Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 075
Guide XI-075

Tromba and bilo spirit possession (Madagascar)

Madagascar (Sakalava; Bara)
A 36 · L 52 · M 1216 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the tradition as described in outsider scholarly ethnography of northwest Madagascar (Lesley Sharp's 1993/1994 study of Ambanja and her 1994 paper on exorcists and psychiatrists; Michael Lambek's 2003 study of Mahajanga, used here only from the publisher's description), with archive metadata for bilo. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). Statements published by Sakalava royal institutions or by bilo practitioners themselves are [uncertain: not verified].

What it is. Tromba and bilo are not therapies. They are living Malagasy spirit traditions, each with its own authorities, and a psychotherapist does not practise them.

  • Tromba is a Sakalava term, now used across Madagascar, for possession by royal ancestors, the spirits of dead Sakalava royalty. The word names the possession experience, the religious institution, a category of spirit, and the medium herself. In the tradition's own terms, tromba spirits speak through mediums, most of whom are women. Each spirit has a distinct personality, and mediums typically do not remember what the spirit did while present. [source: Sharp, The Possessed and the Dispossessed, UC Press e-book] Royal spirits are grouped by dynastic lineage. The oldest and most powerful are held to guide living rulers in major decisions. [source: Gale encyclopedia entry, Sakalava: Religion and Expressive Culture] [uncertain: secondary, unverified] Lambek describes royal ancestors emerging in mediums "to comment on the present", so that history is carried as obligation and ethical practice. [source: cede.ch listing of Lambek, The Weight of the Past]
  • Bilo is documented in the sources cited here only in French national sound-archive metadata. It describes bilo as possession music among the Bara (recorded 1983-1984) that accompanies a healing ceremony called sandratse, in which a sick person is possessed by one or more spirits they wish to be rid of. [source: CREM-CNRS archive item "Bilo, musique de possession"] Any wider account of bilo, including its spread to other groups, its authorities and how it relates to tromba, is [uncertain: not verified].

How change happens, as sources describe it. In Sharp's account, possession and madness are opposite poles of one Malagasy field of experience. Possession by the most powerful spirits is honourable and permanent. Madness is destructive and frightening. Healing works by placing an affliction within the right frame (an honoured spirit to be accommodated, a dangerous spirit to be removed, or an illness), and by repairing social, economic and political as well as bodily trouble. [source: Sharp 1994, Social Science & Medicine abstract, via IDEAS/RePEc] For the psychotherapist, change comes from understanding the client's frame accurately, distinguishing normative experience from disorder, and building a plan the client and their kin can accept, including collaboration with healers or churches when the client wishes. [synthesis]

2. Framework

This is a framework for the psychotherapist's culturally responsive work alongside the tradition, not a protocol of the tradition itself. Phases, session counts and transition criteria are [synthesis]. The CFI content is as APA publishes it. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

Who holds authority in the tradition (as sources describe it).

  • Royal tromba: the Sakalava royal order. Living rulers, the senior royal spirits held to guide them, the mediums (saha) of the most powerful spirits, who are usually commoner women living beside royal tombs, the Sambarivo who serve royalty, and the antimahabo who guard royal tombs. [source: Gale encyclopedia entry, Sakalava: Religion and Expressive Culture] [uncertain: secondary, unverified] Tromba mediums are consulted for spirit permission before some public acts in the Ambanja area. [source: Sharp, UC Press e-book]
  • Other specialists named in the same sources: moasy (herbalists), mpisikidy (diviners), and mediums of other spirit classes. Many tromba mediums also work as healers. [source: Sharp, UC Press e-book] Ambivalence toward healers: in an outsider's ethnographic account from southeast Madagascar, Pierlovisi and Pourchez report that the Malagasy healer is "respected but also feared": the same person is believed able to cure illness or to cause it, and in the second role is called a sorcerer. [source: https://hcs.pitt.edu/ojs/hcs/article/view/176/218] Whether this view extends to tromba mediums who heal is [uncertain: not verified]; ask the client how safe they feel with each helper. [synthesis]
  • Bilo: its leaders and lines of authority are [uncertain: not verified].
  • Protestant healing, which many clients use alongside or instead of tromba: in the Fifohazana revival, lay "shepherds" (mpiandry) are commissioned by the Malagasy Lutheran Church after training and run toby healing communities under church supervision. [source: Rasolondraibe 1989, Word & World]

Phases (therapist's work).

  1. Engagement and cultural assessment (sessions 1-2, individual, optionally with an informant). Goal: the client's own account of the problem, its cause and the help already sought. Use the core CFI and, as needed, the Informant Version. Move on when you can state the client's explanatory model in their words and they agree with your summary.
  2. Differential understanding (sessions 2-4, can overlap with phase 1). Goal: distinguish culturally normative possession or mediumship from a dissociative, psychotic, mood, trauma-related or medical condition, using DSM-5-TR and ICD-11 cultural exclusions and, with consent, a cultural broker. Move on when risk is assessed and a working formulation, including what is not illness for this client, is agreed.
  3. Shared plan (1-2 sessions, family often present). Goal: agree goals, roles of each helper (medium, church, psychiatry, primary care, therapist), consent and information-sharing. Move on when the client has made an informed choice about each pathway.
  4. Ongoing therapy and integration (weekly or fortnightly, open-ended or 8-20 sessions depending on the presenting problem). Goal: work on the agreed problems, help integrate possession, healing or exorcism experiences, and support role or identity conflicts.
  5. Review and ending. Goal: re-run relevant CFI modules, check helpers' roles still fit, plan relapse responses. End when goals are met and the client knows how to re-enter care.

Safeguarding runs across every phase and can interrupt any of them.

3. Guiding principles

  • The tradition belongs to its community. You work alongside tromba and bilo, never as a practitioner. Practical meaning: never offer, simulate or direct possession, mediumship, divination or ceremony. [synthesis, consistent with the outsider status of all sources used]
  • Describe spirits as the client and tradition hold them. Practical meaning: speak of "the spirit your family says has chosen you", neither affirming nor disputing its reality. [synthesis]
  • Possession is not by itself a symptom. DSM-5-TR keeps, in substance, the exclusion of experiences that are a normal part of broadly accepted cultural or religious practice from dissociative identity disorder and dissociative trance; ICD-11 trance and possession trance disorders require the state to be involuntary, unwanted and outside accepted practice. Practical meaning: diagnose only on distress, impairment and what the client and their community regard as abnormal. [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] The exact DSM-5-TR wording is [uncertain].
  • But do not miss illness. Sharp reports that local thinking itself recognises overlap between possession and madness, and that chronic madness often goes uncured. Practical meaning: assess psychosis, mania, depression, trauma and medical causes in every case. [source: Sharp 1994, IDEAS/RePEc abstract]
  • Accept the frame before trying to change anything. Sharp found Protestant exorcists more successful than psychiatrists because they first accepted and then transformed patients' explanations, while psychiatrists failed when they could not accept patients' experiences. Practical meaning: reflect the client's model accurately before offering any other view. [source: Sharp 1994, IDEAS/RePEc abstract]
  • Know the help-seeking landscape. In a 2020-2021 study in northwest Madagascar, 56.5% of people with psychotic symptoms first went to traditional healers and 22.2% to religious practices, and only 12.0% first to psychiatry. [source: Randrianarivo et al., PAMJ Clinical Medicine 2026] In Antananarivo, religious care (mostly Lutheran toby stays) was the most common first step (40%). [source: Bakohariliva et al., Pan African Medical Journal 2018] Practical meaning: expect plural care and ask about all of it.
  • Affliction is social as well as personal. Tromba addresses work, social tension and the local political economy; for migrants in Ambanja it was a route to belonging through fictive kinship. Practical meaning: formulate household, economic and identity stressors, not only symptoms. [source: Sharp, UC Press e-book]
  • Gender matters. Most mediums are women (four of the 98 mediums in Sharp's study were men). Practical meaning: explore what mediumship gives and costs the client as a woman, wife, mother or migrant. [source: Sharp, UC Press e-book]
  • Client choice governs collaboration. Practical meaning: refer to or liaise with a medium, church or healer only when the client asks, with written consent and agreed limits on what is shared. [synthesis] Collaborative-care evidence comes from West Africa, not Madagascar (see section 4).
  • Medicines stay with prescribers. Practical meaning: never advise on fanafody (Malagasy medicine), plant remedies or psychiatric medication; route questions to the prescriber and to primary care. [synthesis]
  • Safety overrides deference. Practical meaning: harm in any setting (restraint, beating, food or water withdrawal, sexual abuse, prolonged exorcism of a distressed person, delay of urgent medical care) triggers your usual safeguarding duties. [synthesis]
  • Mind history and power. Tromba is a source of Sakalava pride and identity and a means of resistance to foreigners and of critique of the present. Practical meaning: be aware that a foreign or biomedical clinician can be heard as one more outsider dismissing the ancestors. [source: Sharp, UC Press e-book]
  • Sources here are outsiders' accounts. Practical meaning: let the client and their community correct you, and hold scholarly descriptions lightly. [synthesis]

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them is a tromba or bilo practice, and none involves ceremony, songs, prayers, sacred objects, initiation or divination. Example language is illustrative. Steps are [synthesis] unless a source is given.

4.1 Cultural humility and self-examination

  • Purpose / when: before and throughout work with Malagasy clients, or anyone describing tromba, bilo or another spirit affliction.
  • Steps: (1) Note your own beliefs about spirits, possession and Christianity, and how they could show in your face or questions. (2) Note your position: foreign or local, biomedical, religious or secular, and what that may mean to a Sakalava client given the tradition's role in identity and resistance to foreigners [source: Sharp, UC Press e-book]. (3) Read about the client's region, but treat ethnography as an outsider's partial account. (4) Bring cases to supervision or consult a Malagasy colleague. [synthesis]
  • Example language (illustrative): "I'm not from your community and I may get things wrong. Please correct me when I do."
  • Watch for: the urge to explain the experience away, or to romanticise it. It is working when the client corrects you freely and brings up spirit matters without being prompted.

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

  • Purpose / when: first assessment, and whenever possession, ancestors or spirit illness come up. APA describes the CFI as designed for any clinician with any individual in any setting. It has 16 questions in four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; and cultural factors affecting current help-seeking. It supports clinical understanding and is not meant as the only basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps: (1) Explain that you will ask how the client and the people around them understand the problem. (2) Work through the four domains in the APA order, in your own words; the form may be reproduced by clinicians for use with their patients, but do not modify or translate it without APA permission. (3) Record the client's own terms, e.g. "tromba", the spirit's name if offered, "njarinintsy", "mpamosavy" (a person who uses magic to harm others) or a church term, without translating them into diagnoses. (4) In domain 4 ask about the relationship with you, including language and any experience of being looked down on in services. (5) Summarise back and check. Time needed is not stated in APA forms; field-trial clinicians found later interviews took less time [uncertain: no figure]. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]
  • Example language (illustrative): "Sometimes people have different ways of describing what is happening. How would you describe it? How would your family, or a medium or the church, describe it?"
  • Watch for: short guarded answers when the client expects ridicule; mixed models (spirit and stress and illness at once) are common and are not contradictions. It is working when the client gives the problem its own name and talks about who else they have seen.

4.3 CFI Informant Version with kin

  • Purpose / when: when family make decisions about care, which is common: in the northwest Madagascar study, decision-makers' education and beliefs shaped first help-seeking. [source: Randrianarivo et al., PAMJ Clinical Medicine 2026] The Informant Version has 17 questions, starting with the informant's relationship to the patient. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
  • Steps: (1) Ask the client's consent and whom they want included. (2) Interview the informant separately or jointly as the client prefers. (3) Note where the kin's view differs (e.g. family sees an honoured royal spirit; client feels ill, or the reverse). (4) Feed differences into the shared plan (4.10). [synthesis]
  • Example language (illustrative): "From what you have seen, what do you think is happening to your sister, and what do you think will help her?"
  • Watch for: the informant speaking over the client, or for a spirit; pressure on a young woman to accept or refuse a calling. Working when both accounts are on the table and the client still has a voice.

4.4 CFI supplementary modules

  • Purpose / when: for depth, at first assessment or later, as add-ons or stand-alone. There are 12 modules. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] Most useful here: Spirituality, Religion and Moral Traditions (relations with ancestors, royal spirits, Christianity or Islam, conversion); Explanatory Model; Cultural Identity (Sakalava or migrant identity; Sharp describes tromba as the one local institution through which migrant women could change identity via fictive kinship [source: Sharp, UC Press e-book]); Coping and Help-Seeking; Social Network; Psychosocial Stressors; Immigrants and Refugees (internal migrants and diaspora); School-Age Children and Adolescents; Caregivers (given to the caregiver).
  • Steps: (1) Pick the modules your core CFI pointed to. (2) Give one or two per session, not all at once. (3) Repeat relevant modules at review. [source for timing flexibility: Supplementary Modules PDF above]
  • Example language (illustrative): "You mentioned you were raised in church and that your grandmother's spirit is a royal ancestor. How do those two parts of your life sit together for you?"
  • Watch for: fatigue from too many questions; religious conflict being the real presenting problem. Working when the formulation sharpens (you can say what the experience means to them and to their network).

4.5 Explanatory-model questions (Kleinman)

  • Purpose / when: to map the client's model of the problem, especially if they name a spirit or sorcery. Kleinman, Eisenberg and Good (1978) proposed eight questions; in paraphrase: what do you call it; what caused it; why did it start then; what does it do and how does it work; how severe and how long; what treatment should you get; what problems has it caused; what do you 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]
  • Steps: (1) Use the questions conversationally. (2) Ask separately about the spirit (who it is, what it wants, whether it is honoured or harmful in the client's view) and about any illness the client also perceives. (3) Note which helper fits each part of the model: medium, moasy, mpisikidy, church, toby, doctor. (4) Write the model in the client's words. [synthesis]
  • Example language (illustrative): "What do you think the spirit wants? And what do you fear most about what is happening?"
  • Watch for: your own questions implying that only one cause is real. Working when the client explains the spirit's role and also says what they want from you.

4.6 Mapping the help-seeking pathway

  • Purpose / when: at assessment, and whenever care stalls. In northwest Madagascar psychiatry was mostly a second or third step, and stays of three months or more occurred only in toby centres; traditional and religious care were seen as more accessible and affordable, psychiatric care as most effective but costly. [source: Randrianarivo et al., PAMJ Clinical Medicine 2026] In Antananarivo, when religious or traditional care came first, improvement in hospital took longer than 10 days in about half of cases. [source: Bakohariliva et al., Pan African Medical Journal 2018]
  • Steps: (1) Draw a timeline with the client: each helper, what they said the problem was, what helped. (2) Note costs, travel and family obligations. (3) Note any current helper whose advice conflicts with yours, without judging it. (4) Use the map for the shared plan. [synthesis]
  • Example language (illustrative): "Let's draw who you have seen so far, a healer, the shepherds, a doctor, and what each one said and did that helped or didn't."
  • Watch for: shame about having seen a healer, or the reverse, fear that you will report them to church or family. Working when the full map, including spirit and church care, is disclosed.

4.7 Distinguishing culturally normative possession from disorder

  • Purpose / when: whenever possession, trance, voices of ancestors or a spirit calling is reported. In Sharp's account, possession by powerful royal spirits is honourable and permanent; some spirits, such as njarinintsy, which frequently possess adolescent schoolgirls, are regarded locally as dangerous and as an illness to be cured; and possession and madness can overlap, with severe cases sometimes taken to psychiatrists. [source: Sharp 1994, IDEAS/RePEc abstract] [source: Sharp, UC Press e-book] DSM-5-TR (in substance) and ICD-11 exclude states that are part of broadly accepted cultural or religious practice; ICD-11 6B63 possession trance disorder requires replacement of identity by an external possessing identity that is involuntary and unwanted; 6B62 trance disorder covers trance without an alternate identity, with distress or impairment. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]
  • Steps: (1) Ask whether the experience happens in an accepted setting and form, and whether the client and community see it as normal, honoured, dangerous or ill. (2) Ask whether it is wanted or unwanted, controllable, and what it costs (work, school, marriage, health). (3) Screen separately for psychosis outside possession states (persistent delusions, disorganisation, hallucinations between episodes), mania, depression and suicidality, trauma and dissociation, substance use, and medical causes (seizures, fever, delirium) via medical review. (4) With consent, ask a Malagasy cultural broker or a community member the client trusts whether the presentation fits accepted patterns. (5) Formulate both what is a disorder, if anything, and what is not. DSM-5-TR's cultural concepts of distress cover idioms, explanations and syndromes; tromba or njarinintsy can be recorded as the client's idiom and explanation without a diagnostic label [synthesis; source for categories: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Whether DSM-5-TR names any Madagascar-specific cultural concept is [uncertain: not verified].
  • Example language (illustrative): "When the spirit comes, is that something you and your family expected and welcome, or something that frightens you? And between those times, how are your sleep, your thoughts, your mood?"
  • Watch for: both errors: pathologising an honoured mediumship, and missing psychosis, mania or a medical emergency because "it's cultural". Red flags: unwanted episodes in unaccepted settings, deterioration between episodes, the community itself calling it madness, risk to self or others. Working when your formulation names what is normative, what is not, and the client agrees.

4.8 Exploring calling, vocation and refusal

  • Purpose / when: when a client (often a woman) experiences illness, dreams or possession as a call to serve a spirit or to Christian ministry, or is torn about it. A student field study reports Malagasy accounts in which refusing a spiritual calling leads to a form of mental illness, and accepting it, as a tromba medium or as Christian service, gives structure and community respect. This is an undergraduate report and is weak evidence. [source: Swift 2006, SIT Digital Collections] Sharp reports that some mediums who suffer excessively seek a way out of possession, and that Protestant exorcists treat problematic possession. [source: Sharp 1994, IDEAS/RePEc abstract]
  • Steps: (1) Ask how the client understands the call and what accepting or refusing would mean for them, their family, their church and their livelihood. (2) Use values work: list what matters on each path. (3) Do not decide for them; clarify that the decision and the authority to confirm a calling lie with their community (mediums, royal authorities, church), not with you. (4) Treat co-occurring depression or anxiety on its own terms. [synthesis]
  • Example language (illustrative): "Some people feel called and want to answer; others want the spirit to leave. What do you want, and who would you need to talk to about it?"
  • Watch for: coercion from either side (kin insisting on mediumship, a congregation insisting on exorcism). Working when the client can state their own wish and the next step within their community.

4.9 Working with interpreters and cultural brokers

  • Purpose / when: when the client prefers Malagasy (or a regional variety) or French, or when you need help judging what is normative (4.7).
  • Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Check the interpreter's own attitude to tromba and to Protestant exorcism before the session; religious conflict can colour translation. (3) Agree that spirit names and local terms are kept, not translated into "demons" or "illness". (4) For a cultural broker, get the client's consent, share the minimum, and ask about patterns, not for a verdict on the client. (5) Respect confidentiality in small diaspora communities. [synthesis]
  • Example language (illustrative): to the interpreter, "Please keep the words the client uses for spirits as they say them, and tell me if a word has no simple equivalent."
  • Watch for: the interpreter softening or judging content; the client holding back because the interpreter is from their congregation or town. Working when the client's own terms reach you intact.

4.10 Shared plan, collaboration and referral with community-sanctioned helpers

  • Purpose / when: when the client wants their care to include a medium, a moasy, a church or toby, or psychiatry, alongside therapy. In northwest Madagascar the authors of a pathways study call for coordination between biomedical, traditional and faith-based providers. [source: Randrianarivo et al., PAMJ Clinical Medicine 2026] Lutheran sources describe shepherds holding healing services in hospital wards at patients' request and some toby centres building dispensaries. [source: Rasolondraibe 1989, Word & World] Trial evidence for collaboration comes from West Africa, not Madagascar: in the COSIMPO cluster trial in Nigeria and Ghana (Gureje et al., The Lancet 2020), collaborative shared care between traditional and faith healers and primary care workers gave a greater fall in psychosis symptoms and fewer harmful practices than enhanced usual care [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]; in a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication to prayer-camp care lowered symptoms but did not significantly reduce days in chains. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] Any established collaboration programme with tromba mediums or bilo practitioners is [uncertain: not verified].
  • Steps: (1) Ask what the client wants from each helper. (2) Agree in writing what, if anything, you may share and with whom. (3) If the client wants contact, ask them how the helper is properly approached in their community; legitimacy comes from the community's own authorities (royal order, mediums' networks, church), not from you. (4) Agree roles: e.g. medium or church for the spiritual dimension, psychiatry or primary care for medical assessment and medicines, you for therapy and coordination. (5) Set safety terms that apply whatever helper is involved (4.15). (6) Review the plan at intervals. [synthesis]
  • Example language (illustrative): "You'd like to keep seeing the shepherds and also see me. What would you like me to know about what they do, and is there anything you'd want me to tell them?"
  • Watch for: splitting (each helper told different stories), helpers asking the client to stop medical care, the client feeling they must choose. Working when the client experiences one coherent plan.

4.11 Liaison with medical and psychiatric care

  • Purpose / when: whenever there is psychosis, mania, severe depression, suicidality, seizures, fever, confusion, pregnancy or physical illness, or the client takes fanafody, plant remedies or psychiatric medicines. Clients may perceive psychiatry as effective but costly and hard to reach. [source: Randrianarivo et al., PAMJ Clinical Medicine 2026]
  • Steps: (1) Arrange medical review for new or changed presentations. (2) Ask, without judgement, what remedies and medicines are being taken and pass the list to the prescriber. (3) Never advise starting, stopping or changing any medicine or remedy. (4) Help the client explain their model to the doctor if they wish. [synthesis]
  • Example language (illustrative): "I can't advise on remedies or tablets, but the doctor needs to know everything you're taking so they can keep you safe. Would you like help telling them?"
  • Watch for: the client hiding remedies from the doctor or medicines from the healer. Working when every prescriber has the full picture.

4.12 Integrating possession, healing or exorcism experiences

  • Purpose / when: after a client has been through tromba healing, a bilo ceremony, deliverance, an exorcism or a toby stay, and wants to make sense of it. Sharp notes that mediums typically do not remember what the spirit did while present, so meaning often comes through others' reports. [source: Sharp, UC Press e-book]
  • Steps: (1) Invite the client to describe the experience only at the level they choose; do not ask for ritual details. (2) Ask what changed afterwards in body, mood, relationships and status. (3) Explore what others told them happened, and how that feels. (4) Link helpful meanings to current goals; process frightening parts with standard trauma-informed methods at a pace the client controls. (5) Respect that some content may be restricted by the tradition. [synthesis]
  • Example language (illustrative): "You don't need to tell me what happened in the ceremony. I'm interested in how you have felt since and what it means for you now."
  • Watch for: distress or shame about what the spirit is said to have done; dissociation in session; signs that the experience was coercive or abusive. Working when the experience becomes part of a coherent story the client owns.

4.13 Working with family, household and community

  • Purpose / when: when a spirit's presence or demands, or a family member's mediumship, shape household life, money, marriage or children. Sharp describes tromba as addressing work, social tensions and political economy, and as creating fictive kin ties. [source: Sharp, UC Press e-book]
  • Steps: (1) Map who in the household relates to the spirit and how. (2) Explore practical burdens and benefits (income from healing, obligations, status). (3) Address conflicts between relatives of different faiths. (4) Keep the client's confidentiality within family sessions. [synthesis]
  • Example language (illustrative): "How has the family's life changed since the spirit came to your mother? What has it brought, and what has been hard?"
  • Watch for: a vulnerable member carrying the family's conflict; children drawn into adult spirit matters. Working when relatives can name needs without blaming the spirit or the client.

4.14 Children and adolescents

  • Purpose / when: a young person, especially a schoolgirl, is said to be possessed, or a family brings a child for spirit-related behaviour. Sharp reports that njarinintsy frequently possess adolescent schoolgirls and are seen locally as dangerous and an illness needing cure. [source: Sharp, UC Press e-book]
  • Steps: (1) Use the CFI School-Age Children and Adolescents module and the Caregivers module. (2) Get consent from those with parental responsibility and the young person's assent. (3) Assess school stress, peer and sexual pressures, family conflict, abuse, trauma, and medical causes. (4) Coordinate with school only with consent. (5) Apply child safeguarding procedures to any harm in any setting. [synthesis; module names from the Supplementary Modules PDF]
  • Example language (illustrative), to the young person: "People at school have been talking about a spirit. What has it been like for you? Is anything else happening that worries you?"
  • Watch for: contagion of episodes in a school, punishment of the young person, missed abuse or trauma. Working when the young person can speak for themselves and adults respond to their needs.

4.15 Safeguarding

  • Purpose / when: whenever any helper, family member or institution uses or proposes practices that harm. A Lutheran account says exorcism of demonic possession can continue as long as the person behaves erratically. [source: Rasolondraibe 1989, Word & World] In the Ghana and Nigeria trials, harmful practices (including chaining) were common at baseline. [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] Whether such harms are documented in Malagasy tromba or bilo settings is [uncertain: not verified].
  • Steps: (1) Ask directly and neutrally about restraint, beating, food or water withdrawal, isolation, sexual contact, being kept from medical care, and prolonged exorcism. (2) Assess risk to the client and to any child. (3) Follow your jurisdiction's adult and child safeguarding procedures and document. (4) Seek urgent medical help for physical danger. (5) Keep naming the tradition respectfully while acting on the harm. [synthesis]
  • Example language (illustrative): "Many people find help from healers and churches. I ask everyone: has anyone ever tied you, hit you, kept food from you, or touched you in a way you didn't want during healing?"
  • Watch for: fear of losing community support if they disclose. Working when the client is safe and still connected to the supports they value.

4.16 Addressing history, identity, migration and racism

  • Purpose / when: when tromba is bound up with Sakalava identity, a migrant's belonging, or experiences of outsiders' contempt. Sharp describes tromba as a source of Sakalava pride, a means of resistance to foreigners and a way to critique the present, and as the institution through which migrant women could become Sakalava through fictive kinship; before the French occupation, tromba mediums held the most important political and spiritual role in one area she describes. [source: Sharp, UC Press e-book]
  • Steps: (1) Use the CFI Cultural Identity and Immigrants and Refugees modules. (2) Explore experiences of having beliefs dismissed by schools, clinics or churches. (3) Ask about the patient-clinician relationship (CFI domain 4) and repair if you are seen as one more dismissive outsider. [synthesis]
  • Example language (illustrative): "Have doctors or teachers ever made you feel your family's beliefs were backward? How is it for you here with me?"
  • Watch for: politeness masking distrust. Working when the client can tell you when something you said felt dismissive.

5. Handling problems

The sources do not address therapy problems directly; all responses below are [synthesis] unless a source is cited.

  • Client will not talk about spirits. Likely fear of ridicule, or of conflict with a church. Response: name that many people use several kinds of help; ask permission; offer the CFI as routine for everyone; return later. Sharp's finding that psychiatrists failed when they could not accept patients' experiences is the reason to make acceptance visible early. [source: Sharp 1994, IDEAS/RePEc abstract]
  • Client wants you to say whether the spirit is real. Response: say honestly that this is a question for the client and their community; your role is to understand what it means for them and help with what troubles them. Do not argue, endorse or diagnose the spirit.
  • Client or family asks you to arrange or attend a ceremony, or to find a medium. Response: decline to arrange or take part; explain that legitimacy comes from the client's own community and its authorities; support the client in approaching them through their usual channels. Any published Sakalava or bilo statement on outsider participation is [uncertain: not verified], and some tromba ceremonies are marketed to tourists, so steer away from commercial routes. [source: vivytravel.com tromba guide, as an example of tourist marketing]
  • Stuck between two systems (e.g. a royal spirit and Protestant faith). Sharp's chapter structure covers conversion and Protestant exorcism of possession. [source: Sharp, UC Press e-book] Response: values work (4.8), CFI Spirituality module, and, if the client wishes, separate conversations with each authority. Do not take a side.
  • Overwhelm or dissociation in session. Response: slow down, ground in the present (orientation to room, time, your voice), shorten the session, and plan for what to do if an episode starts. Never invite, induce or provoke a possession state in therapy. If a possession state appears in session, stay calm, keep the client and others safe, wait, and afterwards ask the client how they would like such moments handled; ask whether their community has a recognised way of caring for them.
  • Escalating psychosis, mania or suicidality. Response: standard risk assessment and crisis pathway, urgent psychiatric or medical review, family involvement with consent. Cultural framing never delays emergency care. In Antananarivo, starting with religious or traditional care was linked to slower improvement in hospital. [source: Bakohariliva et al., Pan African Medical Journal 2018]
  • Non-adherence to medical care because a healer or church advised stopping. Response: do not advise on medicines; explore the client's reasons; offer a joint conversation with the prescriber; with consent, coordinate so helpers are not giving contradictory instructions.
  • Non-attendance. Likely causes: cost, travel, family obligations, a long toby stay (three months or more occurred only in toby centres in one study [source: Randrianarivo et al., PAMJ Clinical Medicine 2026]), or a ceremony period. Response: ask about such periods in advance, offer flexible or remote sessions, keep the door open.
  • Rupture: the client feels judged or pathologised. Response: invite the feedback (CFI domain 4), acknowledge specifically, restate that you are not diagnosing their tradition, and adjust.
  • Family insists on a frame the client rejects. Response: individual time for the client; family session with ground rules; protect the client's right to decide about mediumship, exorcism or treatment; safeguarding if coercion becomes harmful.
  • Possible harm in a healing setting. Response: 4.15; act on the harm while avoiding blanket condemnation of the tradition or of the church.
  • Your own discomfort or fascination. Response: supervision; check whether you are asking ritual details out of curiosity rather than clinical need.
  • Unclear authority or sources. Response: when a claim about the tradition matters to care, ask the client or a broker they trust rather than relying on ethnography; record what is uncertain.

Sources

← Previous · XI-074Sikidy divination (Madagascar)Next · XI-076 →Haitian Vodou