2021] Training has costs and demands, for example time away from work or study, and family obligations. [synthesis]
• Steps:
  1. Let the client set the scope. Some matters may be held in confidence within the training, and you do not ask about them.
  2. Work on practical and emotional concerns: identity, family relationships, finances, work or study, relationships with church communities, doubts, and being torn between paths.
  3. Keep monitoring mental state and risk (see 4.7).
  4. After training, support integration of the new role and any shifts in identity.
  5. If the client decides not to follow the calling, explore what that means to them without steering.
• Example language (illustrative): "You don't need to tell me anything that belongs to your training. I'm interested in how you are managing, in your sleep, your mood, your family, and how you see yourself now."
• Watch for:
  • Worsening distress, unwanted experiences or functional decline during training. Re-assess (4.7).
  • Coercion into or out of training.
  • A minor being trained. The draft regulations (not yet in force) set 18 as the minimum age for divination and herbalism students. [source: Draft THP Regulations 2024; Parliament of South Africa, May 2026]
  It is working when the client describes greater coherence and lower distress, as most participants in the follow-up study reported. [source: van der Zeijst et al. 2022]

4.13 Working with families and communities

• Purpose / when: When a calling, bewitchment fears or a diagnosis divides a family, or when family members are central to decisions. Family and companions provide history that THPs use. [source: Ngubane & De Gama 2024] Healers may cleanse patient and family together, or work at the home, which shows that illness is understood as a family matter. [source: Mzimkulu & Simbayi 2006]
• Steps:
  1. With consent, hold a family meeting (CFI Informant Version or Caregivers module).
  2. Map the explanatory models within the family.
  3. Identify the decision-makers.
  4. Name the shared goal, for example the client's wellbeing.
  5. Agree what each support system will do.
  6. Watch for blame, such as accusations that someone caused the illness through witchcraft.
• Example language (illustrative): "Everyone here wants Sipho to be well, even if you see the cause differently. Can we agree on what each of you will look out for this month?"
• Watch for:
  • Accusations of witchcraft against a relative or neighbour. Assess the risk of violence.
  • Pressure on the client.
  • Caregiver burden.
  It is working when there is less conflict and a shared safety plan.

4.14 Safeguarding where a practice harms

• Purpose / when: When there is restraint, beating, starvation, sexual abuse, exploitation, delay of urgent medical care, harm to a child, a witchcraft accusation that puts someone at risk, or illegal cure claims. Chaining has been documented in West African faith settings. In the Ghana prayer-camp trial, adding psychiatric care reduced symptoms but did not significantly reduce days in chains. [source: Ofori-Atta et al., BJP] In COSIMPO, harmful practices fell with collaboration. [source: COSIMPO]
• Steps:
  1. Assess immediate danger.
  2. Separate the practice from the tradition. Harm is not culture, and culture is not harm. Consult a cultural broker so that you do not misread a legitimate practice.
  3. Follow local child and adult protection law and your professional body's code. [uncertain: not verified — the specific South African reporting provisions]
  4. Report illegal practice by unregistered persons, or cancer and HIV cure claims, to the appropriate authority. [source: THPA s49]
  5. Document facts, not judgements about the tradition.
• Example language (illustrative): "I respect that your family wants traditional help. My concern is the tying up and the missed clinic visits. Those put her at risk, and I have to act on that. Let's think together about how she can keep both kinds of help safely."
• Watch for:
  • Collusion through cultural deference.
  • Over-reporting legitimate practices.
  • Client fear of losing community support.
  It is working when the danger ends while the client keeps the pathways they value.

4.15 Addressing history, mistrust and racism in services

• Purpose / when: When mistrust of clinics, past bad experiences, or a sense of disrespect for traditional healing is present. Patients and families report negative experiences and misunderstandings with services, and healers report feeling under-appreciated. [source: Zabow 2007; Campbell-Hall et al. 2010] The legal history of suppression of traditional healing in South Africa is [uncertain: not verified].
• Steps:
  1. Ask the CFI clinician–patient relationship question directly (Q16, on matters such as perceived racism or language barriers).
  2. Acknowledge past harms without defending services.
  3. Make the respect concrete, for example in how you record the client's model.
• Example language (illustrative): "Some people have felt looked down on at clinics because of their beliefs or language. Has that happened to you, and is there anything about me or this service that makes it harder to speak freely?"
• Watch for:
  • Politeness masking mistrust.
  • Your own defensiveness.
  It is working when the client raises disagreements openly.

4.16 Cultural formulation and documentation

• Purpose / when: At the end of assessment and at reviews. DSM-5-TR Section III gives the Outline for Cultural Formulation alongside the CFI. [source: APA DSM-5-TR Section III]
• Steps:
  1. Record cultural identity, cultural concepts of distress (in the client's terms), psychosocial stressors and supports, cultural features of the relationship with you, and an overall assessment.
  2. Note where the client's model and your diagnosis agree or diverge.
  3. Record healer involvement and consent status.
  4. Avoid recording sacred or confidential detail.
• Example language (illustrative): Note: "Client and family understand the episode as an ancestral calling (ukuthwasa begun March). Client wants it, and the recognised trainer has been consulted with consent. Psychiatric review: no psychotic disorder at present. Plan: monthly review of mood, sleep and function."
• Watch for:
  • Records that read as dismissive.
  • Detail the client would not want shared.
  It is working when the client could read the note and recognise themselves.

5. Handling problems

The sources say little directly about therapy-process problems in this context. Most of the guidance below is [synthesis], with sources noted where they apply.

• Client will not discuss healers or ancestors (guardedness).
  • Normalise dual use, which is common. [source: Campbell-Hall et al. 2010]
  • Ask about family views first, then the client's own.
  • Make clear that nothing they say will be used to dismiss their beliefs.
  • Do not push. Return to the topic at review. [synthesis]
• Client asks you to say whether it is "really" a calling.
  • Decline to adjudicate a question that belongs to the tradition and its practitioners.
  • Offer what you can assess: safety, distress, function, and whether anything else is making them unwell. [synthesis]
  • Illustrative: "Whether it is a calling is not mine to decide. That belongs to you, your family and those who know that path. What I can do is help make sure you are safe and well while you find out."
• The family insists on a calling but the client does not want it, or the reverse.
  • Use the Informant Version and family work (4.3, 4.13).
  • Hold to the client's own wishes.
  • Note that ICD-11 possession trance disorder requires the state to be unwanted, so the client's wishes matter clinically. [source: ICD-11 6B63]
  • Assess coercion. [synthesis]
• Healer advice conflicts with treatment, for example stopping medicines.
  • Do not argue the tradition.
  • With consent, involve the prescriber and, where possible, the healer, to find a plan both can accept (4.10, 4.11).
  • Collaboration studies show common ground is possible, though Western-trained staff were less willing to collaborate. [source: Campbell-Hall et al. 2010; COSIMPO]
• Overwhelm or acute deterioration during ukuthwasa.
  • Treat it as you would any acute deterioration: assess risk and arrange psychiatric or medical review.
  • With consent, inform the trainer.
  • Do not frame admission or treatment as rejecting the calling. Both can proceed. [synthesis] Course data show improvement for most apprentices, but not all. [source: van der Zeijst et al. 2022]
• Non-attendance.
  • Check for practical reasons such as travel, training seclusion or ceremonies, and plan around them. Agree in advance how to resume.
  • Check whether a healer or a church has discouraged therapy. [synthesis]
• Rupture over perceived disrespect.
  • Name it, own your part, and use CFI Q16.
  • Re-centre the client's model. [source: APA CFI] [synthesis]
• Bewitchment fears drive the distress.
  • Work with the fear as the client holds it: its impact, its supports, and what the client is already doing about it.
  • Do not argue about its reality. Psychiatric services have rarely addressed this, and it is a frequent gap. [source: Zabow 2007]
  • Assess the risk to anyone being accused. [synthesis]
• Suspected fraudulent or harmful practitioner.
  • Look for these signs: unregistered practice for gain, cure claims for cancer or HIV, large or escalating fees, sexual or other abuse.
  • Use safeguarding (4.14) and the s49 provisions. [source: THPA s49]
  • The draft regulations give the Council a role in fee disputes. [source: Draft THP Regulations 2024]
• Medical certificates and work.
  • Healers registered with the Council can issue certificates that employers could no longer refuse. Earlier healer associations lacked this standing. [source: The Conversation]
  • Help the client with workplace disclosure if they ask, but do not advise on its legal effect. [synthesis]
• Your own discomfort or over-identification.
  • Use supervision with a culturally informed colleague. Watch for both romanticising and dismissing the tradition (4.1). [synthesis]
• Client from outside South Africa, or in the diaspora.
  • The Act and the Interim Council apply only in South Africa. Practitioner legitimacy elsewhere depends on local law and community recognition. [uncertain: not verified for other countries]
  • Use the Immigrants and Refugees module. [source: APA CFI Supplementary Modules]

Sources

Web sources:

• Traditional Health Practitioners Act, 2007 (Act No. 22 of 2007), s1 Definitions
• Traditional Health Practitioners Act, 2007, s2 Purpose of Act
• Traditional Health Practitioners Act, 2007, s49 Offences
• Traditional Health Practitioners Regulations, 2024 (draft), Government Gazette 50840, Notice 4986
• South Africa wants to regulate traditional healers but it's not easy (The Conversation) [uncertain: author and date not shown; the article gives the Act's year as 2014]
• van der Zeijst et al. (2022) Course of psychotic experiences and disorders among apprentice traditional health practitioners in rural South Africa: 3-year follow-up study. Frontiers in Psychiatry 13:956003
• van der Zeijst et al. (2021) Ancestral calling, traditional health practitioner training and mental illness: an ethnographic study from rural KwaZulu-Natal. Transcultural Psychiatry 58(4)
• Campbell-Hall et al. (2010) Collaboration between traditional practitioners and primary health care staff in South Africa. Transcultural Psychiatry 47(4):610–628
• Mzimkulu & Simbayi (2006) Perspectives and practices of Xhosa-speaking African traditional healers when managing psychosis. Int J Disability, Development and Education 53(4):417–431
• Zabow (2007) Traditional healers and mental health in South Africa. International Psychiatry 4(4):81–83
• Ngubane & De Gama (2024) The influence of culture on the cause, diagnosis and treatment of serious mental illness (Ufufunyana). Culture, Medicine, and Psychiatry 48(3):634–654
• Three perspectives on ukuthwasa: the view from traditional beliefs, western psychiatry and transpersonal psychology (Booi 2005, MA thesis, Rhodes University)
• Dheda (2017) Herbal slimming formulations or remedies interact with antiretroviral therapy. Southern African Journal of HIV Medicine 18(1):a742
• APA DSM-5-TR Cultural Formulation Interview
• APA DSM-5-TR Section III (culture chapter)
• APA CFI Informant Version
• APA CFI Supplementary Modules
• UNMC DSM-5-TR webinar slides (cultural concepts of distress list)
• Dissociative disorders and possession (DSM-5 wording; ICD-11 6B63), PMC9199574
• Lewis (2023) ASWB prep study guide, University of Missouri System (DSM-5-TR paraphrase)
• ICD-11 6B62 Trance disorder (third-party mirror)
• WHO: Traditional medicine in ICD-11 FAQ
• Tanenbaum handout: Explanatory Models of Illness
• Dinos et al. (2017), Cambridge Core (citation of Kleinman et al. 1978)
• Lewis-Fernández et al. (2017) CFI field trial, Br J Psychiatry 210(4):290–297
• COSIMPO, Gureje et al. (2020) The Lancet (PubMed 32861306)
• Centre for Global Mental Health, COSIMPO summary
• Ofori-Atta A, Attafuah J, Jack H, Baning F, Rosenheck R, Joining Forces Research Consortium (2018). Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. Br J Psychiatry 212:34–41. doi:10.1192/bjp.2017.12
• Health Portfolio Committee raises alarm over delays regulating traditional health practitioners (Parliament of South Africa, 28 May 2026)
• Media statement: Committee on Health seriously concerned about failure to operationalise the Traditional Health Practitioners Council (Parliament of South Africa, 26 May 2026)
• A new era for traditional healers: a step towards formalisation and regulation (Cliffe Dekker Hofmeyr, 2025), Polity
• DSM-5 on Culture: A Significant Advance (Cummings 2015), Foundation for Psychocultural Research
• WHO Traditional Medicine Strategy 2014–2023

Books and papers cited by author:

• 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.
• American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).