Malagasy ombiasy

1. Introduction

Version followed: the account of Malagasy healing in Pierlovisi and Pourchez (2014; fieldwork in Southeast Madagascar, April to June 2013, as part of a UNESCO project), read alongside Madagascar's official recognition of traditional medicine (decree n° 2007-805) and its registration structures; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules. Other regions and ethnic groups of Madagascar name and divide these roles differently. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

What it is. Ombiasy is the general Malagasy term for the traditional healer. Pierlovisi and Pourchez also name herbalists, masseurs, traditional midwives, soothsayers and astrologers, plus mediums who communicate with spirits through tromba or bilo possession or through sikidy divination. They stress that names and functions vary by region and society, so any fixed classification is approximate. This is a living, plural system, not a therapy, and the psychotherapist does not practise it. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]

How healing is understood (as the tradition holds it, in an outsider's ethnographic account). Hasina (or masina) is described as an invisible, supernatural force; Blanchy, quoted by the authors, calls it a "sacred power which possesses all the beings especially the ancestors". Healers with much hasina are said to draw their power from the ancestors (razana), and hasina is what is held to make a remedy work: in this account plants alone are not enough without the healer. The healer's roles are therapeutic (treating bodily illness), social (preserving group cohesion), sacred (mediating between visible and invisible worlds to restore order), preventive (advice on marriage or house siting) and collective (treating a village struck by misfortune "as if it was a patient"). Complex illness with supernatural causes is the healer's main domain: taboo (fady) violation, sorcery attack and possession by a vazimba spirit. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]

Ambivalence. The healer is "respected but also feared": the same person is believed able to cure illness or cause it, and in the second role is called a sorcerer. For a client, the healer can therefore be a source of safety and of threat. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]

Where the psychotherapist comes in. Studies of psychosis in Madagascar show that most families seek traditional or religious help first and reach psychiatry late. In Antananarivo (2014-2015), religious care, mostly Lutheran toby camps, came first for 40% of people with psychosis and traditional healers alone for 2.5%; in Northwestern Madagascar (2026 report) traditional healers were the first resort in 56.5% and religious practice in 22.2%. Families sometimes consult a diviner, a priest and a doctor at once "to be sure". The therapist's task is culturally responsive assessment and care alongside these pathways, not replacing or imitating them. Change, from the therapist's side, comes through an accurate shared understanding of the problem in the client's own terms, a plan the family can accept, and timely treatment where a disorder is present. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/] [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [synthesis]

2. Framework

2a. Who holds authority in the tradition

Ancestors and hasina. Within the tradition, a healer's power and legitimacy are attributed to the ancestors and to hasina. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Community recognition. Reninjaza (traditional midwives) are chosen by their community, often through family lineage or a perceived gift; healers' legitimacy is judged by social recognition and reputation. [source: https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2022-12/010072896.pdf] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
State structures. Madagascar legalised traditional medicine by decree in 2007 (the authors cite Article 2 of decree n° 2007-805); Improved Traditional Remedies were allowed into public health centres from 2006. The Pharmacopoeia and Traditional Medicine Service of the Ministry of Public Health has worked since 2008 on integration. Healers register only through a local association belonging to the national association of tradipractitioners (founded 1996; NATM in the English paper, ANTM in French sources). A communal advisory committee assesses legitimacy by reputation, a national committee in Antananarivo validates files, and registered healers receive a number and a professional card. Around 60,000 healers were estimated to practise, with about 2,000 registered. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] [source: https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2022-12/010072896.pdf]
Practical meaning. Registration shows state recognition, but most healers are unregistered, and lack of a card is not evidence of illegitimacy within the community; the law lacks precise criteria for telling legitimate healers from "charlatans". [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Church healing. The Lutheran fifohazana (revival) movement runs toby, church-centred communities caring for sick people, coordinated by a pastor and committee with trained volunteer mpiandry (shepherds); the Ambohibao toby works in partnership with the Lutheran hospital next to it. Its model sorts disorders into natural, spirit-related and mixed, and combines medical care with pastoral care, prayer and exorcism. This is a Christian tradition that asks people to renounce ancestor veneration and divination, so it may be in tension with ombiasy care in the same family. [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf]
Local royal lineages. In some communities descendant royal families (mpanjaka) and elected chiefs hold authority over custom, ceremonies and tombs, as in the twin taboo in Mananjary (see 4.14). [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html]

2b. The psychotherapist's process (phases)

The sources describe no therapist protocol for working with ombiasy clients; the phases below organise the CFI-based work and are [synthesis] unless cited.

Engagement and cultural assessment (sessions 1-2). Goal: the client's (and family's) definition of the problem, causes, help already sought, and expectations. Tools: core CFI (16 questions, four domains), Informant Version with a family member (17 questions), selected supplementary modules. Move on when you can state the client's explanatory model in their words and know which healers, churches and remedies are involved. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Formulation and differential (sessions 2-3). Goal: separate culturally normative experience (e.g. recognised tromba mediumship) from disorder, and screen for risk and medical causes. Move on when a working formulation is shared with the client and the risk picture is clear. [synthesis]
Shared plan (sessions 3-4). Goal: a plan the client and family accept, specifying what you offer, what the healer, church or reninjaza offers, and whether (with written consent) you will liaise. Move on when the client has agreed which parts happen where and what will trigger review. [synthesis]
Ongoing therapy and integration (typically weekly, length set by the presenting disorder). Goal: treat any disorder with standard evidence-based therapy, help the client make sense of healing experiences, and revisit the explanatory model as it changes; the CFI modules can be repeated during treatment. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [synthesis]
Safeguarding (any phase). Restraint, coercion, delay of urgent care, sorcery accusation or child-related harm overrides the sequence. [synthesis]

3. Guiding principles

Plural help-seeking is normal. Expect clients to use ombiasy, church, diviner and clinic at once; ask, never assume one pathway. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]
Attribute, do not adjudicate. Describe hasina, ancestors, fady, sorcery and spirits as the client and tradition hold them; neither confirm nor dismiss. [synthesis]
Regional variation. Ask the client what their community calls each healer and what it does; do not apply a single national typology. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Respect secrecy. Discretion is a traditional value for healers; do not press for what a healer does or ask the client to report it. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
The therapist does not perform the tradition. No divination, blessing, possession work or remedies; your role is assessment, therapy, liaison and safeguarding. [synthesis]
Name the ambivalence. A healer can be feared as well as trusted; ask how safe the client feels with each helper. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Family as decision-makers. Decisions about care are often taken by relatives; include them with the client's consent. Decision-makers' belief in sorcery was linked to first going to traditional or religious healers. [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/]
Timeliness matters. Delayed psychiatric care worsens the prognosis of psychosis in Madagascar, so do not let respect for other pathways become collusion with delay. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]
Cost and trust are real barriers. Traditional and religious care is seen as more accessible and affordable; psychiatric care as more effective but costly. Address cost, distrust and impatience directly. [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]
Never advise on remedies or medicines. Ask what the client takes, record it, and route questions to the prescriber. [synthesis]
Consent governs collaboration. Contact a healer, pastor or reninjaza only if the client wishes it, with explicit consent about what is shared. [synthesis]
Safety and rights over tradition. Physical restraint, coercion, abandonment of children and accusations of sorcery are safeguarding matters, whatever their rationale. [synthesis]
Cultural humility. Treat your own assumptions (biomedical, religious or romanticising) as part of the assessment. [synthesis]

4. Intervention inventory

All interventions are the psychotherapist's own. None involves performing divination, possession work, blessing, massage or remedies. Example language is the author's illustrative wording.

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with Malagasy clients, especially when you notice strong reactions to talk of sorcery, ancestors or exorcism. [synthesis]
Steps: (1) Note your own frame: biomedical scepticism, your religious views, or a romantic view of "authentic" healing. (2) Note the specific tensions in Madagascar: ombiasy care and Lutheran toby care may be rivals within one family, since the toby asks people to renounce ancestor veneration and divination. (3) Bring cases where you feel pulled to take sides to supervision. (4) Check whether you have assumed a single "Malagasy" view; the sources show strong regional and ethnic variation. [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] [synthesis]
Example language (illustrative): "I don't know how your family and your community understand this, and I don't want to guess. Will you teach me?"
Watch for: siding with one helper against another; curiosity that turns into extracting secret knowledge. Working: the client corrects you freely.

4.2 Core Cultural Formulation Interview

Purpose / when: first evaluation of any client; APA describes it as "designed to be used by any clinician" in any setting. It supports understanding and decisions and is not the sole basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Use the official APA form (clinicians may reproduce it for their patients; translation or modification needs APA permission). (2) Cover its four domains in order: cultural definition of the problem; perceived causes, context and supports (including the role of cultural identity); self-coping and past help-seeking, including barriers; current help-seeking preferences and the clinician-patient relationship. (3) In the causes domain, leave room for answers such as fady violation, sorcery, ancestors or spirits; record the client's words. (4) In past help-seeking, ask specifically about ombiasy, diviners, reninjaza, church or toby care, and remedies. (5) In the relationship domain, ask about past experience of hospitals and psychiatrists, including distrust. (6) Allow extra time; the field trial found later interviews took less time, but no reliable minute count is established [uncertain]. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://edoc.unibas.ch/54937/]
Example language (illustrative): "People often look for help in more than one place. Who else have you or your family gone to about this: a healer, a church, a diviner, a doctor?"
Watch for: brief, guarded answers about healers (secrecy, fear of disapproval); answers given by a relative instead of the client. Working: the client names helpers and causes without prompting.

4.3 Informant Version with family

Purpose / when: when relatives make care decisions or the client cannot give a full account (e.g. acute psychosis). [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/]
Steps: (1) Get the client's consent to involve the relative where capacity allows. (2) Use the 17-question Informant Version, starting with the informant's relationship to the client. (3) Ask who in the family decides on treatment and what they believe caused the illness. (4) Compare the informant's model with the client's and note conflicts. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [synthesis]
Example language (illustrative): "In your family, who usually decides where someone goes for help when they are ill?"
Watch for: a relative pressing for withdrawal from care to go to a healer or toby; differences between the client's and family's wishes. Working: you know who decides and why.

4.4 Supplementary modules: Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Immigrants and Refugees

Purpose / when: add-ons or standalone tools when the core CFI shows that religion, ancestors, ethnic identity, or migration (e.g. Malagasy diaspora in France or Réunion) shape the problem; usable at first contact, later, or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [synthesis for diaspora examples]
Steps: (1) Pick the module the core CFI points to. (2) For spirituality: explore Christian affiliation, revival-movement involvement, and relationship to ancestors, without ranking them. (3) For identity: ethnic group and region, which shape healer types and taboos. (4) For immigrants: what help is available from home, and whether the family wants the client to return home for healing. (5) Repeat the relevant module when circumstances change. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [synthesis]
Example language (illustrative): "Some families hold both church faith and respect for the ancestors. How is it in yours, and does it touch on what is happening now?"
Watch for: shame or conflict between church and ancestral obligations. Working: the client describes how the two fit or clash for them.

4.5 Explanatory-model exploration (Kleinman)

Purpose / when: to understand the client's own theory of the illness; use with or within the CFI's Explanatory Model module. Source: Kleinman, Eisenberg and Good (1978), Annals of Internal Medicine. [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader] [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]
Steps: cover the eight areas in your own words: the name of 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 the client thinks they should get; the chief problems it has caused; what they fear most about it. Record terms in Malagasy where offered and ask what they mean. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]
Example language (illustrative): "What do you fear most could happen with this illness?"
Watch for: fear of sorcery by a named person, or that the illness is punishment for a broken fady; these shape both risk and what treatment will feel acceptable. Working: you can restate the model and the client agrees.

4.6 Mapping the pathway to care, without judgement

Purpose / when: at intake and whenever the client misses sessions or treatment changes. In Madagascar most people with psychosis reach psychiatry only after traditional or religious care. [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]
Steps: (1) Draw a simple timeline with the client: each helper consulted (ombiasy, diviner, reninjaza, church deliverance, toby stay, holy water, general practitioner, psychiatry), when, and what changed. (2) Ask what each helper said the problem was. (3) Ask what was helpful and what was hard, including cost. (4) Ask whether any remedies or treatments are ongoing, and note them for the prescriber. (5) Ask what the client wants to continue. [synthesis built on the help-seeking categories reported in the sources above]
Example language (illustrative): "Let's write down everyone who has tried to help, in order. I'm not judging any of them; I want to see the whole picture."
Watch for: long delays before psychiatric contact; repeated withdrawal from hospital; ongoing remedies the prescriber does not know about. Working: the client volunteers a new helper without hesitation.

4.7 Recognising Malagasy idioms and causal concepts as cultural concepts of distress

Purpose / when: when the client explains distress through fady violation, sorcery, ancestors, hasina, or possession by a spirit such as a vazimba. DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Steps: (1) Treat these as cultural explanations that shape meaning and help-seeking, not as diagnoses. (2) No Malagasy concept appears in the DSM-5-TR list of named examples reported in secondary sources (ataque de nervios, dhat, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto, taijin kyofusho); the DSM-5-TR list itself is [uncertain]. (3) Use the explanation to guide the formulation: what it says about responsibility, relationships, and what repair is needed. (4) Assess for any co-occurring disorder independently of the explanation. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] [synthesis]
Example language (illustrative): "You've said this may have come from breaking a fady. What would need to happen for things to be put right?"
Watch for: using the cultural explanation to dismiss a treatable disorder, or treating it as delusional. Working: the formulation holds both the client's meaning and the clinical picture.

4.8 Distinguishing culturally recognised possession and mediumship from disorder

Purpose / when: when a client reports tromba or bilo possession, spirit communication, or possession by a vazimba. Tromba is a recognised mediumship role: Sharp's ethnography of a migrant town describes tromba as central to identity and mediums as "far from powerless", with particular attention to migrant women's and children's search for relief. Possession can be valued mediumship, an affliction the community treats, or neither. [source: https://www.ucpress.edu/books/the-possessed-and-the-dispossessed/epub-pdf] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Steps: (1) Ask whether the experience is part of an accepted role or practice in the client's community, and whether the client sought or welcomed it. (2) Ask a trusted community member or cultural broker, with consent, whether the experience is seen locally as normal, as an affliction, or as unusual. (3) Apply the manuals' cultural exclusions: DSM-5-TR dissociative identity disorder allows identity disruption described as possession but excludes disturbance that is a normal part of a broadly accepted cultural or religious practice; dissociative trance (other specified dissociative disorder) is excluded when it is a normal part of collective cultural or religious practice; ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted, not part of accepted practice, and to cause significant distress or impairment. The exact DSM-5-TR wording is [uncertain]. (4) Assess separately for psychosis, mood disorder, substance use, epilepsy or other medical causes, and refer for medical review where indicated. (5) Do not count culturally shared beliefs about spirits as delusions in themselves; that DSM-5-TR states this explicitly is [uncertain]. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] [source: https://www.findacode.com/icd-11/code-1807490186.html] [synthesis]
Example language (illustrative): "In your community, is this something people would recognise and respect, or something that worries them? What do you make of it?"
Watch for: episodes outside recognised settings, loss of function, distress the client wants relief from, or psychotic features between episodes; equally, pathologising a valued mediumship role. Working: the client and a community informant broadly agree with your reading, and any disorder is named for treatment.

4.9 Working with fear of sorcery and the healer's ambivalent power

Purpose / when: when the client fears sorcery, attributes illness to a person's malice, or fears a healer. In Northwestern Madagascar, belief in witchcraft among decision-makers was linked to first consulting traditional or religious healers; healers themselves may be feared as possible sources of illness. [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Steps: (1) Explore the fear's meaning without confirming or refuting it. (2) Assess its impact: sleep, avoidance, conflict with the suspected person, and safety. (3) Assess risk both ways: risk to the client (from fear, self-harm, or others' actions) and risk to the suspected person (accusation, violence). (4) Work on the distress with standard approaches (e.g. anxiety management, problem solving) framed in the client's terms. (5) If accusations are leading to threats against anyone, follow safeguarding procedures (4.14). [synthesis]
Example language (illustrative): "You're afraid someone has caused this. How is that fear affecting you day to day, and are you or anyone else in danger because of it?"
Watch for: escalation from fear to accusation, especially against children, older women or relatives; fear that seeing you will anger a healer. Working: distress falls and the client can function while their belief remains their own.

4.10 Interpreters and cultural brokers

Purpose / when: when the client prefers Malagasy or French, or when idioms need explanation. [synthesis]
Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Check that the interpreter is comfortable with talk of ancestors, sorcery and possession, and with the client's region. (3) Ask the interpreter to render terms such as fady, hasina or tromba as spoken and flag them, not translate them into clinical labels. (4) Consider confidentiality in small diaspora communities; offer an interpreter from outside the client's network. (5) Brief and debrief the interpreter. [synthesis]
Example language (illustrative): "Please keep the client's own words for anything about ancestors or spirits, and tell me afterwards what they mean."
Watch for: the interpreter softening or judging the client's beliefs; the client withholding because the interpreter knows the community. Working: the client speaks freely and terms are preserved.

4.11 Collaboration and referral with community-sanctioned healers, church carers and reninjaza

Purpose / when: when the client wishes their healer, pastor, toby or reninjaza to be part of care. Malagasy authors call for "structured collaboration between biomedical, traditional, and faith-based care providers" and raise collaboration as an open question. Trial evidence from West Africa (not Madagascar) supports collaboration: in the COSIMPO cluster trial in Nigeria and Ghana (Gureje et al., The Lancet 2020) collaborative shared care between healers and primary care workers reduced psychotic symptoms more than usual care and reduced harmful practices; in a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)) adding psychiatric medication to prayer-camp care reduced symptoms, but days in chains were not significantly reduced. [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [source: https://www.panafrican-med-journal.com/content/article/29/1/full/] [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]
Steps: (1) Ask whether the client wants contact and with whom. (2) Agree in writing what may be shared and what may not. (3) Where relevant, ask whether the healer belongs to a local association within the national tradipractitioners' association, while recognising that most practising healers are unregistered. (4) For church care, note that some toby work in formal partnership with hospitals, and that pastors and mpiandry there are trained to refer to doctors when the nature of a disorder is unclear. (5) In contact, ask about the helper's understanding and plans; do not ask about methods. (6) Agree shared warning signs that will prompt referral to medical or psychiatric care. (7) Document and review. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf] [synthesis for steps]
Example language (illustrative): "Would it help if I spoke with your healer or pastor? You decide what I can share, and we can agree it together first."
Watch for: pressure from the family to replace treatment; any restraint or coercion in the setting (4.14); a helper discouraging needed medication. Working: helpers support attendance and the plan is coherent to the client.

4.12 Asking about remedies and medicines (without advising)

Purpose / when: when the client takes healer-prepared remedies, herbal teas (tambavy), or Improved Traditional Remedies alongside prescribed medicine. [source: https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2022-12/010072896.pdf] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Steps: (1) Ask what the client takes, for what, and from whom, without asking for contents or preparation. (2) Record it and, with consent, inform the prescriber or GP. (3) Do not advise starting, stopping or changing any remedy or medicine; route all such questions to the prescriber. (4) Note symptoms that may need medical review. [synthesis]
Example language (illustrative): "Are you taking anything from a healer or the market alongside your tablets? Your doctor should know, so they can check it fits safely."
Watch for: stopping prescribed medication on a helper's advice; new physical symptoms. Working: the prescriber has a full list.

4.13 Perinatal work alongside reninjaza

Purpose / when: for pregnant or postnatal clients who use a reninjaza (traditional midwife). Reninjaza offer massage, herbal teas, nutrition advice, protective practices, postnatal visits and breastfeeding advice, often encourage antenatal visits and refer complications; many women prefer them because health facilities feel unwelcoming. Official discourse is ambivalent, and the Ministry recognises them as tradipraticiennes while blaming them for maternal deaths. [source: https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2022-12/010072896.pdf]
Steps: (1) Ask about the reninjaza's role in the pregnancy without criticism. (2) Explore what makes clinic care hard (reception, relationships, family presence). (3) Screen for perinatal depression, anxiety and psychosis as usual. (4) With consent, support the reninjaza's existing role in accompanying the woman to a facility. (5) Share obstetric and psychiatric warning signs with the client and family. [synthesis]
Example language (illustrative): "Your reninjaza clearly matters to you. How could she and the clinic both be part of looking after you and the baby?"
Watch for: delayed help for obstetric emergencies or postnatal psychosis; the client feeling judged for her choice. Working: the client attends checks and keeps her trusted support.

4.14 Safeguarding

Purpose / when: whenever any practice, in any setting, harms or risks harm: physical restraint or chaining, coercive withdrawal from treatment, delay of urgent medical care, sorcery accusations, or child-related harm. One child-related example is documented: the twin taboo in parts of the Vatovavy-Fitovinany region (Mananjary), where twins are given up or abandoned under a custom upheld by local royal lineages and chiefs, and change has come partly through a community ceremony lifting the taboo and through care centres. Separately, delayed psychiatric care worsens the prognosis of psychosis. [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html] [source: https://www.panafrican-med-journal.com/content/article/29/1/full/] [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]
Steps: (1) Ask directly, in every case of residential healing or church care, about restraint, food, sleep and freedom to leave. (2) Assess immediate risk and medical need. (3) Follow your local adult and child safeguarding procedures and duties; consult your safeguarding lead. (4) Separate the practice from the people: families often act from fear or obligation. (5) For children, never name the child outside the record; consider assent as well as consent. (6) Keep the therapeutic alliance where you can while acting on duty. [synthesis]
Example language (illustrative): "When you stayed there, were you ever tied, locked in, or stopped from leaving or eating?"
Watch for: pressure on a mother to give up a child; a child blamed for misfortune; urgent physical symptoms treated only spiritually. Working: risk is reduced and the family remains engaged.

4.15 Consent and safety around touch-based traditional care

Purpose / when: when the client receives massage from masseurs or a reninjaza, or blessing involving laying on of hands. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] [source: https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2022-12/010072896.pdf]
Steps: (1) The therapist does not touch. (2) Affirm the client's right to agree to touch beforehand and to stop it at any time. (3) Ask whether any touch felt unsafe, painful or sexual; sexual or genital touch is never part of legitimate care and is a safeguarding matter. (4) Refer for medical review of injuries or pain. [synthesis]
Example language (illustrative): "You always have the right to say no or stop, even with someone you respect. Has any treatment felt wrong to you?"
Watch for: reluctance to criticise a respected healer; signs of injury. Working: the client can describe their boundaries.

4.16 Integration of healing and possession experiences

Purpose / when: after a client has been through traditional, toby or deliverance care, or a possession episode, and wants to make sense of it. [synthesis]
Steps: (1) Invite the client's account in their own terms; do not ask for ritual details. (2) Explore what changed (symptoms, relationships, status, obligations to ancestors or church). (3) Identify any distress, shame or conflict (e.g. between church and ancestors) and work on it. (4) Link helpful changes to ongoing goals. [synthesis]
Example language (illustrative): "What did that time mean for you, and what has stayed with you since?"
Watch for: traumatic elements (restraint, fear, coercion); new obligations that cause strain. Working: the experience becomes part of a coherent personal story.

4.17 Family engagement, cost and retention

Purpose / when: when families withdraw clients from care against advice, often from distrust, impatience with slow improvement, or cost. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/] [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/]
Steps: (1) Meet the family early, with consent. (2) Explain the expected course of improvement plainly. (3) Ask about cost and practical barriers and address what you can. (4) Agree what the family will do if they want to try another helper (tell you, keep medication going unless the prescriber says otherwise, keep an appointment). (5) Keep the door open after any withdrawal. [synthesis]
Example language (illustrative): "If you decide to try another kind of help, please tell us, and let's keep one appointment booked so we don't lose touch."
Watch for: silent disengagement. Working: the family returns or keeps contact.

5. Handling problems

The sources name the barriers (delay, distrust, cost, impatience, withdrawal against advice, secrecy, conflict between church and ancestral care); the responses below are [synthesis] unless cited. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/] [source: https://www.clinical-medicine.panafrican-med-journal.com/content/article/21/15/full/] [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]

Client will not talk about healers. Likely causes: fear of disapproval, secrecy expected of healer relationships, or fear of the healer. Response: normalise plural help-seeking, explain you will not ask about methods, and return to it later. "Many people see a healer as well as a doctor. You can tell me as much or as little as you want." (illustrative)
Stuck: client and family hold a purely supernatural model and see no role for you. Response: do not argue the cause; agree on shared targets (sleep, safety, functioning, family conflict) and offer help with those while the other helper addresses the cause.
"Resistance" that is really cost or distrust. Response: ask about money, travel and past hospital experiences directly (CFI relationship domain); offer practical solutions; acknowledge poor past treatment.
Family wants to take the client out of treatment. Response: meet them, explain expected timelines, agree a contact plan (4.17), and keep the door open; if the client lacks capacity and is at serious risk, follow your legal and safeguarding framework. Withdrawal toward a toby was linked by Malagasy clinicians to distrust, impatience and economics. [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]
Non-adherence to medication on a helper's advice. Response: do not take sides; with consent, inform the prescriber; explore what the helper said and what the client fears about the medicine; invite a joint conversation if the client wants it.
Overwhelm during a possession or dissociative episode in session. Response: speak calmly, reduce stimulation, address the client by name, ensure physical safety, and wait; afterwards ask how such episodes are usually understood and handled in their community, and assess for medical causes. Do not attempt to engage the spirit.
Conflict between church (toby) and ancestral obligations. Response: explore both loyalties without ranking them; use the Spirituality, Religion and Moral Traditions module; consider separate conversations with each helper only if the client wants. [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf]
Rupture: client feels judged or that you dismissed their explanation. Response: name it, apologise for the specific moment, restate their model in their words, and ask what would help. "I think I brushed past what you said about the ancestors. I'd like to understand it properly." (illustrative)
Rupture: client fears you will report their family or healer. Response: explain clearly what you must report (harm, restraint, child risk) and what stays confidential; avoid surprise.
The therapist is asked to endorse or perform a practice. Response: decline warmly; explain your role; support the client's own route to the community's legitimate helpers.
Sorcery accusation against a relative or child. Response: assess risk to the accused person, follow safeguarding procedures, and work with the family's fear rather than the accusation (4.9, 4.14).
A helper is registered but you are concerned about practice, or unregistered but trusted. Response: registration is not a sufficient test of safety or legitimacy; base concern on observed harm and the client's experience. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218]
Diaspora clients far from home healers. Response: ask what help the family arranges from home and what the client wants; respect transnational care while monitoring for delay. [synthesis] [uncertain: not verified]
Therapist's own discomfort or fascination. Response: supervision; check whether curiosity serves the client.

Sources

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