Sikidy divination (Madagascar)

1. Introduction

Version followed: sikidy as scholars and Malagasy institutions describe it (the EHESS ethnomathematics project of 2001–2007, Malagasy church and medical authors, and the official tradipraticien framework as reported by Didier 2017). The therapist's procedures follow the DSM-5-TR Cultural Formulation Interview (APA 2022) and Kleinman's explanatory-model questions (Kleinman, Eisenberg and Good 1978).

What it is. Sikidy is the Malagasy word for divination. It names a divination system that scholars link to Arabic geomancy [source: https://ehess.modelisationsavoirs.fr/sikidy/home.html]. Most people know its basic rules, but specialist diviners, the mpisikidy or ombiasy, hold the expert knowledge and are described as "a specialist in guiding people" [source: https://ehess.modelisationsavoirs.fr/sikidy/home.html]. In secondary accounts, sikidy was central to pre-Christian Malagasy religion and the royal courts. It was consulted on fate (vintana) and on timing and choices: journeys, planting, weddings, exhumations, marriage partners, lost objects and migrations [source: https://en.wikipedia.org/wiki/Sikidy] (secondary; [uncertain] for details).

Role in healing. Malagasy and outsider scholars report that sikidy is used to find out why someone is ill. Possible causes include sorcery, spirits, ancestral discontent, broken taboos (fady), and moral causes the Lutheran theologian Rasolondraibe calls tsiny (blame) and tody (retributive justice). The diviner then prescribes remedies, which may include offerings or protective charms [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/9-4_Studies_In_Ministry/Healing%20Ministry%20in%20Madagascar.pdf] [source: https://en.wikipedia.org/wiki/Sikidy]. A Malagasy historical series reports that sikidy was consulted mainly in serious cases, such as grave illness [source: https://www.lexpress.mg/2026/08/la-destinee-du-malgache-sous-le-signe.html].

What this guide covers. Sikidy is a divinatory tradition, not a psychotherapy. A psychotherapist does not cast or interpret sikidy and does not act as an ombiasy. This guide covers what the therapist does alongside it when a client, or the client's family, consults diviners. That work is culturally responsive assessment, formulation, collaboration and safeguarding. In this framing, change happens when the therapist understands the client's own account of the illness and the diviner's place in it, takes it seriously without endorsing or dismissing it, and builds a care plan the client and family can accept [synthesis]. The plan can run alongside ombiasy, church and biomedical care, which many Malagasy families combine [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].

2. Framework

This is a framework for the therapist's work, not stages of sikidy. Session counts are guidance only [synthesis].

Who holds authority in the tradition

Diviners. Authority rests with the mpisikidy or ombiasy. In the EHESS account, their standing rests on specialist knowledge and on what they hold within the tradition, including knowledge of medicinal plants and woods [source: https://ehess.modelisationsavoirs.fr/sikidy/home.html]. Secondary accounts describe a long apprenticeship with initiation and informal ranks. Many people claim the title, but only some are recognised as true professionals. Historically, Antemoro diviners trained at Matitanana were especially influential [source: https://en.wikipedia.org/wiki/Sikidy] [uncertain: secondary source].
The state. Madagascar's Ministry of Public Health has a Service de la pharmacopée et de la médecine traditionnelle. The state-created Association nationale des tradipraticiens de Madagascar (ANTM) certifies practitioners. Decree no. 2007-805 defines the tradipraticien de santé in four categories: traditional midwife, tradi-therapist, herbalist and medico-droguist. Healers without recognition are called guérisseurs. The ministry registers only practitioners who use plants. Diviners such as the mpisikidy are listed among healing specialities, but magico-religious practice is knowingly left outside registration, though not banned [source: https://shs.cairn.info/article/AUTR_081_0159/pdf?lang=fr]. State registration therefore does not tell you whether a diviner is recognised. That recognition comes from the community.
Churches. Christian churches are a major alternative authority. The Malagasy Lutheran revival (fifohazana, from 1894) runs toby healing communities staffed by trained lay mpiandry (shepherds). In the Ambohibao toby, patients are asked to renounce divination, witchcraft, magic and ancestor veneration [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://wordandworld.luthersem.edu/wp-content/uploads/pdfs/9-4_Studies_In_Ministry/Healing%20Ministry%20in%20Madagascar.pdf].
Royal clans and elders. Some fady are enforced by royal clans and their elected chiefs, who control ceremonies, family tombs and community decisions. The Mananjary twin taboo is one example [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html].

Phases of the therapist's work

Preparation (before or alongside session 1). Goal: examine your own assumptions about divination, sorcery and Christianity in Madagascar, and arrange an interpreter if needed (Malagasy, French). Move on when you can state your own biases and have a plan for language.
Cultural assessment (sessions 1–2). Goal: complete the core CFI with the client and, with consent, the Informant Version with a relative, and map the help-seeking pathway. The CFI has 16 questions in four domains [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. The time estimate is [uncertain]: the DSM-5 field trial found that later interviews took less time but gave no minutes [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. Move on when you can state the client's name for the problem, its cause, what any diviner said, and what the client hopes for.
Formulation and differential (sessions 2–3). Goal: weigh culturally normative experience against disorder, with cultural consultation, and screen risk. Move on when you have a working formulation that both you and the client can recognise.
Shared plan (session 3–4). Goal: agree on goals, whether and how to coordinate with an ombiasy, toby, church or prescriber, and the consents needed. Move on when the plan is agreed and documented.
Treatment, integration and review (ongoing; reassess every 4–6 sessions). Goal: deliver the agreed therapy, integrate what the client brings back from consultations, and re-run the relevant CFI modules as needed. The modules can be repeated during treatment [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Safeguarding (throughout). It overrides the phase order whenever someone is at risk.

Format: individual sessions, with family sessions where the family makes care decisions. In one Antananarivo study, relatives often decided on care, and many families took patients out of hospital against advice to go to a toby [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].

3. Guiding principles

You work alongside the tradition, not inside it. In practice: never cast, interpret, endorse or reinterpret a sikidy reading. Ask what it means to the client [synthesis].
Attribute, don't adjudicate. In practice: describe vintana, fady, ancestors and sorcery as the client and tradition hold them, for example "in your family's understanding…", neither as fact nor as superstition [synthesis].
Authority lies in communities. In practice: recognition of a diviner comes from the community and lineage, not the ministry register, which covers only plant users [source: https://shs.cairn.info/article/AUTR_081_0159/pdf?lang=fr].
Medical pluralism is normal. In practice: expect clients to combine diviners, toby, deliverance, holy water and psychiatry, and ask about each without ranking them. In an Antananarivo study, religious care was the first step in 40% of admissions [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
Religious tension is part of the clinical picture. In practice: a Christian client may feel guilt about a family consultation with an ombiasy, or the reverse. Treat this as material to explore, not a side issue [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].
Accept the client's explanation while widening options. In practice: Sharp found that exorcists succeeded partly by accepting and reframing patients' explanations of possession, while psychiatrists who could not accept them often struggled. Work from within the client's account [source: https://ideas.repec.org/a/eee/socmed/v38y1994i4p525-542.html].
The CFI supports diagnosis but never replaces it. In practice: use it to understand the problem and plan care, not as the sole basis for a diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Avoid both pathologising and missing illness. In practice: possession or a spirit call may be normative, but psychosis can still be present. Delayed psychiatric care worsened the prognosis of psychosis in Antananarivo [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
Never advise on remedies or medicines. In practice: ask about any plant remedies or charms the client was given, record them, and route any medicine question to the prescriber. Never suggest starting, stopping or changing a medicine [synthesis].
Collaborate only on the client's terms. In practice: contact a diviner, toby or church only with explicit, specific consent, and say what you will and will not share [synthesis].
Agency within destiny. In practice: when a reading frames an outcome as fated, explore the choices the client still has and what the tradition itself offers for responding to a destiny. Historical accounts describe rites meant to counter a harmful destiny [source: https://www.lexpress.mg/2026/08/la-destinee-du-malgache-sous-le-signe.html] [synthesis].
Safeguarding is not negotiable. In practice: cultural respect never overrides a duty to act on abandonment, restraint, violence or dangerous delay of care [synthesis].
Know the history. In practice: missionary and colonial history shaped how sikidy is viewed. Clients may expect clinicians to disapprove, so state your openness explicitly [synthesis]; the details of historical suppression are [uncertain: not verified].

4. Intervention inventory

Every intervention below belongs to the psychotherapist. None of them involves casting, reading or interpreting sikidy, or giving its remedies. Where a step is not from a cited source, it is marked [synthesis].

4.1 Cultural humility and self-examination

Purpose / when: Use before and throughout work with clients who consult diviners. It surfaces your own assumptions, whether biomedical, Christian, secular or romanticising, that could distort assessment [synthesis].
Steps:
1. Write down what you believe about divination, sorcery and ancestors, and where those beliefs come from (training, faith, media).
2. Note any reflex to correct, convert, rescue or exoticise.
3. Learn the local landscape from attributed sources: how the ombiasy, toby, tromba mediums and psychiatry relate (see section 2).
4. Bring cases to supervision or cultural consultation.
Example language (illustrative): To yourself: "Am I asking this to understand, or to show the client that the diviner was wrong?"
Watch for: Feeling contempt or awe toward the diviner. Asking fewer questions about sikidy than about medication. Working: you can describe the client's view in terms they would endorse.

4.2 Opening the topic of diviner consultation without judgement

Purpose / when: Use at intake and whenever illness, misfortune or a major decision comes up. Clients often do not mention diviners to clinicians unless asked [synthesis].
Steps:
1. Normalise that care is often plural (ombiasy, mpanandro, toby, church, doctor) [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
2. Ask open questions about who else has been consulted, what was said, and how the client felt about it.
3. Ask permission before going deeper. Do not ask for the content of the reading or how it was done; take only what the client chooses to share.
4. Record it in the client's own words.
Example language (illustrative): "Many families I work with have also seen a church healer, an ombiasy or a doctor. Has anyone else helped you or your family think about this? You only need to tell me what you're comfortable sharing."
Watch for: Guarded answers, glances at relatives, or switching languages, which can signal fear of disapproval. Working: the client volunteers later consultations without prompting.

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

Purpose / when: Use in sessions 1–2 to clarify the problem from the client's and their network's perspective: its meaning, sources of help and expectations of care. APA states it is designed for any clinician, any individual and any setting [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: Use the official APA form, which clinicians may reproduce for use with their patients. Modifying or translating it needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Work through its four domains in your own conversational order:
1. Cultural definition of the problem (Q1–3).
2. Cultural perceptions of cause, context and support (causes Q4–5; stressors and supports Q6–7; cultural identity Q8–10).
3. Self-coping and past help seeking (Q11–13). This is where diviner, toby and church consultations usually emerge.
4. Current help seeking (preferences Q14–15; clinician–patient relationship Q16) [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
5. Summarise back and note which subtopics need a supplementary module.
Example language (illustrative): "What do you and your family call what is happening? … What do you think caused it? … Who have you gone to for help, and what did they say?"
Watch for: The client giving "clinic answers" that differ from what they tell family. Working: the causes named in Q4–5 match what emerges later. The DSM-5 field trial found the CFI "feasible, acceptable and useful" [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].

4.4 CFI supplementary modules and Informant Version

Purpose / when: Use when the core CFI shows that sikidy, ancestors, church or migration are central. The modules can be used at the first evaluation, later, or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps:
1. Choose the relevant modules. Spirituality, Religion, and Moral Traditions covers Christian, ancestral and dual affiliations. Explanatory Model covers fate, fady and sorcery causes. Coping and Help-Seeking covers ombiasy, toby and clinic. Social Network covers kin who decide on care. Cultural Identity covers region, clan and ancestry. Immigrants and Refugees is for clients in the diaspora. Caregivers is given to the caregiver [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
2. With consent, use the Informant Version (17 questions) with a relative who took part in decisions [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
3. Compare the client's and informant's accounts and note where they differ.
Example language (illustrative): To a relative: "Your family has been part of these decisions. How do you understand what is happening, and what have you done to help?"
Watch for: A relative speaking for an adult client who wants to speak for themselves. Divergent accounts of who chose the diviner. Working: you can name each person's view and where they agree.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: Use when the cause the client names (vintana, fady, ancestors, sorcery, tsiny or tody) shapes what treatment they will accept.
Steps: Ask, in your own words, the eight explanatory-model questions: 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 should receive; the chief problems it has caused; and what they fear most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]. Add a question about what the diviner or others concluded and whether the client agrees. Then set out your own model briefly and look for overlap.
Example language (illustrative): "You said the ombiasy linked this to something unresolved with the ancestors. Do you see it that way too? What worries you most if it isn't resolved?"
Watch for: Several models held at once (for example, both "stress" and "a broken fady"). This is common, not contradiction [synthesis]. Working: the client can say how your plan fits their own model.

4.6 Mapping the help-seeking pathway

Purpose / when: Use at assessment and whenever there is a delay or drop-out. It shows sequence, cost, who decided, and what helped.
Steps:
1. Draw a timeline with the client of each consultation: family, ombiasy or mpisikidy, mpanandro, tromba medium, toby, deliverance, holy water, general doctor, psychiatry.
2. For each, note who decided, the cost, what was advised, and what changed.
3. Note gaps where urgent care was delayed. In the Antananarivo study, starting with religious or traditional care was associated with slower improvement in hospital [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
Example language (illustrative): "Let's draw the path you've taken since this began: who you saw first, then next, and what each one suggested."
Watch for: Shame about having "tried everything", and financial strain. Working: the map reveals what the client values in each helper, which you can build into your plan.

4.7 Working with Malagasy idioms of fate, taboo and blame

Purpose / when: Use when the client speaks of vintana (destiny), fady (taboo), ancestors (razana), sorcery, or tsiny and tody.
Steps:
1. Ask what the term means in the client's family and region, since meanings vary.
2. Reflect it back using the client's word, attributed: "in your understanding".
3. Explore its emotional load (guilt, fear, obligation) and its social load (who is blamed, who must act).
4. Link these to targets you can work on, such as sleep, conflict and grief, without replacing the idiom [synthesis].
Example language (illustrative): "When you say this is tsiny, who do you feel is blaming you, or whom are you blaming?"
Watch for: Rasolondraibe describes tsiny and tody as moral causes tied to social wrongdoing [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/9-4_Studies_In_Ministry/Healing%20Ministry%20in%20Madagascar.pdf]. Explore interpersonal conflict here. Working: the client can discuss the conflict without fear of being judged.

4.8 Supporting decisions a diviner has advised on

Purpose / when: Use when a reading has guided a decision about timing, a marriage partner, a journey, migration or an exhumation, as secondary accounts report sikidy does [source: https://en.wikipedia.org/wiki/Sikidy] [uncertain: secondary source], and the decision now affects the client's wellbeing.
Steps:
1. Clarify the decision, who sought the reading, and who must comply.
2. Explore the client's own wishes alongside the advice.
3. Help the client consider the options within their tradition, such as asking elders or another recognised specialist, without suggesting a counter-reading.
4. Support communication with family [synthesis].
Example language (illustrative): "The advice was to delay the wedding. What do you want? Is there someone in your family whose view would help you decide?"
Watch for: Coercion presented as fate, especially around marriage, children or inheritance. Working: the client feels like a participant in the decision, not only bound by it.

4.9 Distinguishing culturally normative experience from disorder

Purpose / when: Use when the client reports possession, a spirit call, dreams summoning them to spiritual work, or hearing ancestors. Among the Sakalava, Sharp describes possession and madness as opposite ends of a spectrum, in which possession by powerful spirits can be honourable and lasting [source: https://ideas.repec.org/a/eee/socmed/v38y1994i4p525-542.html]. A student study reports that a call through possession or a recurring dream summons some women to spiritual work as tromba mediums or mpiandry [source: https://digitalcollections.sit.edu/isp_collection/333].
Steps:
1. Establish whether the experience is part of a broadly accepted collective practice. Ask whether family and community recognise it as such.
2. Ask whether it is voluntary or wanted, and about distress and impairment.
3. Apply the diagnostic exclusions. DSM-5 DID Criterion D excludes disturbance that is "a normal part of a broadly accepted cultural or religious practice" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]; DSM-5-TR keeps this in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] (exact wording [uncertain]). ICD-11 6B63 possession trance disorder requires a state that "is involuntary and unwanted" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. ICD-11 6B62 trance disorder excludes accepted cultural or religious practice [source: https://www.findacode.com/icd-11/code-1807490186.html].
4. Screen separately for psychotic, mood and substance-related symptoms, and for medical causes.
5. Consult a cultural broker or a community member the client trusts.
Example language (illustrative): "In your community, how do people tell the difference between a spirit choosing someone and someone being ill? Which does this feel like to you and your family?"
Watch for: The DSM-5-TR note that culturally sanctioned beliefs should not be counted as psychotic symptoms is [uncertain: not verified]; apply it cautiously. Watch for declining function, disorganisation, and the family itself calling it "madness". Working: the client, family and you agree on what is normative and what needs treatment.

4.10 Using cultural concepts of distress and classification carefully

Purpose / when: Use when documenting or coding a presentation shaped by Malagasy idioms.
Steps:
1. DSM-5-TR describes cultural concepts of distress as including "idioms, explanations or perceived causes, and syndromes" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Treat vintana, fady and sorcery attributions as explanations or perceived causes in this sense [synthesis].
2. The DSM-5-TR glossary examples, as a secondary source lists them, include ataque de nervios, dhat syndrome, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto and taijin kyofusho [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. No Malagasy concept appears among them [uncertain: list per secondary source]. Do not force a Malagasy presentation into one of these.
3. Record the client's own term with a plain description, and use the Outline for Cultural Formulation in the record.
Example language (illustrative): In notes: "Client attributes symptoms to a breach of family fady (client's term). The family consulted an ombiasy, which the client experienced as supportive."
Watch for: Reifying a lay explanation as a syndrome. Working: the record would be recognisable to the client.

4.11 Interpreters and cultural brokers

Purpose / when: Use with Malagasy- or French-speaking clients, or whenever religious or ancestral meanings need explaining [synthesis].
Steps:
1. Use a trained interpreter, not a family member, for assessment.
2. Brief them on confidentiality and on the sensitive topics ahead, such as sorcery, church affiliation and diviners.
3. Check that the interpreter is not affiliated with a group the client may fear judgement from, for example a revival congregation or a rival clan.
4. Debrief after the session about terms and nuance.
5. Use a cultural broker for consultation, with the client's consent.
Example language (illustrative): To the interpreter: "Please translate the client's words for spiritual experiences exactly, and tell me afterwards if a word carries a meaning I might miss."
Watch for: The interpreter softening or editorialising talk of diviners or sorcery. Working: the client uses their own terms freely.

4.12 Collaboration and referral with community-sanctioned healers

Purpose / when: Use when the client wants their ombiasy, a toby or a church healer involved in care, or wants coordination with psychiatry.
Steps:
1. Confirm the client's wish and which helper, then obtain specific written consent covering what will be shared.
2. Recognition comes from the community; state registration covers only plant-using tradipraticiens [source: https://shs.cairn.info/article/AUTR_081_0159/pdf?lang=fr]. Ask the client and family who is recognised, rather than checking a register.
3. Agree roles. You hold the psychological care. The diviner's or church's role is theirs to define. Psychiatry holds medication.
4. Agree red flags that trigger medical review, such as stopping eating, aggression or suicidality.
5. In faith-based toby, staff are trained to refer to doctors when unsure of a diagnosis, so use that pathway [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf].
6. Regional evidence, from West Africa and not Madagascar: the COSIMPO cluster trial (Gureje et al., The Lancet 2020) found that collaborative shared care between traditional and faith healers and primary care gave a greater fall in psychosis symptoms and in harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]. In the Ghana prayer-camp trial (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.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. Equivalent trial evidence from Madagascar: [uncertain: not verified].
Example language (illustrative): "Would it help if I spoke with the people at the toby so we aren't pulling you in different directions? I would only share what you agree to."
Watch for: Collaboration being read as your endorsement of every practice. Lowered symptoms with continued restraint, as in the Ghana trial. Working: consistent messages, and earlier medical review when needed.

4.13 Working with conflict between church and ancestral pathways

Purpose / when: Use when a client is torn between a church that asks them to renounce divination and ancestor veneration [source: https://wordandworld.luthersem.edu/wp-content/uploads/pdfs/24-2_Witness_And_Worship:the_Legacy_Of_Loehe/Holistic%20Approach%20to%20Mental%20Illness.pdf] and kin who consult an ombiasy.
Steps:
1. Map each person's position.
2. Explore the client's own beliefs, which may be dual.
3. Work with the guilt, fear and loyalty conflict.
4. Help the client decide what they will and will not take part in, and how to tell family.
5. Do not take sides between religions [synthesis].
Example language (illustrative): "Part of you wants to honour your grandparents' way, and part of you fears it goes against your faith. Can we look at both without rushing to a choice?"
Watch for: Scrupulosity, or fear of spiritual punishment from either side. Working: the client can hold the conflict and make a choice they own.

4.14 Remedies, charms and medicines: record and route

Purpose / when: Use when the client has received plant remedies or protective charms from a diviner or healer, or is weighing them against prescribed medicine. Diviners may also hold plant knowledge [source: https://ehess.modelisationsavoirs.fr/sikidy/home.html].
Steps:
1. Ask neutrally what was given and whether the client is taking it.
2. Record it without assessing it.
3. With consent, inform the prescriber or GP so they can check for interactions and safety.
4. Never advise starting, stopping or changing any remedy or medicine.
5. Explore what the remedy means to the client, such as protection or reconciliation [synthesis].
Example language (illustrative): "Your doctor needs to know everything you're taking so they can keep you safe. Would you be willing for me to let them know about the remedy, or to tell them yourself?"
Watch for: The client stopping prescribed medicine because a reading said the illness is not "medical". Route this to the prescriber promptly. Working: the prescriber is informed and the client stays engaged with both.

4.15 Destiny, hopelessness and risk assessment

Purpose / when: Use when a reading or belief frames the client's fate as bad or fixed, or links illness to an unavoidable cause [synthesis].
Steps:
1. Ask directly about hopelessness and suicidal thoughts using standard risk assessment.
2. Explore whether the tradition itself offers ways to respond to a harmful destiny; historical accounts describe rites meant to counter it [source: https://www.lexpress.mg/2026/08/la-destinee-du-malgache-sous-le-signe.html]. Ask the client, without proposing any rite.
3. Build a safety plan that includes trusted spiritual and family supports.
4. Where there is risk, use lethal-means counselling (safe storage and removal) [synthesis].
Example language (illustrative): "When you were told this was your destiny, did it ever make you feel there's no point going on?"
Watch for: Fatalism hiding suicidal intent, and family pressure tied to a reading. Working: the client names reasons for living and supports from within their world.

4.16 Working with families, kin decision-makers and the diaspora

Purpose / when: Use when relatives choose or pay for consultations and care. In the Antananarivo study, relatives often decided, and many removed patients against advice to take them to a toby [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
Steps:
1. With consent, hold a family meeting.
2. Use the Informant Version or the Caregivers module.
3. Acknowledge the family's efforts and costs.
4. Share a simple explanation of the condition and warning signs.
5. Agree what each party will do.
6. For diaspora clients, ask about obligations to kin and ancestors at home, such as tombs and ceremonies, and about remote consultations [synthesis].
Example language (illustrative): "You've gone to great lengths for your son. Let's agree together on what we each watch for, and when he needs a doctor quickly."
Watch for: Discharge against advice and financial exhaustion. Working: the family contacts you before changing the care plan.

4.17 Safeguarding

Purpose / when: Use whenever a practice linked to readings, fady or healing harms someone.
Steps:
1. Know the documented risks:
  - Dangerous delay of psychiatric or medical care [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
  - Child abandonment. Under the Mananjary twin taboo, twins have been abandoned at birth; the response has included adoption centres, and UNICEF has studied a community where chiefs lifted the taboo [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html].
  - Historical extreme responses to children born under feared birth signs [source: https://www.lexpress.mg/2026/08/la-destinee-du-malgache-sous-le-signe.html].
  - Restraint in faith-healing settings, documented in Ghana [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. Its prevalence in Madagascar is [uncertain: not verified].
  - Sorcery accusations against relatives [synthesis].
2. Assess immediate risk.
3. Follow your jurisdiction's child and adult protection procedures.
4. Where possible, work with respected community or clan figures, who may support change from within. The UNICEF example and researchers' calls for support rather than forced abandonment of tradition point this way [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html].
5. Never name minors in records shared outside the service.
Example language (illustrative): "I respect your family's traditions. I also have a duty to make sure every child is safe, so I need to talk with you about what will happen to the babies."
Watch for: Abuse hidden as tradition, and tradition misread as abuse. Consult before concluding. Working: the protective action keeps the family engaged.

4.18 Addressing history, mistrust and the clinician–patient relationship

Purpose / when: Use when the client expects clinicians, many of them Christian or trained abroad, to disapprove of diviners. Sharp notes that psychiatrists who cannot accept patients' experiences often struggle [source: https://ideas.repec.org/a/eee/socmed/v38y1994i4p525-542.html].
Steps:
1. Use CFI Q16 and the Patient–Clinician Relationship module to ask about language barriers, discrimination and past experiences of care [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
2. Name differences openly.
3. Repair any moments where you dismissed something [synthesis].
Example language (illustrative): "Some people have felt doctors looked down on their family's ways. Has that happened to you? I'd want to know if I ever do that."
Watch for: Polite compliance without engagement. Working: the client corrects you.

5. Handling problems

Sources on sikidy do not address psychotherapy problems directly. The responses below are [synthesis] unless a source is cited.

The client asks you to interpret a reading or say whether it is "true". Decline warmly and redirect to what it means to them: "I'm not the right person to read that, but I'd like to understand what it meant for you." Never offer a competing interpretation [synthesis].
The client asks you to refer them to a diviner, or to find one. You do not broker spiritual services. Explore what they hope for, and suggest they find a recognised specialist through their own family and community pathways. State registration does not identify diviners [source: https://shs.cairn.info/article/AUTR_081_0159/pdf?lang=fr] [synthesis].
Stuck: the client sees therapy as irrelevant because the cause is spiritual. Return to the explanatory model (4.5). Ask what kind of help the client thinks would fit, and offer concrete targets within their frame, such as sleep, worry, grief and family conflict. Sharp's finding that accepting the patient's explanation aids healing supports working from within it [source: https://ideas.repec.org/a/eee/socmed/v38y1994i4p525-542.html].
Resistance born of fear of judgement. Name your openness explicitly and normalise plural care (4.2). Slow down on sorcery topics, which can carry danger or shame [synthesis].
Overwhelm: fear after a reading of misfortune or sorcery. Ground the client and stabilise first, then assess risk (4.15). Don't argue with the content. Help the client identify protective supports they trust [synthesis].
Non-adherence: stopping medication on spiritual advice. Do not advise on the medicine. Inform the prescriber with consent, and explore the conflict between helpers. Seek coordination (4.12, 4.14) [synthesis].
Discharge or drop-out to a toby or healer. This is common in Antananarivo [source: https://www.panafrican-med-journal.com/content/article/29/1/full/]. Keep the door open, agree warning signs with family, and with consent offer to liaise with the toby. Toby staff are trained to refer to doctors when unsure [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: the client felt you dismissed their tradition. Acknowledge it specifically, apologise, and ask what you missed. Use CFI Q16 [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [synthesis].
Family and client disagree about the cause or the helper. Use the Informant Version and joint sessions. Support the adult client's autonomy while keeping the family's goodwill (4.16) [synthesis].
Religious conflict within the client. See 4.13. If the client wants it, involve their own pastor or mpiandry. Avoid any appearance of you endorsing or opposing renunciation [synthesis].
Uncertainty about whether possession or a spirit call is normative or illness. Consult a cultural broker and the family. Use the DSM and ICD exclusions (4.9). Review over time rather than deciding in one session. If psychosis is plausible, arrange a psychiatric assessment without delay, given the worse prognosis with delayed care [source: https://www.panafrican-med-journal.com/content/article/29/1/full/].
Your own discomfort, attraction or alarm. Take it to supervision. Do not seek out ceremonies or readings yourself to "understand" the client; that is outside your role [synthesis].
Remote or diaspora clients facing obligations they cannot meet at home. Explore guilt and grief about distance from ancestors and tombs. Help the client find a way to honour the obligations that their family recognises [synthesis].
Safeguarding concerns that the family frames as tradition. Follow 4.17, consult early, act on immediate risk, and seek respected community figures to support protective change [source: https://archive.crin.org/en/library/news-archive/madagascar-twins-taboo-splits-community.html].

Sources

Sikidy, Malagasy healing and institutions

Cultural assessment, classification and collaboration

Books and articles cited by reference only (details as listed in the sources above [uncertain: not verified])

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.
Chemillier M, Jacquet D, Randrianary V, Zabalia M (2007). Aspects mathématiques et cognitifs de la divination sikidy à Madagascar. L'Homme 181.
Chemillier M (2007). Les Mathématiques naturelles. Paris: Odile Jacob.
Ascher M (1997). Malagasy Sikidy: A Case in Ethnomathematics. Historia Mathematica 24.
Decary R (1970). La divination malgache par le Sikidy. Paris: P. Geuthner.
Sharp LA (1993/1994). The Possessed and the Dispossessed: Spirits, Identity, and Power in a Madagascar Migrant Town. University of California Press.

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