Gnawa lila and Hamadsha (Morocco)

1. Introduction

Version followed: for Gnawa, the community heritage as UNESCO inscribed it in 2019 (decision 14.COM 10.b.26, file 01170) and as Gnawa associations describe it. For the Hamadsha, Vincent Crapanzano's 1973 ethnography (an outsider's account) and later attributed scholarship. For the clinician's side, the DSM-5-TR Cultural Formulation Interview (CFI), with the DSM-5 (2013) Informant Version and Supplementary Modules.

What these traditions are. Gnawa (also spelled Gnaoua) and the Hamadsha are two Moroccan healing and devotional traditions. Each has its own bearers and its own sources of authority. The psychotherapist works alongside them and never performs them.

Gnawa. UNESCO describes Gnawa as musical events, performances, fraternal practices and healing rituals in which "the secular and the sacred" mix. It calls Gnawa "first and foremost a Sufi brotherhood music" with mostly religious lyrics "invoking ancestors and spirits." UNESCO traces it to groups and individuals affected by slavery and the slave trade, going back at least to the 16th century. It is now part of Morocco's culture and identity. In cities, UNESCO describes an all-night "therapeutic possession ritual" of rhythm and trance. In rural areas, it describes communal meals offered to marabout saints. Practitioners call the night ceremony a lila. [source: UNESCO 01170; Madili 2025]
Who seeks Gnawa healing. Within Gnawa understanding, spirits called jinn or mluk ("owners") can be male or female, Muslim or non-Muslim, benevolent or harmful. They are held to inhabit a person, who is then called meskoun ("inhabited"), and to cause physical illness, misfortune or mental distress. In this understanding the spirit is accepted and appeased rather than expelled. Madili reports that clients include people with physical and psychological illness. Some people sponsor a lila when they are not ill at all. Most participants are women, both Arab and Amazigh (Berber). [source: Madili 2025, pp. 112–116]
Hamadsha. The Hamadsha are Sufi brotherhoods that trace their origins to two saints of the late 17th and early 18th centuries, Sidi Ali ben Hamdush and Sidi Ahmed Dghughi. Crapanzano describes them as healers who treat "spiritual and psychogenic ailments" through pilgrimages and trance dances. Their rituals are also known for "acts of self-mutilation." The brotherhoods take patients in as members, which gives them "new roles and a symbolic framework" for their distress. [source: UC Press, The Hamadsha] Sidi Ali ben Hamdush died in the early 18th century (1719 or 1722–23 by different accounts); his tomb is in the village of Sidi Ali in the Zerhoun area, about 34 km from Meknes, and Sidi Ahmed's is in the village of Beni Ouarad. [source: TDV İslâm Ansiklopedisi, "Hamâdişe"] Possession is often attributed to Aisha Qandisha; some adherents regard her as a jinn and others reject that view. [source: Wikipedia, Hamadsha (tertiary)] [uncertain: the Aisha Qandisha details are secondary, unverified]
How the traditions meet. Musical groups of several brotherhoods, including the Gnawa, Hamadsha and ʿīsāwa, take part in the annual pilgrimage to Sidi Ali. Witulski's ethnography shows that music and spirits pass between the Gnawa and Hamadsha, between outdoor processions and indoor healing ceremonies, shaped by audience requests, clients' needs and what the spirits are held to want. [source: Witulski 2016 abstract] The Hamadsha's annual gathering (mawsim) at the saints' tombs takes place about a week after the night of the Prophet's birthday (mawlid). [source: TDV İslâm Ansiklopedisi, "Hamâdişe"]

How change happens in the clinician's work. In these traditions, healing is understood as restoring a right relationship with spirits, saints and baraka (blessing), and as giving the afflicted person a new place in a community. Both points are attributed to the traditions and their ethnographers. They are not stated here as fact, and they are not dismissed. The psychotherapist's change model is different. Distress becomes workable when it is understood in the client's own terms (the explanatory model). Care should respect the help the client chooses, guard against harm, and tell culturally normative experience apart from illness. This is a clinical framework for working alongside the traditions, not a therapy in its own right. [source: APA CFI; synthesis]

2. Framework

This framework is a structure for the clinician's own culturally responsive work. Neither tradition sets out phases for psychotherapists. [synthesis]

Phase	Goal	Typical format	Move on when
A. Preparation and self-examination	Know your own assumptions about spirits, Islam, Africa, Morocco and possession. Arrange an interpreter (Darija, Tamazight, French) if needed.	Before contact; supervision	You can name your own biases and you have a plan for language
B. Cultural assessment	Hear the problem in the client's terms	Core CFI (16 questions), usually within the first 1–2 sessions; Informant Version with family; modules as needed	You can state the client's name for the problem, its cause, the help already sought and the client's preferences
C. Differential and risk	Tell a culturally normative experience (e.g. possession within lila or Hamadsha practice) apart from a disorder needing other care; screen for safety	1–2 sessions; consult a cultural broker; medical and psychiatric referral where indicated	You have a working formulation, and urgent medical or psychiatric needs are routed
D. Shared plan	Agree how therapy fits with the help the client chooses (family, brotherhood, mqaddema or maâlem, fqih, shrine, psychiatry)	1 session, revisited	The client has consented to any contact between helpers, and confidentiality limits are clear
E. Ongoing therapy and integration	Treat the agreed problems; help the client make sense of ceremonial experiences in their own frame	Weekly or fortnightly; length set by the presenting problem	Goals are met, or the client chooses to rely on community care
F. Review	Check the plan, risk and the relationship	Every 6–8 sessions, and after any lila, pilgrimage or crisis	Continue, adjust or end

The CFI can be given at the first evaluation, later in care, or repeatedly. The modules can be used as add-ons or on their own. The APA gives no administration time. A figure of about 15–20 minutes for the core CFI is often quoted [uncertain: not verified]. [source: APA CFI; APA Supplementary Modules; Lewis-Fernández et al. 2017]

3. Guiding principles

Work alongside, not inside. You do not organise, recommend or join a lila or Hamadsha ritual as part of therapy. Your work is assessment, therapy, coordination and safeguarding. [synthesis]
Authority rests with the community. Within Gnawa, women organise the ceremony and hold the main ritual authority: the mqaddema, guardian of the house (dar), hires the musicians. The maâlem (master musician) leads the music, and diviners and mediums hold specialist roles. In the Hamadsha, the saints' descendants care for the tombs and a muqaddim is the chief caretaker. At heritage level, associations such as Yerma Gnaoua (founded 2009) and the Ministry of Culture speak for Gnawa. [source: Madili 2025, pp. 114–117; Wikipedia, Hamadsha; Yerma Gnaoua] UNESCO's Committee records that Gnawa knowledge passes mainly informally within families and close circles, that the Yerma-Gnaoua Association initiated the nomination in 2013, and it encouraged Morocco to recognise women's active role in the practice. [source: UNESCO Decision 14.COM 10.B.26] In practice: ask the client whose authority they recognise; do not decide it for them.
Attribute, do not adjudicate. Describe jinn, mluk, Aisha Qandisha and baraka as the client and tradition hold them. In practice: say "in your understanding" or "as your family sees it," never "the spirit" as fact or "the so-called spirit." [source: CFI intent; synthesis]
Normative experience is not illness. DSM-5-TR and ICD-11 exclude trance or possession that is part of a broadly accepted collective cultural or religious practice. In practice: a person who goes into trance within a lila and returns to everyday functioning is not, on that basis, disordered. [source: Lewis 2023 (DSM-5-TR paraphrase); PMC9199574 review; ICD-11 6B62 and 6B63]
Missing illness is also a harm. Psychosis, mania, epilepsy, delirium, depression and substance problems can present in a spirit idiom. In practice: assess fully even when the client's frame is spiritual. [synthesis]
Use the CFI as an aid, not a verdict. The CFI supports understanding and decisions and is not meant to be the only basis for a diagnosis. [source: APA CFI]
The client chooses their pathways. Patients in Morocco often use healers and psychiatrists side by side. In practice: plan for both pathways rather than asking the client to choose between them. [source: Stein 2000]
Consent governs every contact. Speak to a mqaddema, maâlem, muqaddim, fqih or family member only with the client's specific consent. [synthesis]
Respect heritage and history. Gnawa grew out of the experience of enslaved sub-Saharan Africans. Racism and the stigma of madness can attach to both the person and the practice. In practice: ask how these affect the client. [source: UNESCO 01170; Madili 2025; synthesis]
No ritual instruction. Do not describe, teach, prescribe or evaluate songs, colours, offerings, incense, sacrifices or divination. Do not suggest that clients seek ceremonies through festivals, tourism or other paths outside the community. [synthesis]
Never advise on medicines or remedies. Send questions about medication, herbs or fumigations to the prescriber or doctor. [synthesis]
Safety overrides deference. Restraint, confinement, beating, self-injury, sexual exploitation, harm to children or delay of urgent medical care trigger your normal safeguarding duties. [source: Stein 2000; TelQuel 2015; synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is Gnawa or Hamadsha healing. [source: per item]

4.1 Cultural humility and self-examination

Purpose: to stop your own assumptions shaping the assessment. These might be that possession is always pathology, that Gnawa is only festival music, or that Moroccan clients are all alike. Do this before the first session and again whenever you feel strong reactions. [synthesis]
Steps:
1. Write down what you believe about jinn, saints, trance, Sufism and Moroccan healers, and where those beliefs came from.
2. Note any exposure you have had to Gnawa through festivals or recordings. UNESCO and Witulski both describe Gnawa as present in both festival and healing settings. Do not assume that a performance you have seen tells you what a healing lila means to a client. [source: UNESCO 01170; Witulski 2012]
3. Bring these reactions to supervision, especially fascination, disdain or a wish to take part.
4. Consider your position: your nationality, religion, gender and how far you resemble the colonial or psychiatric institutions the client may associate with you.
Example language (illustrative): "I know a little about Gnawa from the outside, but I don't know what it means in your family. I'd like to learn that from you."
Watch for: romanticising the tradition, asking for ritual details out of curiosity, treating the client as a cultural informant, or the opposite: quickly dismissing the client's frame as superstition. It is working when the client corrects you freely and your formulation uses their words.

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

Purpose: to clarify the problem from the point of view of the client and their social network: what it means to them, where they might find help, and what they expect from services. Use it with every client whose problem is framed in terms of spirits, magic, the evil eye or saints, and with any Moroccan client where the cultural meaning is unclear. [source: APA CFI]
Steps:
1. Introduce it as a way to understand the problem in the client's own terms. Say there are no right answers.
2. Cover the four APA domains in order, paraphrasing the questions in your own words:
  - cultural definition of the problem (Q1–3)
  - perceived causes, stressors and supports, and the role of cultural identity (Q4–10)
  - self-coping, past help seeking and barriers (Q11–13)
  - current preferences and the clinician–patient relationship, including any concerns about racism or language (Q14–16)
3. Under past help seeking, ask by name about each type of helper. This might include family, a fqih or imam, a mqaddema or maâlem, a Hamadsha group, a shrine visit, Quranic healing (ruqya), a doctor and a psychiatrist. Do not ask what was done in the ceremony.
4. Record answers in the client's words, including Darija terms (e.g. meskoun, jnun, s'hur for sorcery).
5. Summarise back to the client and correct as needed.
6. The APA allows clinicians to reproduce the CFI for use with their patients. You need APA permission to modify or translate it.
Example language (illustrative): "Sometimes people describe problems in their own words to family or community. How would you describe what is happening to you?" / "Have you or your family looked for help anywhere else, for example with a fqih, at a shrine, with Gnawa or a brotherhood, or with a doctor? What was helpful and what wasn't?"
Watch for: answers that sound guarded, which may mean the client expects ridicule. Repeat that you will not judge. Notice discrepancies between the client's and the family's accounts. It is working when the client gives their own name for the problem and their own preferences for help. [source: APA CFI; Stein 2000; synthesis]

4.3 CFI Informant Version

Purpose: to hear the family's account, with the client's consent. In Morocco, families often take decisions about lila sponsorship, shrine stays and psychiatric admission. [source: APA Informant Version; TelQuel 2015; synthesis]
Steps:
1. Get the client's consent and agree what can and cannot be shared.
2. Use the 17-item structure: first the informant's relationship to the client, then the same four domains.
3. Ask the family who they think holds authority over the problem: a mqaddema, maâlem, muqaddim, imam, fqih or doctor.
Example language (illustrative): "Your daughter has agreed that I can hear your view. What do you think is happening to her, and what has the family tried?"
Watch for: a family explanation used to override what the client wants, for example pressing for a ceremony or a residential stay. Watch also for signs of coercion. It is working when you can describe the family's model and the client's model side by side.

4.4 Supplementary modules (select as needed)

Purpose: to go deeper where the core CFI shows a need. The APA lists 12 modules. Those most relevant here are: Explanatory Model; Spirituality, Religion and Moral Traditions; Coping and Help-Seeking; Cultural Identity; Social Network; Patient–Clinician Relationship; Immigrants and Refugees (for diaspora clients); School-Age Children and Adolescents; Caregivers. [source: APA Supplementary Modules]
Steps:
1. Choose a module from the core CFI subtopic that raised questions. The core form shows which module expands each subtopic.
2. Give it then, or schedule it for the next session. Repeat it later in care if the picture changes, for example after a lila or a pilgrimage.
3. In the spirituality module, explore what Islam, Sufism, saints and baraka mean to the client, and whether the client belongs to a brotherhood or is attached to a Gnawa house. Do not ask for the content of rites.
4. In the cultural identity module, explore Gnawa descent, Black Moroccan identity, being Amazigh or Arab, migration, and any experience of racism.
Example language (illustrative): "You mentioned the Hamadsha helped your uncle. Is that brotherhood part of your own religious life, or more your family's?"
Watch for: module fatigue, so keep sessions short. Watch also for questions that feel like an inquiry into whether the client is a good enough Muslim. It is working when the modules yield information that changes the plan.

4.5 Explanatory-model questions (Kleinman)

Purpose: to make the client's model of illness explicit and to negotiate a shared plan. Use these questions alongside the CFI or on their own for a brief check-in. [source: Kleinman, Eisenberg & Good 1978, via Tanenbaum handout]
Steps: ask, in your own words, about eight things: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and whether it will last a short or long time; what treatment the client should receive; the main problems it has caused; and what the client fears most about it. Then set your clinical model beside theirs and look for common ground (e.g. both agree sleep and fear must improve).
Example language (illustrative): "In your understanding, why did this start after your wedding and not before?" / "What do you fear most could happen if this isn't dealt with?"
Watch for: the fear question often brings out concerns about madness, marriage prospects, sorcery by a relative, or a spirit's demands. Note these for risk and family work. It is working when the client agrees that your plan addresses what matters to them.

4.6 Mapping the care landscape without judgement

Purpose: to understand every source of help the client uses so that they do not have to hide any of them. Stein reports that Moroccan patients often see both traditional healers and psychiatrists. In one case, a patient's fqih helped him stay on his medication. [source: Stein 2000]
Steps:
1. Draw a simple map with the client of everyone involved: family, brotherhood or Gnawa house, mqaddema, maâlem, fqih or raqi, shrine, GP, psychiatrist, and you.
2. For each helper, ask what they said is wrong, what they advised, the cost, and how the client felt.
3. Ask whether any helper has told the client to stop medical treatment or to avoid therapy.
4. Agree which helpers you may know about and which you may contact (see 4.10).
Example language (illustrative): "Many people I see use more than one kind of help. You don't need to choose between them here. Who else is helping you at the moment?"
Watch for: cost and indebtedness. Madili notes rising musicians' fees. Watch also for helpers who give conflicting instructions, and for hidden residential stays. It is working when the client tells you about a new helper without being asked. [source: Madili 2025, p. 117; synthesis]

4.7 Using idioms and cultural concepts of distress

Purpose: to name distress in terms the client recognises, and to use DSM-5-TR's cultural concepts framework (idioms, explanations or perceived causes, and syndromes) correctly. [source: APA DSM-5-TR Section III]
Steps:
1. Identify whether the client's term is an idiom of distress, a cause (e.g. jinn, sorcery, evil eye), or a named syndrome.
2. Note that DSM-5-TR's glossary does not list a Gnawa- or Hamadsha-specific concept. The closest DSM entries are the possession forms of dissociative disorders (4.8). The exact list of DSM-5-TR glossary entries is [uncertain: not verified].
3. Use the client's term in the session and in your notes ("distress the client attributes to mluk"), alongside any diagnosis.
Example language (illustrative): "When you say you are meskoun, what does that feel like day to day, in your body, your sleep, your mood?"
Watch for: turning the idiom into a diagnosis ("possession = DID"). Treat it as the client's explanation and assess symptoms separately. It is working when the client uses both their own term and descriptions of symptoms with you. [source: Madili 2025, p. 112; synthesis]

4.8 Distinguishing normative possession and trance from disorder

Purpose: to avoid two errors. One is pathologising trance or possession that is part of a lila or Hamadsha practice. The other is missing a psychotic, dissociative, neurological or medical illness. [source: ICD-11; DSM-5 and DSM-5-TR as noted]
Steps:
1. Context. Did the experience happen within a recognised collective practice that the client and their community accept? Both DSM-5-TR dissociative trance and the DSM-5 dissociative identity disorder (DID) criteria exclude experiences that are a normal part of a broadly accepted cultural or religious practice. 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 recurrent episodes, or one lasting several days, and significant distress or impairment. [source: PMC9199574; Lewis 2023; findacode ICD-11 mirror]
2. Control and wish. Does the state come only in the ceremony, or does it intrude at work, at home or at night? Is it wanted or feared?
3. Function between episodes. Look at work, family, self-care and sleep.
4. Other symptoms. Screen for features outside the tradition's expectations: persistent hallucinations, fixed beliefs that family and community members themselves see as unusual, disorganisation, mania, depression with suicidality, cognitive decline, seizures, and substance use.
5. Medical screen. Refer for medical review where there is first-onset disturbance, confusion, possible seizures, head injury or a physical cause.
6. Cultural broker. Ask a culturally knowledgeable colleague or community member, with consent, whether the presentation is typical of the tradition.
7. Diagnosis. Use DID (possession form), other specified dissociative disorder (dissociative trance), or ICD-11 6B62 or 6B63 only when the criteria are met, never for the practice itself. A DSM-5-TR note that culturally sanctioned beliefs should not count as psychotic symptoms is often cited [uncertain: not verified].
Example language (illustrative): "When this happens during a lila, how is it for you afterwards? And does it ever happen when there's no ceremony, at home or at work?" / "Does your family see what's happening now as the same thing, or as something different?"
Watch for: the family or community themselves saying "this is different" or "this is not the jinn", which is a strong sign of illness. Watch also for escalating episodes, loss of function, and risk to self or others. It is working when your formulation would make sense both to a psychiatrist and to someone who knows the tradition. [synthesis]

4.9 Interpreters and cultural brokers

Purpose: to make sure language is not a barrier, and to get informed context without making the client your informant. [source: APA CFI Q16; synthesis]
Steps:
1. Offer an interpreter in the client's language (Darija, Tamazight varieties, French). Check that the client accepts this particular interpreter, given the risks to confidentiality in small communities.
2. Brief the interpreter to translate spirit terms literally and not to soften or correct them.
3. For cultural consultation, use a colleague with relevant knowledge or a community member the client approves. Share only what the client has consented to share.
Example language (illustrative): "Would you be comfortable with an interpreter? If you know the person, we can choose someone else."
Watch for: an interpreter who is embarrassed by or disapproves of Gnawa or Hamadsha belief, or who comes from the client's network. It is working when the client speaks at length and uses their own idioms.

4.10 Collaboration and referral with community-sanctioned figures (client's choice)

Purpose: to coordinate with the figures the client recognises when the client wishes it. This might be a mqaddema, maâlem or muqaddim, or a religious figure such as an imam or fqih.
Evidence: collaborative care between traditional or faith healers and primary health care for psychosis (COSIMPO trial, Nigeria and Ghana) reduced symptoms more than usual care, and harmful practices fell in both arms. A trial in a Ghanaian prayer camp found that adding psychiatric medication reduced symptoms but did not significantly reduce days in chains. No formal Moroccan programme linking Gnawa or Hamadsha practitioners with mental health services is documented in the sources cited here [uncertain: not verified]. [source: COSIMPO via PubMed 32861306; Ofori-Atta et al.]
Steps:
1. Ask whether the client wants any contact, with whom, and for what purpose, for example "so they know I am also seeing a psychiatrist."
2. Get specific written consent covering what will be shared.
3. Make contact respectfully, as a colleague in the client's care rather than an evaluator. Do not ask about rites.
4. Agree only on shared, practical points: safety, continuing medical treatment, no restraint, and when to call each other or emergency services.
5. Record the agreement and review it with the client.
6. Never refer a client to a ceremony or a healer yourself. If the client asks where to go, help them think about trusted people in their own family and community.
Example language (illustrative): "If it would help, and only if you want, I could speak with the mqaddema your family trusts, just to agree how we can both support you safely. What would you want me to say, and not say?"
Watch for: pressure from either side to drop the other kind of care, a demand for money linked to referral, or you being drawn into endorsing a healer. It is working when the client experiences their helpers as cooperating, not competing. [synthesis]

4.11 Integrating ceremonial and pilgrimage experiences

Purpose: to help the client make sense of a lila, a Hamadsha gathering or a visit to Sidi Ali in their own frame, and link it to their therapy goals. [synthesis]
Steps:
1. Ask about the client's experience and meaning, not about procedure: what changed, what they felt, what the community's response meant to them.
2. Note any new role or obligations. Crapanzano describes the Hamadsha incorporating patients into the brotherhood with "new roles." Madili describes an initiatory illness followed by a calling for some Gnawa roles. [source: UC Press, The Hamadsha; Madili 2025, pp. 116–117]
3. Explore what helped (belonging, release, recognition) and anything distressing (fear, exhaustion, shame, injury).
4. Connect what helped to everyday coping: support, rest and meaning.
Example language (illustrative): "You said you felt lighter after the lila. What do you think made the difference, and how can we keep some of that going in your week?"
Watch for: a temporary lift followed by relapse, distress about a spirit's demands, or a sense of being trapped by new obligations. It is working when the client can hold both their own meaning and their therapy goals.

4.12 Medical and medication interface

Purpose: to keep medical care safe while respecting the client's beliefs. [synthesis]
Steps:
1. Ask whether any helper has advised fumigations, ingested remedies, amulets, fasting or stopping medication. Note the answers, without evaluating remedies.
2. Route all questions about medicines, remedies and their interactions to the prescriber or doctor. Do not advise starting, stopping or changing anything yourself.
3. If the client has an injury, possible infection, or a physical problem attributed to spirits, encourage prompt medical review.
Example language (illustrative): "That's a question your doctor needs to answer. Shall we write it down so you can ask them this week?"
Watch for: stopping medication after a ceremony, and wounds or burns that have not been seen by a doctor. It is working when the client tells both you and the prescriber about traditional care.

4.13 Safeguarding

Purpose: to respond to harm whatever its cultural frame. [source: Stein 2000; TelQuel 2015; synthesis]
Context: in June 2015 Morocco's Ministry of Health ran the "Karama" (dignity) operation to evacuate people held around the Bouya Omar shrine. Of 822 people, 795 were moved to hospitals and 27 were taken home by their families. Bouya Omar is a saint's shrine, not a Gnawa or Hamadsha site, but it shows the risks of confinement in a care setting. Stein reports that some fqihs include beating among their methods. Crapanzano's publisher notes that Hamadsha rituals are known for self-mutilation. [source: TelQuel 2015; Stein 2000; UC Press, The Hamadsha]
Steps:
1. Ask directly about restraint, chaining, locked confinement, beating, food or sleep deprivation, sexual contact, threats, exploitative fees, and injuries.
2. Assess self-injury in any context, including injury during trance, as you would any self-harm: medical care, risk assessment, and the client's own meaning.
3. For children and dependent adults, follow local child-protection and adult-safeguarding procedures. Never name minors in any shared record outside protected systems.
4. Discuss with a supervisor, and report as your jurisdiction requires.
5. Separate the practice from harm. A lila is not in itself a safeguarding concern. Coercion, injury or exploitation are.
Example language (illustrative): "I ask everyone who has received help elsewhere: were you ever held, tied, hit or kept somewhere against your will? Were you ever asked for money you felt you couldn't refuse?"
Watch for: fear of reprisal from family or helpers, and minimising ("it was for my own good"). Watch also for your own hesitation to act out of cultural deference. It is working when the client is safe and still feels respected.

4.14 Working with families and communities

Purpose: in a lila, a Gnawa client may host family and neighbours, and a Hamadsha client may be absorbed into a brotherhood. Family and community are part of the care system, so work with them. [source: Madili 2025, p. 116; UC Press, The Hamadsha]
Steps:
1. With the client's consent, hold a family meeting using the Informant Version themes (4.3).
2. Map the family's decisions: who pays, who decides on a ceremony, a shrine or a hospital.
3. Negotiate shared goals, such as sleep, safety, returning to work or study, and continuing medication.
4. Address stigma, for example the client being labelled mahboul (mad) or worries about marriage [synthesis].
Example language (illustrative): "Everyone here wants Samira to be well. Can we agree on two or three signs that would tell us she is getting better, whatever help she uses?"
Watch for: the family overruling the client, blame between family members (for example sorcery accusations against a relative), and pressure on the therapist to take sides. It is working when the family supports the agreed plan.

4.15 Heritage, slavery history and racism

Purpose: to respect that Gnawa grew out of the experience of enslaved sub-Saharan Africans, and to recognise racism and marginalisation in Morocco and in the diaspora. Madili links some features of the lila to the historical relationship between slave and owner. [source: UNESCO 01170; Madili 2025, p. 115]
Steps:
1. Using the cultural identity module, ask how the client relates to Gnawa or Black Moroccan heritage.
2. Explore experiences of racism, including in health services, and how they affect trust in you.
3. Validate any pride in the heritage now recognised by UNESCO, as well as any pain about how it is treated.
Example language (illustrative): "Some people tell me the Gnawa tradition carries a lot of history for their family. What does it carry for you?"
Watch for: the client feeling exoticised, for example by being asked about the festival. It is working when the client brings identity themes up on their own.

4.16 Gender and women's ritual authority

Purpose: to understand that in Gnawa healing, women hold the main ritual authority (the mqaddema and female diviners and mediums) and that most participants are women. Madili quotes a maâlem saying that "Gnawa was made for women only." The lila may be a space where everyday gender norms are relaxed. [source: Madili 2025, pp. 114–117]
Steps:
1. Ask what the Gnawa house or the lila means to the client as a woman, or as a man in the brotherhood.
2. Explore conflicts with spouses or relatives about taking part, and about its cost.
3. Recognise that a calling to a ritual role is, in the tradition's terms, a vocation and not a symptom. Assess any distress about it separately.
Example language (illustrative): "What does it mean to you to be part of that house? Has it changed anything at home?"
Watch for: domestic control or violence linked to the client's participation, and economic strain. It is working when the client can talk openly about gender and family pressures.

4.17 Clients who met the traditions through festivals or tourism

Purpose: to help clients who have no community connection but have attended a lila or Gnawa event in a tourist or festival setting, or who want a 'healing trance' experience. Gnawa appears both in festivals, such as the Essaouira Gnaoua and World Music Festival, and in healing settings. [source: Yerma Gnaoua; Witulski 2012]
Steps:
1. Explore what the client hoped for and what happened.
2. Assess any after-effects: anxiety, dissociation, or distress about a perceived spirit.
3. Do not encourage the client to seek ceremonies outside legitimate community pathways. Point out that ritual authority rests with the community's own bearers.
4. Offer your usual evidence-based care for any symptoms.
Example language (illustrative): "It sounds as if that night stirred something up for you. Let's look at what's happening now, and at what kind of support would actually help."
Watch for: spiritual seeking used to avoid other problems, and re-traumatisation. It is working when the client's symptoms ease and they hold a respectful view of the tradition.

5. Handling problems

The sources do not discuss psychotherapy problems with Gnawa or Hamadsha clients. All the guidance below is [synthesis] unless a source is given.

Client withholds traditional care for fear of ridicule. Normalise using more than one kind of help: Stein reports that this is common in Morocco [source: Stein 2000]. Ask again later in the CFI. Never react with surprise or disapproval. (illustrative) "Lots of people use both. Knowing helps me not to work against what's helping you."
Stuck: "Only the spirits can fix this. Why talk?" Do not argue about the cause. Agree on goals the client values in their own model (sleep, family peace, being able to work) and offer talking as a support for those goals. Revisit the explanatory-model questions about severity and fear.
Resistance to the psychiatric referral you think is needed. Explain your concern in terms of function and safety, not cause. Offer to coordinate with the figures the client trusts (4.10). If risk is high, follow emergency procedures whatever the explanation.
Overwhelm after a lila or a pilgrimage. Use grounding and stabilisation. Check sleep, eating and medical issues. Assess for dissociative or psychotic features (4.8). Do not interpret the experience for the client; ask what it meant to them.
Non-adherence to medication after a ceremony. Do not advise on the medication. Explore the client's reasons, inform the prescriber with consent, and if the client agrees, ask a trusted helper to support continuing treatment (one patient's fqih did this [source: Stein 2000]).
Rupture: the client feels you insulted the tradition. Acknowledge it and apologise specifically. Ask what would repair trust. Review your own reaction in supervision. Use the Patient–Clinician Relationship module [source: APA Supplementary Modules].
Rupture: the family sees you as against the healer. Hold a family meeting, restate respect for their choices, and set out the safety limits clearly.
Client asks you to attend, sponsor or arrange a lila or Hamadsha ritual. Decline warmly. Explain that ritual authority belongs to the community's bearers (mqaddema, maâlem, muqaddim), and keep the focus on your role.
Client asks your opinion on whether the spirit is real. Reflect it back: what matters is the client's understanding and what helps. Do not assert or deny the existence of spirits.
Client distressed by a calling or obligation. In the tradition's terms, initiatory illness and calling can lead to a ritual role [source: Madili 2025, pp. 116–117]. Explore the client's ambivalence, cost and family position without pathologising the vocation. Still assess depression or anxiety on their own terms.
Spirit or sorcery accusations against a family member. Assess the risk of conflict or violence. Work on family communication. Safeguard any child accused or at risk.
Self-injury linked to trance. Treat it as self-harm for medical and risk purposes, while respecting that the client may give it ritual meaning. Ensure wound care. Do not discuss or evaluate the practice itself [source: UC Press, The Hamadsha (self-mutilation noted)].
Financial exploitation. Explore costs openly (Madili notes rising musicians' fees [source: Madili 2025, p. 117]). Support the client's own decisions, and act where there is coercion.
Confinement or restraint disclosed. Follow safeguarding procedures (4.13). The 2015 Bouya Omar evacuation shows that such settings exist in Morocco [source: TelQuel 2015].
Diaspora client cut off from community authority. Explore what legitimate community connection means for them (family, local mosque, Moroccan associations) and do not substitute yourself or online sources. Use the Immigrants and Refugees module.
Clinician over-identification or fascination. Bring it to supervision. Keep session time on the client's goals, not on the tradition.

Sources

Web sources:

Books and articles cited:

Crapanzano, V. (1973). The Ḥamadsha: A Study in Moroccan Ethnopsychiatry. University of California Press.
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.

UNESCO nomination form (file 01170): not drawn on; Gnawa details above follow the UNESCO element page and the Committee decision text.

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