Ethiopian kitel betash, awalaj and wogesha

1. Introduction

Version followed: the three-category description of Ethiopian community healers in Kahissay, Fenta and Boon's 2015 ethnography of rural Tehuledere (South Wollo, Amhara Region), read alongside Ethiopian regulatory and maternal-health studies; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) as the American Psychiatric Association publishes it.

This is not a psychotherapy and not a single tradition. It is three groups of community health practitioners in Ethiopia, described by Ethiopian researchers [source: Kahissay et al. 2015]:

Kitel betash (herbalists). Healers in the Tehuledere study report treating conditions such as jaundice, haemorrhoids, herpes zoster, digestive complaints, eczema, snakebite, gout and vitiligo with plant remedies. This is the healers' own account; the sources cited here give no evidence that these remedies are effective or safe [source: Kahissay et al. 2015]. Some combine remedies with incantations or, in this mainly Muslim community, Dua prayer. Their knowledge is described by healers as God-given and passed on through families, apprenticeship and oral teaching.
Awalaj (traditional birth attendants, TBAs). These are women who attend labour and birth, give postnatal care, counsel pregnant women and offer spiritual support. Their knowledge passes within families or through informal apprenticeship. Mothers often feel more comfortable with them than with male clinicians.
Wogesha (also spelled wegesha; bone-setters). They treat fractures and dislocations, including dislocated jaws, by examination and manipulation. Their standing comes from long practical experience, and families with long service histories are respected.

In the study community, healers were often the first point of contact. People saw them as faster, cheaper and more effective than biomedical care for fractures and childbirth. Some conditions were attributed to supernatural causes such as jinn or the evil eye, which people believed biomedicine cannot treat. Use of both systems was pluralistic, sometimes one after the other and sometimes at the same time [source: Kahissay et al. 2015]. These are the communities' and healers' own accounts, reported by researchers. They are given here neither as fact nor as dismissal.

The psychotherapist does not practise any of these crafts. Your work happens alongside them: understanding what a client (in Ethiopia or in the diaspora) has used and why, assessing risk, working with the client's explanatory model, and coordinating with medical and community care when the client wishes. Change, from the therapist's side, comes from care that makes sense within the client's own framework. Such care reduces delay, shame and conflict between help sources, and keeps physical and safeguarding risks in view [synthesis].

2. Framework

Who holds authority [source: Kahissay et al. 2015; Usure et al. 2024; Teshome 2017]

Within the practice: healer families and lineages, mentors in long apprenticeships, and community reputation. Elders and social networks steer people towards particular healers. Preparation knowledge is closely guarded and taught without a formal curriculum.
State regulation: Proclamation No. 661/2009 defined traditional medicine and practitioners, and the Ethiopian Food and Drug Authority (EFDA) Proclamation 1112/2019 amended it. EFDA regulates herbal medicinal products. Regional health bureaus or regulatory offices register and license practitioners and premises. The Ministry of Health includes traditional herbal medicine in its strategic plans, and Ethiopian Public Health Institute laboratories can test products. Regulators interviewed in 2021–2022 estimated that 80–90% of healers practise without registration. They described many of the instruments as still in draft. Healers have criticised certification for reflecting biomedical standards rather than indigenous knowledge.
Maternity care: TBAs were prohibited from attending births around 2012, when the Health Development Army was created. The specifics were set locally, and some communities fined women who gave birth at home and the attendants who helped them [source: Hill et al. 2019]. In a remote zone, a 2021 study still found TBAs working with no integration into the formal system [source: Kassie et al. 2022]. In a national cohort of pregnant women (PMA Ethiopia baseline, 2,186 women), about 59% perceived that their community accepts TBA-assisted childbirth, with lower acceptance in Addis Ababa and SNNPR; the authors propose a liaison role for TBAs between pregnant women and the formal system [source: BMC Public Health 2024, PMA Ethiopia]. No current national policy text on TBAs was found; whether the prohibition still stands, and how it varies by region, is [uncertain]. Practically, ask the client what applied where they lived rather than assuming.
Health extension workers (HEWs) act as bridges. They train healers, supply basic materials such as gloves and gauze, and use healers to share health information. No formal referral system between healers and clinics was found [source: Kahissay et al. 2015].

Phases of the psychotherapist's work [synthesis, organised around the CFI; source for CFI content: APA DSM-5-TR CFI]

Phase	Goal	Typical format	Move on when
1. Engagement and cultural assessment	Understand the problem in the client's terms, what help they have used (healers, religious help, clinics) and why	Sessions 1–2; core CFI, Informant Version with a family member if the client agrees; interpreter if needed	You can state the client's explanatory model back to them and they agree with it
2. Safety and medical screening	Identify physical risks (bone-setting, perinatal, herbal–medicine overlap) and safeguarding concerns	Woven into sessions 1–3; liaise with GP, obstetric or orthopaedic care	Urgent medical issues are routed, and safeguarding is addressed or ruled out
3. Shared formulation and plan	Agree goals that respect both help systems	1 session, revisited	The client endorses a plan that names which concerns go to which helper
4. Ongoing therapy with collaboration	Evidence-based treatment for the presenting disorder, with healer or community input when the client wishes	Usual course for the disorder; supplementary CFI modules as needed	Goals reviewed; coordination is working or deliberately not used
5. Integration and review	Make sense of healing experiences, outcomes and any complications	Final sessions; follow-up	The client can describe their own plan for future help seeking

The APA does not give a time for the CFI. The DSM-5 field trial reported that later interviews took less time than the first. A figure of about 15–20 minutes for the core CFI is [uncertain] [source: APA DSM-5-TR CFI; Lewis-Fernández et al. 2017].

3. Guiding principles

You are alongside, not inside, the tradition. Do not prepare, recommend or assess remedies, birth practices or bone-setting. Your expertise is psychological assessment, therapy and coordination [synthesis].
Authority sits with healer families, communities and regulators. Ask the client who their healer is and how that person is recognised. Do not judge legitimacy yourself [source: Kahissay et al. 2015; Usure et al. 2024].
Pluralism is normal. Expect sequential or concurrent use of several help sources. Ask about it routinely and without judgement [source: Kahissay et al. 2015].
Practical reasons matter as much as belief. Cost, distance, lack of drugs, time and communication drive choices. Address access before attributing choices to "culture" [source: Kahissay et al. 2015; Worku et al. 2019].
Attribute spiritual causation. Jinn, evil eye and spirit possession are reported as causes by many clients. Record them in the client's words, neither endorsing nor dismissing them [source: Kahissay et al. 2015; Teshager et al. 2020].
Normative experience is not automatically illness. Use the DSM-5-TR cultural exclusions and ICD-11 trance and possession definitions before you diagnose [source: DSM-5 possession and trance criteria as quoted in PMC9199574; ICD-11 6B62 and 6B63].
Physical safety comes first. Bone-setting complications, perinatal emergencies and herb–medicine overlaps go to medical colleagues promptly [source: Worku et al. 2019; synthesis].
Never advise on medicines or herbs. Do not tell a client to start, stop or change any remedy or prescription. Route questions to the prescriber [synthesis].
Touch. Psychotherapy here involves no touch. When clients describe healer contact, frame consent as theirs: explicit agreement before and during, the right to stop, and never sexual or genital contact [synthesis].
Safeguard children without stereotyping communities. Some practices (e.g. infant uvulectomy and milk-tooth extraction, reported as advised by a few TBAs) are safeguarding concerns. Respond to the specific act, not to the community [source: Kassie et al. 2022; synthesis].
Avoid adding shame. Clients may have been fined or scolded for a home birth, or may expect blame for seeing a bone-setter. Make it safe to disclose [source: Hill et al. 2019; synthesis].
Consent governs collaboration. Contact a healer, elder or religious leader only with the client's explicit, specific consent and an agreed limit on what is shared [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them is a kitel betash, awalaj or wogesha practice, and none teaches one. Example language is illustrative unless quoted.

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout work with Ethiopian or Ethiopian-diaspora clients who use community healers. It checks your own assumptions about "traditional" care, for example that it is backward, or that it is always benign [synthesis].
Steps: (1) Before the first session, note your own reactions to herbal, birth and bone-setting care, and where you learned them. (2) Separate what you know about Ethiopia (regions, languages, Orthodox, Muslim and Protestant communities) from what you assume. (3) Note structural factors in your service, such as interpreter access, cost and appointment length, that echo the reasons clients give for preferring healers (time, communication, cost). (4) Review your notes after sessions for evaluative words like "non-compliant" or "superstitious" and rewrite them descriptively [synthesis; reasons for preference: Kahissay et al. 2015].
Example language (illustrative): "I don't know much about how people at home look after a broken bone or a birth, so please teach me what matters to you."
Watch for: Over-identifying with either system. Romanticising healers or reflexively blaming them both close down disclosure. It is working when the client corrects you freely and volunteers details of healer use.

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

Purpose / when: At first assessment, or whenever cultural factors are shaping the problem, help seeking or the relationship. APA describes it as usable by any clinician in any setting. It informs understanding and decisions and is not the sole basis of a diagnosis [source: APA DSM-5-TR CFI; APA DSM-5-TR Section III].
Steps: Work through the four domains in your own words, following the official form: (1) the cultural definition of the problem; (2) cultural perceptions of cause, context and support, including stressors, supports and the role of cultural identity; (3) self-coping and past help seeking, including barriers; (4) current help-seeking preferences and the clinician–patient relationship, including perceived racism and language barriers. In domain 3, name the help sources explicitly: herbalist, birth attendant, bone-setter, religious healer, clinic, family, elders. Clinicians may reproduce the form for their own patients. Modifying or translating it needs APA permission [source: APA DSM-5-TR CFI].
Example language (illustrative): "People often see several kinds of helpers for the same problem, at home and here. Who have you seen so far, and what did each of them say?"
Watch for: Socially desirable answers. People in Ethiopian studies under-reported home births where these were sanctioned [source: Hill et al. 2019]. Watch also for literal translation of terms, and for the client deferring to you. It is working when the client's description of the problem gets richer and their own words for it appear.

4.3 CFI Informant Version with a family member

Purpose / when: When family members shape decisions. Elders and family advice are key reasons for using healers, and in an Ethiopian psychiatric sample 64.3% said family did not recognise how severe the illness was [source: Kahissay et al. 2015; Teshager et al. 2020]. The Informant Version has 17 questions: one about the relationship, then the four core domains [source: APA CFI Informant Version].
Steps: (1) Get the client's consent about who is interviewed and what may be shared. (2) Interview the informant, separately if appropriate. (3) Compare the two accounts and note where they agree and differ. (4) Bring the differences back to the client, never the informant's confidences, unless agreed.
Example language (illustrative): "Your mother may see this differently. Would it help if I heard her view, and you decide what I say back?"
Watch for: Family overriding the client, and coercion around treatment choices. It is working when the plan is one the family can live with and the client still owns.

4.4 Supplementary modules: Explanatory Model, Spirituality, Coping and Help-Seeking, Social Network, Immigrants and Refugees, Caregivers

Purpose / when: As add-ons where a core CFI topic needs depth. They can be used at first evaluation, later in care, or repeatedly [source: APA CFI Supplementary Modules]. For this population the most relevant are the Explanatory Model module (spiritual or natural causation), Spirituality, Religion and Moral Traditions (Muslim Dua, religious healers), Coping and Help-Seeking (healer use), Immigrants and Refugees (diaspora clients), and Caregivers (family carers) [synthesis on selection].
Steps: (1) Choose the module that matches the gap left after the core CFI. (2) Use the official module, adapting delivery but not item content. (3) Record findings in the formulation.
Example language (illustrative): "You said your faith matters in how you understand this. Can we spend some time on that today?"
Watch for: Interview fatigue. Use one module per session. It is working when new information changes your formulation or plan.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: To map the client's understanding of the problem. This matters especially when the client attributes it to jinn, evil eye, spirit possession or sin, which are common attributions in Ethiopian samples (e.g. spiritual possession 29.3%, evil eye 9.7%, sinful act 7.3% among psychiatric outpatients in Mekelle) [source: Teshager et al. 2020; Kahissay et al. 2015]. Kahissay and colleagues used Kleinman's cultural systems model to frame their study.
Steps: Ask, in your own words, Kleinman's eight areas: what the client calls the problem; 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 they think they should get; the chief problems it has caused; and what they fear most [source: Tanenbaum handout; Kleinman, Eisenberg & Good 1978]. Then summarise the model back to the client, and ask where your care fits within it.
Example language (illustrative): "So for you, the pain in your arm and the bad sleep began after the evil eye, and the herbs and prayer are the right care for that part. Where do you think talking with me might help?"
Watch for: Treating the model as a barrier to correct. It is working when the client agrees with your summary and accepts a role for your care within their model.

4.6 Asking about healer consultation without judgement

Purpose / when: Routinely, at intake and at reviews. Healers are often the first point of contact, and use may be concurrent with your care [source: Kahissay et al. 2015].
Steps: (1) Normalise first. (2) Ask about each healer type by name: kitel betash, awalaj, wogesha, religious healers. (3) Ask what was done in general terms, what the healer advised (including any restrictions, such as avoiding certain foods, alcohol or sex for months, which herbalists in the study prescribed), and how the client felt about it. (4) Ask whether the healer would welcome contact with you. (5) Record it neutrally [source for restrictions: Kahissay et al. 2015; steps: synthesis].
Example language (illustrative): "Many people from Ethiopia see a herbalist or a bone-setter as well as a doctor, and it helps me to know. Have you seen anyone like that for this?"
Watch for: Concealment out of fear of blame or sanctions. Prolonged restrictions may affect mood, relationships or nutrition; route nutrition and medical questions on. It is working when disclosure continues at later sessions.

4.7 Cultural concepts of distress and normative experience versus disorder

Purpose / when: When the client reports spirit possession, jinn affliction, evil eye or trance, or when others label their experience as illness. DSM-5-TR describes cultural concepts of distress as idioms, explanations and syndromes, and its culture chapter includes them [source: APA DSM-5-TR Section III]. No Ethiopian-specific term appears in the DSM-5-TR list as university-hosted slides report it (ataque de nervios, dhat, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto, taijin kyofusho) [source: UNMC slides; uncertain].
Steps: (1) Record the client's idiom and its cause in their words. (2) Ask whether the experience is accepted in their community or religious setting, and whether they or their community regard it as wanted or as a problem. (3) Apply the cultural exclusions. Possession-form identity disruption counts towards dissociative identity disorder only if it is not a normal part of broadly accepted cultural or religious practice, and dissociative trance likewise. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary, unwanted and outside accepted cultural or religious practice, with distress or impairment [source: DSM-5 criteria quoted in PMC9199574; DSM-5-TR keeps them in substance per Lewis 2023 study guide, exact wording [uncertain]; ICD-11 6B62 mirror]. (4) Separately assess for psychosis, mood disorder, PTSD and medical causes. The DSM-5-TR note that culturally sanctioned beliefs should not count as psychotic symptoms is [uncertain: not verified]. (5) Consult a cultural broker or community member, with consent, if unsure.
Example language (illustrative): "In your community, when someone is troubled by a spirit like this, is it something people expect and know how to handle, or is it seen as an illness?"
Watch for: Both errors. Pathologising an accepted religious experience, and missing psychosis or depression because a spiritual explanation is offered. It is working when your diagnostic reasoning holds up against both the client's account and a broker's view.

4.8 Routing herbal-remedy and medicine questions to the prescriber

Purpose / when: When a client uses kitel betash remedies alongside prescribed medicines, or asks you whether to continue either. Ethiopian regulators report weak control of healer-prepared products, no binding national herbal pharmacopoeia, no standardised preparation methods, and labels often lacking product names [source: Usure et al. 2024]. Herbalists themselves say some remedies are effective and others may not be [source: Kahissay et al. 2015].
Steps: (1) Ask which remedies and prescribed medicines the client uses, by name if known, without asking about preparation or amounts. (2) With consent, tell the prescriber or GP and suggest the client bring the remedy or its label to that appointment. (3) Do not advise starting, stopping or changing anything. (4) Note new physical symptoms, such as yellowing of the skin, which the client may already link to jaundice care, and route them to medical review [synthesis].
Example language (illustrative): "I'm not the right person to say whether the herbs and your tablets go together. Can we let your doctor know, so they can check?"
Watch for: The client stopping prescribed medicine in favour of a remedy, or the reverse, without telling anyone. It is working when the prescriber knows the full picture.

4.9 Physical-safety screening after bone-setting

Purpose / when: When a client has seen, or plans to see, a wogesha for a fracture or dislocation. At Black Lion Hospital in Addis Ababa, 58% of amputations performed for gangrene were attributed to tight bamboo splints applied in traditional bone-setting. Bone-setting was also identified as a leading cause of delay before hospital treatment. In the same study, 29.9% of fracture patients preferred traditional bone-setting, citing cost (96.4% thought it cheaper) and speed (92.9% thought it quicker) [source: Worku et al. 2019].
Steps: (1) Ask whether an injury was treated by a bone-setter, and whether it has been seen by a doctor. (2) Ask in plain terms about worsening pain, swelling, numbness, colour or temperature change, or a bad smell in the limb. Any of these means same-day medical assessment [synthesis; red-flag list is general clinical practice, not from the Ethiopian sources]. (3) Do not comment on how the setting was done. (4) If the client prefers the bone-setter, respect that while making sure they know where to go urgently. (5) Frame consent about touch as the client's own right: they may ask for an explanation, refuse, or stop, and contact should never be sexual [synthesis].
Example language (illustrative): "I'm not judging who set your arm. I just want to check one thing: is it getting more painful, numb or a different colour? If it is, that needs a doctor today."
Watch for: Minimising pain to avoid blame, and delay because of cost or distance. It is working when red flags are reported early and medical review happens.

4.10 Working with birth experiences (awalaj care, home birth and facility birth)

Purpose / when: With pregnant or postnatal clients, or people carrying distress from a past birth, perinatal loss or sanctions. Mothers often prefer female awalaj and home birth. In some areas TBAs were prohibited from attending births and women were fined for home births, under local arrangements [source: Kahissay et al. 2015; Kassie et al. 2022; Hill et al. 2019]. TBAs in one zone reported using herbal remedies for nausea, labour pain and pushing [source: Kassie et al. 2022]. The safety of these remedies is not established in the sources cited here. Any remedy used in pregnancy or labour belongs with the midwife or obstetric team, and heavy bleeding, prolonged or obstructed labour, or fever after birth are emergencies needing skilled facility care [general obstetric safety practice, not from the Ethiopian sources].
Steps: (1) Ask about the birth story openly, including who attended and what the client valued. (2) Ask about any shame, fines or scolding linked to where the birth happened. (3) Screen for perinatal depression, anxiety and birth-related trauma with your usual validated tools. (4) Make sure obstetric and midwifery care is in place for a current pregnancy, and that the client knows emergency routes. (5) Where the client wants an awalaj's emotional or spiritual support as well, help them plan how to combine it with medical care [synthesis].
Example language (illustrative): "Some women have told me the birth attendant at home felt safer than a hospital. What would make you feel safe this time?"
Watch for: Hidden home births, which may follow sanctions [source: Hill et al. 2019, citing Burkina Faso research]. Watch also for unresolved perinatal grief and self-blame. It is working when the client discloses fully and has a birth plan they trust.

4.11 Adjustment after a complication (disability, amputation, loss)

Purpose / when: When a client has had a serious outcome after healer or medical care, such as an amputation after gangrene or a perinatal death [source for gangrene link: Worku et al. 2019].
Steps: (1) Assess for depression, PTSD and complicated grief. (2) Explore the meanings the client gives the outcome (fate, God's will, blame of the healer, self-blame, family conflict). (3) Use your standard evidence-based treatment for the disorder identified. (4) Address anger at helpers without taking sides. (5) Link to rehabilitation and peer support [synthesis].
Example language (illustrative): "Part of you may blame the bone-setter, and part of you may blame yourself for going. Both can be true and still hurt."
Watch for: Suicidal thinking. Assess risk with your usual standard practice. It is working when the client can talk about the loss without collapsing into blame.

4.12 Collaboration and referral with community healers and HEWs

Purpose / when: When the client wants their healer, elder, religious leader or health extension worker involved. In Tehuledere, no formal referral system existed, but both sides were interested. Some healers already referred TB, HIV and diabetes to health centres. Clinic staff referred snakebite, jaundice and haemorrhoids to healers. One bone-setter said clinicians should refer suitable cases to them rather than compete [source: Kahissay et al. 2015]. As collaboration evidence, a cluster trial in Nigeria and Ghana found that collaborative care between traditional or faith healers and primary care workers gave greater symptom reduction in psychosis and fewer harmful practices [source: Gureje et al. 2020 via PubAnnotation].
Steps: (1) Get specific written consent: who, what may be shared, and for how long. (2) Ask the client how the healer prefers to be approached. (3) Agree roles: which concerns the healer addresses, which ones you and medical colleagues address, and what you will each tell the other. (4) Keep confidentiality and the client's right to withdraw. (5) In the diaspora, ask whether the healer is in contact from Ethiopia or is local, and do not refer to anyone outside the client's own trusted pathway [synthesis].
Example language (illustrative): "Would you like me to speak with your family's herbalist, or would you rather keep that separate? Either is fine."
Watch for: Pressure from family to involve or exclude a healer, and role confusion. It is working when the client experiences their helpers as working together.

4.13 Interpreters and cultural brokers

Purpose / when: Whenever the client's preferred language is not yours. The CFI explicitly covers language barriers in the clinician–patient relationship [source: APA DSM-5-TR CFI].
Steps: (1) Use a trained interpreter in the client's preferred language. Ask in advance about community overlap, since small diaspora communities may know each other. (2) Brief the interpreter on keeping healer terms (kitel betash, awalaj, wogesha) and cause terms in the original as well as translated. (3) Use a cultural broker, separately and with consent, for questions of meaning, not for diagnosis [synthesis].
Example language (illustrative): "Please tell me the word your client uses as well as the English, because the word may carry more meaning."
Watch for: Interpreters softening disclosures of healer use. It is working when terms are rendered consistently.

4.14 Working with families and elders

Purpose / when: When elders' advice or family decisions determine where the client seeks help, which is common [source: Kahissay et al. 2015]. In Mekelle, family shame (24.1%) and not knowing where to seek help (52.5%) delayed psychiatric care [source: Teshager et al. 2020].
Steps: (1) Map who decides about care. (2) With consent, invite key family members. (3) Give information about where help is available and what to expect. (4) Address stigma directly. (5) Respect elders' role while keeping the client's own choices central [synthesis; stigma and awareness from Teshager et al. 2020].
Example language (illustrative): "Your uncle's advice clearly matters to everyone. What would he need to know to feel comfortable with this plan?"
Watch for: The client's voice disappearing in family meetings. It is working when the family supports the agreed plan.

4.15 Safeguarding

Purpose / when: When a practice harms or risks harm. Examples include infant uvulectomy or milk-tooth extraction, which health professionals reported a few TBAs advising [source: Kassie et al. 2022]; delay of urgent care for a fracture or a birth emergency [source: Worku et al. 2019]; and coercive or violent practices in any mental-health care setting, such as chaining (documented in Ghanaian prayer camps) [source: Ofori-Atta et al., prayer-camp trial].
Steps: (1) Gather facts calmly: what, to whom, when. (2) Follow your local child-protection and adult-safeguarding procedures and duty-to-report rules. (3) Consult a safeguarding lead and, where possible, a cultural broker, so that response is proportionate and does not stereotype the community. (4) Keep the client informed about what you must share. (5) Never name minors in notes beyond what procedures require [synthesis].
Example language (illustrative): "I respect that this is done in your community. Because it involves a baby's health, I have to talk with a colleague about it, and I'll tell you what happens next."
Watch for: Both errors: misreading a benign practice as abuse, and accepting harm because it is labelled tradition. It is working when the child is safe and the family stays engaged.

4.16 Integrating healing experiences

Purpose / when: After the client has received healer care, whether helpful or not, and wants to make sense of it alongside therapy [synthesis].
Steps: (1) Ask what the experience meant, without asking for ritual or remedy details. (2) Link helpful meanings, such as relief, family support or faith, to the therapy goals. (3) Explore any conflict between helpers' messages. (4) Update the formulation.
Example language (illustrative): "After you saw the herbalist and prayed, what changed for you, inside and in the family?"
Watch for: Pressure on the client to choose one system. It is working when the client can hold both kinds of help without guilt.

4.17 Addressing access barriers and racism in services

Purpose / when: When cost, distance, waiting, short appointments or discrimination push clients away from services. These are among the main reasons people in Ethiopia give for using healers, and the CFI asks about perceived racism [source: Kahissay et al. 2015; Worku et al. 2019; APA DSM-5-TR CFI].
Steps: (1) Ask directly about past experiences of being dismissed or discriminated against. (2) Offer longer first appointments where possible. (3) Reduce practical barriers such as transport and interpreter booking. (4) Repair any rupture your service caused [synthesis].
Example language (illustrative): "Has anyone in a clinic made you feel judged for seeing a healer? I'd like to do better than that."
Watch for: Polite non-return. It is working when attendance holds.

5. Handling problems

The Ethiopian sources describe community preferences, regulation and complications. They do not address psychotherapy, so the responses below are [synthesis] unless a source is named.

The client conceals healer use. This is likely where blame or fines have occurred [source: Hill et al. 2019]. Normalise pluralism, ask about each healer type by name, and state that disclosure will not change your care. Return to it at reviews.
The client asks you to endorse or judge a healer or remedy. Say this is outside your role. Offer to help them get a medical view, and explore what they hope the remedy will do.
The client stops prescribed medicine for a remedy, or the reverse. Do not advise. With consent, inform the prescriber promptly, and explore the reasons (cost, side effects, beliefs).
Bone-setting red flags with reluctance to go to hospital. Acknowledge cost and speed concerns, which most patients in the Addis Ababa study cited [source: Worku et al. 2019]. Be clear and calm that the symptoms need same-day review, and problem-solve transport. Document what you advised.
Pregnancy, with a wish to give birth at home with an awalaj. Explore the client's reasons and fears about facilities. Make sure they have obstetric contact and emergency routes. Do not threaten or shame, as sanctions can push births out of sight [source: Hill et al. 2019]. Follow local safeguarding rules only where a specific risk to mother or baby is identified.
Stuck: spiritual and psychological explanations compete. Return to the explanatory model and agree a both-and plan. For example, the client continues religious or healer care for the spiritual cause while therapy targets sleep, mood or trauma symptoms.
Overwhelm on revisiting a complication or birth trauma. Slow down, use grounding and pacing, and titrate trauma work by your standard trauma-focused protocol. Check safety between sessions.
Resistance from family or elders. Invite them with consent, give clear information about where help is available, and address stigma [source: Teshager et al. 2020 on stigma and awareness]. Avoid positioning yourself against the healer.
Non-adherence to sessions. Check practical barriers first (cost, distance, time, communication) before attributing absence to belief [source: Kahissay et al. 2015].
Rupture: the client feels judged about traditional care. Name it, apologise for your part, and ask what respectful care would look like. Use CFI domain 4 on the clinician–patient relationship [source: APA DSM-5-TR CFI].
Spirit possession, or a distressing experience the community calls normal. Apply the cultural exclusions, consult a broker with consent, and still assess for psychosis, mood disorder and medical causes. ICD-11 6B63 applies only to involuntary, unwanted states outside accepted practice [source: PMC9199574].
A practice harmful to a child is disclosed (e.g. infant uvulectomy) [source: Kassie et al. 2022]. Follow child-protection procedures, consult a safeguarding lead, and keep the family engaged where safe.
The client reports touch by a healer that felt unsafe or sexual. Treat it as a disclosure of possible abuse. Support the client, follow safeguarding and reporting duties, and do not frame it as tradition.
The client asks you to find them a healer. Do not refer outside the client's own trusted community pathway. Explore whom their family or community trusts, and note that most Ethiopian healers are unregistered, according to regulators' estimates [source: Usure et al. 2024].
Diaspora clients far from their healers. Explore loss of those supports, how the client keeps contact, and what local community or religious resources they trust.

Sources

← Previous · XI-071Ethiopian debtera Next · XI-073 →Malagasy ombiasy