Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 070
Guide XI-070

Zar (Horn of Africa, Egypt)

Ethiopia and Sudan
A 34 · L 54 · M 1215 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: zar as its practitioners describe it in public (the Mazaher ensemble and Makan centre, Cairo), with ethnography and clinical literature as attributed outsider context (Boddy on northern Sudan; the Mianji and Semnani review covering Sudan, Ethiopia, Egypt and Iran; Israeli clinical studies of Ethiopian immigrants). The therapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI), with ICD-11 for trance and possession codes.

What zar is. Zar (zār) is a spirit-possession tradition of north-east Africa and nearby regions. Scholars use the word for three things: a class of spirits, the affliction those spirits are held to cause, and the rites that settle relations with them [source: Mianji and Semnani 2015]. Practitioners and reports place its roots in Ethiopia and Sudan, with variants in Egypt, North Africa, the Arabian Peninsula and the Persian Gulf coast of Iran [source: Al-Monitor 2022; Mianji and Semnani 2015]. In Ethiopia it is reported among Amhara Christians and among Ethiopian Jews, including those now in Israel. In northern Sudan Boddy studied it in the village she called Hofriyat. In Egypt it is described among Nubians and in Cairo [source: Mianji and Semnani 2015].

How change happens, as the tradition holds it. Within the tradition, a zar spirit that has afflicted a person is usually not expelled for good. The relationship is settled and maintained, often with yearly obligations, and the spirit, not the person, is held responsible for behaviour shown in possession [source: Mianji and Semnani 2015]. Some Egyptian practitioners reject the label "exorcism". The Mazaher lead singer Madiha describes the aim as inner harmony and stress relief [source: Pan African Music 2022]. Mazaher's founder calls zar "a very old healing ritual" [source: Al-Monitor 2022].

Scholarly readings (outsiders' accounts, attributed). I. M. Lewis read zar as a way for women to cope with a subordinate social position. Boddy linked spirits' interest in married women to fertility. Kennedy described Nubian zar as a form of psychotherapy that relieved lasting tension [source: Mianji and Semnani 2015, summarising these authors]. These are interpretations, not the community's own account.

The therapist's place. A psychotherapist does not perform zar or any part of it. Authority belongs to the tradition's own leaders, and to the client's family and religious community. Your work is culturally responsive assessment, formulation and therapy alongside the tradition. This means understanding what zar means to this client, telling culturally normative possession apart from illness, and coordinating with people the client trusts when the client wants that [synthesis].

Diagnostic status. DSM-IV-TR listed zar in its glossary of culture-bound syndromes. Mianji and Semnani report that zar is not among the DSM-5 examples of cultural concepts of distress [source: Mianji and Semnani 2015]. This fits the nine-entry DSM-5 glossary [source: Teodoro and Afonso 2020]. The DSM-5-TR examples given in secondary sources do not include zar. Whether DSM-5-TR names zar anywhere in its text is [uncertain: not verified]. No UNESCO Intangible Cultural Heritage inscription for zar was identified. Sudan's 2025 inscription, Al-Jertiq, is a different Nubian ritual of protection and fertility [source: UNESCO decision 20.COM 7.B.41]. Whether zar is on any UNESCO list or national inventory is [uncertain: not verified].

2. Framework

Zar has no therapy protocol, so this framework describes the psychotherapist's work with a client for whom zar is relevant. The phases are [synthesis] built on the CFI's structure [source: APA CFI].

Who holds authority in the tradition.

  • Ceremony leaders. In Sudan and Egypt they are called shaykh (male) or shaykha (female). On Iran's Gulf coast they are bābā zār or māmā zār. Many leaders are reported to have been possessed themselves and to have learned to manage their spirits [source: Mianji and Semnani 2015].
  • In Egypt, the ensemble's senior women singers. Umm Sameh learned from her mother and grandmother from age 11 [source: Al-Monitor 2022].
  • Musicians.
  • Beyond the zar group, the client's own religious authorities: Ethiopian Orthodox clergy, imams, rabbis. Some of them oppose zar, and some offer their own healing, such as Orthodox holy-water sites [source: Al-Monitor 2022; BJPsych Open 2021 holy water study].
  • No licensing body, council or official register for zar practitioners was identified [uncertain: not verified].

Context that shapes referral.

  • In Egypt, Mazaher's founder describes the group as the last one performing zar in public [source: Al-Monitor 2022].
  • Devout Muslims have long condemned zar as pagan or blasphemous, and modernisers have called it backward [source: Al-Monitor 2022; Pan African Music 2022].
  • Clients may therefore hide involvement from you, their family or their mosque or church [synthesis].

Phase A. Engagement and cultural assessment (sessions 1–3).

  • Goals:
    • Build safety.
    • Use an interpreter where needed.
    • Run the core CFI, plus the modules the client's answers point to.
    • Elicit the client's explanatory model.
    • Ask about zar and other help-seeking without judgement.
    • Take a full medical and psychiatric history.
  • Format: individual sessions of 50–90 minutes. Add an informant interview with family if the client agrees.
  • Move on when you can state the client's own name and cause for the problem, their goals, what help they have sought, and an initial risk picture [synthesis].

Phase B. Differential formulation (sessions 2–4, overlapping with A).

  • Goals:
    • Distinguish culturally normative zar possession from DSM dissociative identity disorder, other specified dissociative disorder (dissociative trance), ICD-11 6B62 trance disorder and 6B63 possession trance disorder, psychosis, conversion symptoms, depression, anxiety and medical illness.
    • Arrange medical review.
    • Consult a cultural broker or community member where the client consents.
  • Move on when a working formulation, written using the Outline for Cultural Formulation, has been shared with the client and the client broadly accepts it [synthesis].

Phase C. Treatment alongside the tradition (typically 8–20 sessions, open-ended where distress is chronic) [synthesis].

  • Goals:
    • Treat any co-occurring disorder with standard evidence-based methods, adapted to the explanatory model.
    • Work on the stressors the client links with affliction: marriage, fertility, migration, isolation.
    • Coordinate with family.
    • Coordinate with a zar leader or religious healer when the client wants this and it is safe.
    • Help the client integrate their experiences.
  • Move on when goals agreed in the client's own terms are met, and no safeguarding concern is open.

Phase D. Consolidation and ending.

  • Plan for relapse and for the yearly obligations the tradition may expect [source: Mianji and Semnani 2015, on yearly appeasement].
  • Agree how the client would recognise a return of distress, and plan re-contact.

Throughout. Screen for risk at every phase. The Nubian presentations described include "a strong wish to die" [source: Mianji and Semnani 2015]. Revisit the CFI modules as care proceeds. APA allows modules at intake, later, or repeatedly [source: APA CFI Supplementary Modules].

3. Guiding principles

  • Describe, do not decide, the spiritual reality. Speak of zar spirits as the client and their tradition hold them, neither confirming nor dismissing them. Practically: "In your understanding…", never "There is no such thing" or "The spirit wants…". [synthesis]
  • The therapist is alongside, never a practitioner. Practically: do not take part in, imitate, recommend, schedule or attend ceremonies as a clinician, and do not give advice on how a ceremony should be done. [synthesis]
  • Authority rests with the community. Leaders (shaykh, shaykha, bābā or māmā zār), ensembles, families and the client's religious community decide what is legitimate [source: Mianji and Semnani 2015]. Practically: the client decides whether anyone is contacted, and who.
  • Possession is not a diagnosis. DSM excludes experiences that are a normal part of a broadly accepted cultural or religious practice from dissociative diagnoses. ICD-11 possession trance disorder requires the state to be "involuntary and unwanted" [source: PMC9199574; Lewis 2023 study guide; findacode ICD-11 mirror]. Practically: assess distress, impairment, wantedness and fit with the client's own group norms before you code anything.
  • Do not miss illness either. Zar is often invoked after ordinary or medical treatment has failed, for headaches, lethargy, infertility, pain, or apathy and withdrawal [source: Mianji and Semnani 2015]. Practically: always arrange medical review, and keep psychiatric differentials open.
  • Culture is local and changing. Gender, religious and class patterns differ by place. In Ethiopia a larger share of men are affected than elsewhere in Africa. In Israel men became more susceptible after migration [source: Mianji and Semnani 2015; Arieli and Aychen 1994]. Practically: never assume from a country label, and ask.
  • Stigma and secrecy are expected. Religious condemnation and elite contempt are documented [source: Al-Monitor 2022; Pan African Music 2022]. Practically: say explicitly that you will not judge, and protect confidentiality, including from family members unless the client agrees.
  • Social meaning matters. Scholars link zar to marriage, fertility, sex segregation and isolation [source: Mianji and Semnani 2015, on Lewis and Boddy]. Practically: explore relationships and roles as possible stressors without reducing the client's experience to them.
  • Consent governs collaboration. Practically: get written, specific consent for each contact, limit what you share to what is needed, and record it. [synthesis]
  • Safety overrides deference. Practically: harm, coercion, abuse or delay of urgent medical care triggers safeguarding, whoever the practitioner is. [synthesis]
  • Humility about evidence. No controlled evaluation of zar as mental-health care was identified. Healing claims stay attributed [uncertain: not verified]. Practically: do not tell clients zar will or will not help.
  • Never advise on medicines. Some leaders are reported to hold that injections and similar treatments can agitate spirits [source: Mianji and Semnani 2015]. Practically: explore the belief, and send any decision about starting, stopping or changing medication to the prescriber.

4. Intervention inventory

Every intervention below is the psychotherapist's own work. None of them is a zar procedure.

4.1 Cultural humility and self-examination

  • Purpose: Reduce the risk that your own beliefs distort assessment. Those beliefs might be religious objection to spirit possession, secular scepticism, exoticism, or assumptions about gender or about Islam and Ethiopian Orthodoxy. Use it before and throughout work with the client [synthesis].
  • Steps:
    1. Before the first session, write down what you associate with "zar", "possession", "exorcism" and the client's country. Media images from films, such as Egypt's horror film Al Taweeza, are reported to shape stereotypes [source: Al-Monitor 2022].
    2. Note any reaction you have to the CFI patient-clinician relationship questions, which cover perceived racism and language barriers.
    3. Take your reactions to supervision. This matters most if you share the client's religious background and hold views on zar's legitimacy.
    4. After each session, check whether you steered the client toward your own explanation.
  • Example language (illustrative): "I don't share your background, so I'll be asking a lot of questions. Please correct me whenever I get something wrong."
  • Watch for: pressing biomedical explanations; curiosity that turns into fascination with ritual detail; the client becoming guarded or over-polite. It is working when the client corrects you freely and brings material they had hidden at first.

4.2 Core Cultural Formulation Interview (16 questions)

  • Purpose: Get the client's own definition of the problem, its causes, stressors and supports, the role of cultural identity, coping and help-seeking, and expectations of care. Use it at intake with every client, and especially when spirits or zar are mentioned [source: APA CFI].
  • Steps:
    1. Explain the purpose.
    2. Work through the four domains in order:
      • Cultural Definition of the Problem (Q1–3).
      • Cultural Perceptions of Cause, Context and Support (Q4–10).
      • Cultural Factors Affecting Self-Coping and Past Help Seeking (Q11–13).
      • Cultural Factors Affecting Current Help Seeking (Q14–16).
    3. Use the client's own words, such as "zar", "wind" or the spirit's name if the client offers it, in your follow-up questions.
    4. Record answers verbatim where you can.
    5. The APA form may be reproduced by clinicians for use with their patients, but translating or modifying it needs APA permission [source: APA CFI].
    6. Do not use the CFI alone as the basis for a diagnosis [source: APA CFI].
    7. The time it takes varies. Field-trial clinicians found later interviews quicker. A fixed duration is [uncertain: not verified] [source: Lewis-Fernández et al. 2017].
  • Example language (illustrative): "People describe problems like this in different ways. How would you describe it to your family or friends?" Then: "You said some people would call it zar. What does that word mean to you?"
  • Watch for: the client giving the answer they think a clinic wants, such as "stress" or "depression", while holding a spirit explanation privately. Ask how their family would describe it. It is working when the client offers more than one explanation and says which one they favour.

4.3 CFI supplementary modules

  • Purpose: Go deeper where the core CFI points to particular areas [source: APA CFI Supplementary Modules]. For zar, the most relevant modules are:
    • Explanatory Model.
    • Spirituality, Religion and Moral Traditions.
    • Cultural Identity.
    • Coping and Help-Seeking.
    • Social Network.
    • Psychosocial Stressors.
    • Immigrants and Refugees.
    • Patient-Clinician Relationship.
    • Older Adults (several Israeli cases were aged 40 or over [source: Arieli and Aychen 1994]).
    • Caregivers, given to the caregiver.
  • Steps:
    1. Choose modules from the core CFI's cross-references.
    2. Give them at intake, later, or repeatedly [source: APA CFI Supplementary Modules].
    3. For the spirituality module, ask about every affiliation: Orthodox Christian, Muslim, Jewish, Sufi. Ask how each one regards zar. A client may belong to a mosque or church that condemns it and still take part [source: Al-Monitor 2022; Mianji and Semnani 2015].
    4. For immigrants, ask when symptoms began relative to migration. In one Israeli series, new episodes appeared within two years of arrival in every case [source: Arieli and Aychen 1994].
  • Example language (illustrative): "How does your church, or mosque, see zar? And how do you see it yourself? Those can be different."
  • Watch for: conflict between affiliations. This is a frequent source of shame and secrecy [synthesis]. It is working when the client can describe each group's view without feeling forced to choose one.

4.4 Kleinman explanatory-model questions

  • Purpose: Map the client's illness model, the name, cause, timing, course and feared outcome, in a form you can use for treatment planning. Use it alongside or instead of the CFI Explanatory Model module [source: Tanenbaum handout, paraphrasing Kleinman et al. 1978].
  • Steps: Ask the eight questions in your own words:
    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 be short or long?
    6. What treatment should you receive?
    7. What are the main problems it has caused?
    8. What do you fear most about it?
    Then summarise the model back to the client and ask whether you have got it right.
  • Example language (illustrative): "You've told me zar can stay with a person for a long time. What would a good outcome look like for you: no symptoms at all, or living well with it?"
  • Watch for: the belief, reported in the literature, that zar is permanent and needs ongoing appeasement [source: Mianji and Semnani 2015]. If you set "cure" as the goal, you may clash with this model. It is working when you and the client agree goals in the client's terms.

4.5 Non-judgemental inquiry about zar and other healers

  • Purpose: Learn about past and current help-seeking: zar groups, Orthodox holy water, Qur'anic healing, Sufi practices, biomedical care. This tells you about risks, supports and possible collaborators. Ask in every assessment [source: APA CFI, Q12–13; synthesis].
  • Steps:
    1. Normalise multiple help-seeking.
    2. Ask what was tried, in what order, what helped, and what was costly or frightening.
    3. Ask whether anyone involved has told the client to stop or avoid medical care.
    4. Ask about money spent, because traditional ceremonies may be costly [synthesis].
    5. Do not ask for, or record, ritual content, songs or sacred items.
  • Example language (illustrative): "Many people I see have tried several kinds of help: doctors, religious healing, community ceremonies. Whatever you've tried, I won't judge it. What has been helpful, and what hasn't?"
  • Watch for: disclosure followed by anxiety about being reported or mocked. Reassure the client and keep to the limits of confidentiality. It is working when the client tells you about both helpful and harmful experiences.

4.6 Differential assessment: normative possession versus disorder

  • Purpose: Avoid two errors. One is pathologising a culturally normative experience. The other is missing psychosis, a dissociative disorder, depression, conversion symptoms or medical illness [source: Mianji and Semnani 2015; Grisaru et al. 1997]. Use it whenever possession, trance, unusual speech or movements are reported.
  • Steps:
    1. Find out whether possession happens within, or outside, the settings the client's group accepts. Within the tradition, trance occurs mainly in ritual contexts, and being entranced alone does not make someone "possessed" [source: Mianji and Semnani 2015].
    2. Ask whether the client wants the experience, accepts it, or finds it alien and unwanted. ICD-11 6B62 and 6B63 require an involuntary, unwanted state outside accepted practice, with distress or impairment [source: findacode ICD-11 mirror; PMC9199574].
    3. Check the DSM criteria:
      • Dissociative identity disorder: identity disruption may be described as possession, and it is excluded when it is a normal part of accepted practice.
      • Other specified dissociative disorder, dissociative trance: excluded when it is part of a broadly accepted collective practice [source: PMC9199574; Lewis 2023 study guide].
    4. Screen for psychotic features: persistent, distressing beliefs or perceptions beyond what the client's own group would accept, thought disorder, and decline in functioning.
      • How DSM-5-TR words its note on culturally sanctioned beliefs is [uncertain: not verified].
      • In the Israeli series, 8 of 13 cases were classed as neurotic and 5 as atypical psychotic, and most remitted quickly [source: Arieli and Aychen 1994].
    5. Screen for depression and suicidality, anxiety, and conversion symptoms, all of which the literature reports [source: Mianji and Semnani 2015].
    6. With consent, ask a family member or a cultural broker whether the presentation is typical for zar in the community.
  • Example language (illustrative): "When the zar comes, is it at gatherings where that is expected, or does it also happen at home or work when you don't want it?" And: "Do people in your community who know zar see what is happening to you as usual, or as something different?"
  • Watch for: involuntary movements, mutism and "incomprehensible language". These have been mistaken for neurological or psychiatric illness [source: Grisaru et al. 1997]. It is working when you can name a reasoned working diagnosis, or no diagnosis, that the client and a cultural informant find credible.

4.7 Medical screening and parallel care

  • Purpose: Zar is often invoked when physical complaints, such as headache, lethargy, pain, nausea, appetite loss or infertility, have not responded to medical care [source: Mianji and Semnani 2015]. Medical causes must be ruled out and kept under review. Use this at intake, and whenever a new physical symptom appears.
  • Steps:
    1. Ask what medical investigations and treatments have been done.
    2. With consent, liaise with the GP or physician.
    3. Refer for neurological review where there are seizure-like movements, mutism or episodes of altered consciousness.
    4. If the client fears that injections or medication will "anger" the spirit, explore that fear, then refer any medication decision to the prescriber. Do not advise on it yourself [source: Mianji and Semnani 2015, on leaders' beliefs; synthesis].
  • Example language (illustrative): "I'd like your doctor to check the headaches too, alongside anything else you're doing about them. Would that be all right?"
  • Watch for: medical care being delayed because of spirit attribution; a client with infertility who has been told the cause is solely spiritual. It is working when medical and cultural help-seeking go on side by side without the client having to hide either.

4.8 Interpreters and cultural brokers

  • Purpose: Get accurate meaning across languages and avoid stigmatising translations. Clients may speak Amharic, Arabic (Egyptian or Sudanese), Tigrinya, Nubian languages or Persian [synthesis]. Use whenever language or cultural distance is significant.
  • Steps:
    1. Use a trained interpreter, not a family member, for assessment.
    2. Brief the interpreter beforehand on the topics, and ask about any religious stance that might colour their translation.
    3. Check that the client accepts the interpreter's community and gender. In small diaspora communities, people may know each other.
    4. With the client's consent, consult a cultural broker, such as a community health worker or someone familiar with zar in that community, on what is normative.
    5. Do not share identifying details with the broker without consent [synthesis].
  • Example language (illustrative): To the interpreter beforehand: "Please translate the client's words as closely as you can, including words for spirits, without softening or explaining them."
  • Watch for: the interpreter adding judgement, for example calling zar sinful; the client going quiet with a same-community interpreter. In Ethiopian immigrants, 8 of 13 cases spoke a distinctive "zar language" [source: Arieli and Aychen 1994]. Treat this as data, not as incoherence. It is working when the client's own terms come through intact.

4.9 Informant interview and family work

  • Purpose: Understand family views, conflicts and supports, and get collateral history. Use when the client agrees, or with carers [source: APA CFI Informant Version; CFI Caregivers module].
  • Steps:
    1. Get the client's consent, including on what may be discussed.
    2. Use the CFI Informant Version: its first question covers the informant's relationship to the patient, then the same four domains follow [source: APA CFI Informant Version].
    3. Explore family views on zar. Spouses, parents and religious relatives may disagree.
    4. Explore marital and fertility pressures, which the literature links to zar affliction in married women [source: Mianji and Semnani 2015, on Boddy].
    5. Explore gender-role shifts after migration [source: Arieli and Aychen 1994].
  • Example language (illustrative): "Your wife has told me about the zar. How do you understand what she's been going through?"
  • Watch for: coercion, for example a family forcing or forbidding participation; domestic abuse; the client's account being overridden. It is working when the family can tolerate different explanations and support the agreed plan.

4.10 Collaboration and referral with community-recognised healers (only when the client wishes)

  • Purpose: Coordinate care with a zar leader (shaykh or shaykha) or with a religious healer the client trusts, such as Orthodox clergy at a holy-water site or an imam. The aim is to reduce conflicting messages and support safety. Use this only at the client's request or with their clear agreement.
  • Evidence base. No zar-specific collaboration programme was identified [uncertain: not verified]. Evidence on collaboration with traditional and faith healers comes from other settings:
    • The COSIMPO trial in Nigeria and Ghana used collaborative shared care for psychosis. It reduced symptoms and harmful practices [source: Gureje et al. 2020].
    • In a Ghanaian prayer-camp trial, adding medication reduced symptoms but did not significantly reduce days in chains [source: Ofori-Atta et al.].
    • A BJPsych Open study described active collaboration between holy-water healers and psychiatry in Ethiopia [source: BJPsych Open 2021].
    • The Israeli authors recommended combining traditional and modern approaches [source: Arieli and Aychen 1994].
  • Steps:
    1. Ask whether the client wants any contact, with whom, and for what purpose. Typical purposes are sharing a safety plan, agreeing that medical care continues, or understanding the client's obligations.
    2. Get written consent specifying what may be shared.
    3. Let the client or family make the introduction. Do not seek out practitioners yourself, and never send a client to a ceremony.
    4. In any contact, respect the leader's authority over their tradition. Keep to your role: mental health, safety, medical care.
    5. Agree what each side will do, and when you will review it.
    6. Record everything.
    7. Stop if there is any sign of harm or coercion [synthesis].
  • Example language (illustrative): "You said the shaykha has known you for years. Would it help if, with your permission, I spoke with her about how we can both support you? I wouldn't discuss the ceremonies themselves, only your safety and your health care."
  • Watch for: the client feeling pushed into contact; conflicts over medication; breaches of confidentiality in close-knit communities. It is working when the client experiences one coordinated plan rather than competing demands.

4.11 Working with stigma, religious conflict and secrecy

  • Purpose: Address shame where the client's family, religious community or social class condemns zar as pagan, blasphemous or backward [source: Al-Monitor 2022; Pan African Music 2022]. Use whenever the client shows conflict or hides participation.
  • Steps:
    1. Name the conflict neutrally.
    2. Explore what the client values in each group or tradition.
    3. Help the client decide what to disclose, and to whom.
    4. If appropriate and wanted, consult the client's own religious adviser about the client's spiritual distress.
    5. Avoid taking a theological position yourself [synthesis].
  • Example language (illustrative): "It sounds as if part of you finds comfort with the zar group, and part of you worries what your mosque would think. We don't have to settle which is right. Can we look at how each one affects you?"
  • Watch for: scrupulosity, guilt-driven depression, or isolation from either community. It is working when the client's distress about the conflict falls, whatever choice they make.

4.12 Migration, acculturation and gender-role change

  • Purpose: Address stressors linked to migration. In one Israeli series, every new zar episode began within two years of migration. The authors linked men's greater susceptibility in Israel to the loss of male status as women's position changed [source: Arieli and Aychen 1994]. Use with immigrant and refugee clients.
  • Steps:
    1. Use the CFI Immigrants and Refugees module.
    2. Map losses: role, status, language, community, ceremonial resources.
    3. Screen for trauma from displacement and conflict, which is relevant for Sudanese clients [synthesis].
    4. Treat co-occurring post-traumatic stress, depression or anxiety with standard evidence-based therapies, using the client's explanatory model in how you frame them.
    5. Help the client rebuild social networks.
  • Example language (illustrative): "You said the zar came back after you arrived here. What changed for you when you moved?"
  • Watch for: distress framed only in spirit terms when there are concrete losses you could help with; unrecognised trauma. It is working when functioning improves and the client links some distress to circumstances that can change.

4.13 Integrating experiences of possession and participation

  • Purpose: Help the client make sense of past or ongoing zar experiences, whether these were helpful, frightening or both, and fit them into their self-understanding. Use when the client wants to talk about them [synthesis].
  • Steps:
    1. Invite the client's own account of meaning and effects. Do not ask for ritual content.
    2. Validate relief or community belonging where the client reports it. Some participants and practitioners describe stress relief and harmony [source: Pan African Music 2022].
    3. Process frightening or coercive elements as you would any distressing experience.
    4. Connect the experiences with the client's goals.
  • Example language (illustrative): "What did being part of that group give you? Was there anything about it that was hard?"
  • Watch for: retraumatisation, dissociation in session, or idealising or demonising the tradition. It is working when the client can hold a nuanced, self-authored view.

4.14 Safeguarding

  • Purpose: Protect clients and children from harm, whatever its setting. No source here documents specific harms in zar groups. The categories below are general safeguarding concerns for spiritual healing [synthesis; uncertain: not verified for zar specifically].
  • Steps:
    1. Screen for physical restraint, beating, deprivation of food or sleep, sexual exploitation, financial exploitation, forced participation, and withholding of urgent medical care.
    2. For children, follow local child-protection procedures, and never name minors in records you share.
    3. Where harm is disclosed, follow your mandatory reporting and adult safeguarding duties.
    4. Tell the client before you report, where that is safe.
  • Example language (illustrative): "Has anyone, in any kind of healing, ever hurt you, kept you somewhere against your will, or told you not to see a doctor?"
  • Watch for: fear of retaliation; the client minimising harm out of loyalty. It is working when risks are documented, acted on, and the client remains engaged.

4.15 Cultural formulation and documentation

  • Purpose: Write a formulation that integrates cultural identity, the cultural conceptualisation of distress, psychosocial stressors and supports, cultural features of the client-clinician relationship, and an overall assessment. This follows the DSM-5-TR Outline for Cultural Formulation [source: APA Section III].
  • Steps:
    1. Summarise each element in the client's terms.
    2. State whether possession is judged normative or meets the criteria for a disorder, and why.
    3. Record collaborations and consents.
    4. Share a plain-language version with the client.
    5. Avoid stigmatising language [source: APA Section III].
  • Example language (illustrative): "Here's how I've understood things so far, in your words and mine. Tell me what I've got wrong."
  • Watch for: diagnostic labels written into records that the client or their community would find shaming. It is working when the client recognises themselves in the formulation.

5. Handling problems

The zar sources say little about problems in psychotherapy. The guidance below is [synthesis] unless a source is cited.

  • Client will not talk about zar, or denies it after hinting at it.
    • Likely causes are stigma, religious condemnation, or fear of being labelled mad [source: Al-Monitor 2022; Pan African Music 2022].
    • Respond by naming that many people use several kinds of help, and repeating your stance of not judging. Do not press. Come back to it through CFI help-seeking questions later.
    • Illustrative: "You don't have to tell me anything you're not comfortable with. If it ever feels relevant, I'm interested, not judging."
  • Client asks whether the spirit is real, or asks you to endorse zar.
    • Do not confirm or dismiss it. Reflect the client's understanding back, and stay with what helps.
    • Illustrative: "I can't speak for the spirit world. What I can do is help with how this is affecting your life, in a way that fits what you believe."
  • Client asks you to recommend a zar leader or ceremony, or to attend one.
    • Decline to recommend, arrange or attend. The client and their community decide on legitimate leaders. Offer to coordinate with someone they already trust (4.10).
    • In Egypt the public face of the tradition is very small. Mazaher's founder calls it the last group performing in public [source: Al-Monitor 2022]. Do not treat performances for audiences as a referral route.
  • Family or religious leader opposes zar and pressures the client, or pressures you.
    • Hold the client's autonomy. Use family sessions (4.9) to lower conflict. Do not side with either camp theologically.
  • Spirit attribution risks medical delay, such as headaches, seizures or infertility untreated.
    • Frame medical review as "as well as", not "instead of" (4.7). If a serious condition is going untreated, escalate as you would in any case of medical neglect.
  • Medication conflict: the belief that injections or medicines anger the spirit [source: Mianji and Semnani 2015].
    • Explore the belief and its source. Involve the prescriber.
    • With consent, a trusted community figure may help the client consider options. Never advise the client yourself to start, stop or change medication.
  • Possession or dissociation in session.
    • Stay calm and keep the setting safe. Speak to the client by name, calmly, and wait. Do not address the spirit as a separate party or attempt any ritual response.
    • Once the episode ends, explore it with the client. If episodes are frequent, involuntary and impairing outside accepted contexts, review the differential diagnosis (4.6), including ICD-11 6B63 and seizure disorders.
  • Psychotic symptoms alongside zar beliefs.
    • Do not let the cultural frame mask psychosis. In one series, 5 of 13 possessed Ethiopian immigrants were classed as atypical psychotic [source: Arieli and Aychen 1994].
    • Arrange psychiatric assessment, and use a cultural informant to judge what is outside the group's norms.
  • Suicidality. Assess directly. A "strong wish to die" is among the presentations described in Nubia [source: Mianji and Semnani 2015]. Follow standard risk assessment and safety planning, and do not accept spirit attribution as a reason to defer risk management.
  • Stuck therapy: the client sees the problem as permanent and spiritual, so talking will not help.
    • Use the explanatory model (4.4) to find goals the client values: sleep, work, marriage, managing obligations. Frame therapy as support for living well with the affliction, not as a rival cure.
  • Rupture: the client feels you dismissed or exoticised their experience.
    • Name it, apologise specifically, and ask what would help. Revisit the CFI Patient-Clinician Relationship module.
  • Non-adherence to sessions or homework.
    • Check for practical barriers first: cost, travel, gender of therapist, interpreter fit, ceremony calendar. Then check for clashes with the explanatory model. Shape tasks to fit the client's daily religious practice.
  • Confidentiality in small diaspora communities. Check whether the client knows the interpreter or broker. Limit details in letters, and agree in advance what you may say to whom.
  • Safeguarding disclosure.
    • Follow 4.14. Explain your duties beforehand where you can.
    • Distinguish practices that are unfamiliar to you from those that are harmful. Seek specialist safeguarding advice rather than relying on cultural assumptions in either direction.
  • Therapist's own discomfort, whether religious objection or fascination. Take it to supervision. Consider referral if you cannot keep a neutral stance (4.1).

Sources

Web sources

Books and papers cited by author

  • Boddy J. (1989). Wombs and Alien Spirits: Women, Men, and the Zār Cult in Northern Sudan. Madison: University of Wisconsin Press; xxi, 399 pp. Content cited here via Mianji and Semnani.
  • Boddy J. Wombs and Alien Spirits (Wellcome Collection catalogue record)
  • 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.
  • Works by I. M. Lewis, J. G. Kennedy (Nubian zar), A. Young (Amhara) and R. Natvig are cited only as Mianji and Semnani summarise them. Their full bibliographic details are [uncertain: not verified].
← Previous · XI-069Christian prayer camps and healing churchesNext · XI-071 →Ethiopian debtera