Tukano and Piaroa ecological shamanism

1. Introduction

Version followed: Indigenous-authored accounts come first. These are João Paulo Lima Barreto (Yepamahsã/Tukano) on Tukano health specialists and the Bahserikowi centre (2017), and the UNESCO listing of the Pirá Paraná "jaguar shamans of Yuruparí" (2011). Outsider ethnography is used as attributed context: Reichel-Dolmatoff's Tukano/Desana "ecological" model as summarised and critiqued by Cayón (2001), Overing on the Piaroa ruwang, and Freire and Zent on Piaroa health. The clinician's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). Legal frameworks are Colombia's Decreto Ley 480 de 2025 (SISPI), with Brazil and Venezuela as sources report them.

What this is. "Tukano and Piaroa ecological shamanism" is a scholars' label, not a therapy. It names a reading, associated above all with Gerardo Reichel-Dolmatoff, of the healing and protective specialists of the Eastern Tukanoan peoples of the Vaupés/upper Rio Negro (Colombia and Brazil; including Tukano/Yepamahsã, Desana, Tuyuka and Makuna). The same lens is applied to the specialists of the Piaroa of the Orinoco basin in Venezuela. In Reichel-Dolmatoff's model, as Cayón summarises it, the cosmos is a closed and finite energy system. The specialist perceives imbalances in people and animal populations, restores balance and imposes hunting and fishing restrictions. Illness is understood as "una infracción a las normas culturales" (an infraction of cultural norms). [source: https://www.redalyc.org/pdf/1050/105015287009.pdf] This model has been strongly contested by later ethnographers working with the Makuna. Cayón argues that Tukanoan thought concerns cosmic order, not energetic equilibrium, and that ecological relations are social relations with other beings. [source: https://www.redalyc.org/pdf/1050/105015287009.pdf] [source: https://revistas.icanh.gov.co/index.php/rca/article/view/1285] Tukano authors reject the generic word pajé and the "exoticised" image behind it. They also reject framing their medicine as "religion" or "spirits", and prefer the term "medicina indígena". [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]

How the communities describe health and change. These accounts are attributed. They are neither asserted nor dismissed.

Tukano (Barreto). Health and illness are "cosmopolitical". They depend on keeping reciprocal relations with the waimahsã, beings who own and look after places, animals, plants and weather. Breaking that reciprocity produces social, environmental or bodily imbalance. Specialists (yai, kumu, baya) diagnose the origin of an illness and then treat or protect. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Pirá Paraná communities describe their specialists' calendar of rituals as aiming to "heal, prevent sickness and revitalize nature". [source: https://ich.unesco.org/en/RL/traditional-knowledge-of-the-jaguares-of-yurupari-00574]
Piaroa (Freire and Zent). Health is a balance of biophysical, social and symbolic forces. A healthy person "vive bien con sus parientes" (lives well with their kin). Illness results from external aggression, breaches of social norms or contagion. Most illnesses are associated with eating or seeing particular animals. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] Overing describes the ruwang as the Piaroa political and religious leader and a "constructor of worlds" whose knowledge maps the universe. [source: https://periodicos.sbu.unicamp.br/ojs/index.php/ideias/article/view/8677762]

The psychotherapist's role. You do not perform, imitate or adapt any of this. The healing, protective and diagnostic work belongs to specialists trained and recognised within their own peoples. Your work runs alongside it. It covers culturally responsive assessment (the CFI and explanatory models), careful diagnosis, collaboration with community-sanctioned specialists when the client wishes, support for integration, and safeguarding. This guide gives no ritual procedure, sung or spoken formulas, sacred objects, plant or snuff use, initiation or diagnostic methods of the specialists. [synthesis]

Who holds authority.

Tukanoan peoples. The specialists themselves (yai diagnoses, kumu treats, baya is master of dances and also a kumu) hold authority over this knowledge. They train for many years under a senior specialist. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf] [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] On the Pirá Paraná, the Association of Captains and Traditional Indigenous Authorities of the Pirá Paraná (ACAIPI) has led safeguarding work with Gaia Amazonas. [source: https://ich.unesco.org/en/assistances/safeguarding-of-the-traditional-knowledge-for-the-protection-of-sacred-natural-sites-in-the-territory-of-the-jaguars-of-yurupari-vaupes-province-colombia-01224]
Colombia. Decreto Ley 480 de 2025 establishes the Sistema Indígena de Salud Propia e Intercultural (SISPI) as state policy. It places planning and implementation with Indigenous self-government health structures (Gobierno Propio), names "los sabedores ancestrales" as system actors and provides for recognising "sabios, sabias y autoridades tradicionales en materia de salud". [source: https://sidn.ramajudicial.gov.co/SIDN//NORMATIVA/TEXTOS_COMPLETOS/5_DECRETOS/DECRETOS%202025/Decreto%20Ley%200480%20de%202025.pdf]
Brazil. Bahserikowi (Centro de Medicina Indígena da Amazônia, Manaus) was founded in 2017 by Barreto with specialists from several peoples. It describes itself as an additional option, not a replacement for official care. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Mongabay reports that a 2017 federal measure allowed Indigenous healers to take part in SUS care through SESAI, via the Special Indigenous Health Districts (DSEI). [source: https://news.mongabay.com/2020/04/shamans-in-the-city-brazil-clinic-offers-traditional-amazonian-treatments] [uncertain: not verified]
Piaroa (Venezuela). Freire and Zent describe community leaders who are usually also the shamans. Within the community, the chant-healer and the specialist with the highest ritual authority are the main figures. A Piaroa Congress (1984) and a Piaroa-led party, PUAMA (1998), represent the people politically. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] A current Venezuelan legal framework for Piaroa traditional medicine is [uncertain: not verified].

A note on the scholarship. The "ecological shamanism" label comes from outsider ethnography. Reichel-Dolmatoff's model is contested on substance (see above). In 2012, documents presented in Vienna linked him to the SS and the Nazi party before his emigration. Commentators argued this calls for a re-examination of his idealisation of "pure", "isolated" peoples. [source: https://www.lasillavacia.com/?p=28244] Treat any outsider account, including this guide's, as secondary to what a client and their own specialists and authorities say. [synthesis]

2. Framework

This is not a phased therapy. Below is a phased structure for the psychotherapist's own work with a Tukanoan or Piaroa client, or any client whose care involves these specialists. It is built from the CFI and from the community and legal sources above. Phase names, sequencing and session counts are [synthesis]. No source sets a session count.

Phase 0. Preparation (before or between sessions).

Goal: know your own assumptions. Learn the client's people, language and the local care pathways (SISPI health structures in Colombia, DSEI/SESAI and Bahserikowi in Brazil, community leadership among the Piaroa). Arrange an interpreter or cultural broker if needed.
Move on when you can name the likely care pathways and have checked your own framing (for example, that you are not treating the specialists' work as "belief" set against "real" treatment). [synthesis]

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

Goal: understand the problem in the client's terms. Use the core CFI (16 questions in four domains), selected supplementary modules, and an informant interview with consent. The APA does not intend the CFI as the sole basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Administration time is [uncertain]. In the field trial, later interviews "required less time". [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 perceived cause, who they have consulted or want to consult, and what they expect from you.

Phase 2. Formulation and risk.

Goal: produce a cultural formulation. Decide what is culturally normative experience and what is disorder, assess risk, and agree a shared description of the problem.
Move on when the client recognises the formulation as theirs and risk is assessed and documented.

Phase 3. Collaborative planning.

Goal: agree a plan that respects the client's right to choose biomedical, traditional, intercultural or combined care. Colombia's Decreto Ley 480 de 2025 states this right ("derecho de opción al tratamiento en salud", art. 20) and recognises cultural objection. [source: https://sidn.ramajudicial.gov.co/SIDN//NORMATIVA/TEXTOS_COMPLETOS/5_DECRETOS/DECRETOS%202025/Decreto%20Ley%200480%20de%202025.pdf] Set up liaison with specialists or authorities only with explicit consent.
Move on when roles are clear: what you do, what the specialist does, what the prescriber or physician does, and how information is shared.

Phase 4. Ongoing work (weekly or fortnightly; length set by the presenting problem).

Goal: deliver your own evidence-based treatment for the presenting problem, adapted with the formulation. Support integration of what happens in Indigenous care. Work with kin and community relationships, and with displacement, discrimination and urban life. Review safeguarding throughout.
Revisit Phase 1 modules when the client's situation changes (a move, a new illness explanation, a family conflict). The APA notes the modules can be repeated during treatment. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]

Phase 5. Review and ending.

Goal: review outcomes in the client's own terms as well as standard measures, and confirm continuing links with community care.
End when goals are met and the client knows how to return. [synthesis]

3. Guiding principles

Authority stays with the people and their specialists. Defer to yai, kumu, baya, Piaroa specialists and traditional authorities on their own knowledge. Never position yourself as a practitioner of it. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679]
Use the client's terms, not "shaman" or "pajé". Ask what word they use for the specialist and for the illness. Barreto rejects the generic label and its exoticism. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679]
Do not frame Indigenous medicine as religion or belief. Barreto describes "sagrado", "fé" and "espíritos" as imported Christian categories. Describe waimahsã or märimü as the client describes them, without endorsing or dismissing. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
Neither system is ranked above the other. Integration, not hierarchy, is the stance quoted from clinicians working with Indigenous health. In practice, plan for both systems to act within their own competence. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
Treat outsider ethnography as attributed context. Reichel-Dolmatoff's "ecological" model is one contested outsider reading. Do not use it to interpret a client. [source: https://www.redalyc.org/pdf/1050/105015287009.pdf]
Health is relational and territorial. In both peoples' accounts, wellbeing depends on relations with kin, other beings and places. So ask about relationships, food, places and conduct, not only symptoms. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679]
Respect restricted knowledge. Specialists withhold sensitive knowledge, and some ritual contexts are restricted by gender and age. Never ask a client to disclose formulas, ritual content or training secrets. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [source: https://ich.unesco.org/en/RL/traditional-knowledge-of-the-jaguares-of-yurupari-00574]
The client chooses. Their right to choose biomedical, traditional or combined care, and to refuse on cultural grounds, is written into Colombian law. Elicit preferences, explain your view honestly and document the choice. [source: https://sidn.ramajudicial.gov.co/SIDN//NORMATIVA/TEXTOS_COMPLETOS/5_DECRETOS/DECRETOS%202025/Decreto%20Ley%200480%20de%202025.pdf]
Consent governs every contact with healers and kin. Share no information with a specialist, family member or authority without the client's specific consent, except under safeguarding law. [synthesis]
Do not seek or broker ceremonies. Neither suggest nor arrange ceremonies or plant medicines for clients, and never take part yourself. Refer only along pathways the people themselves sanction. [synthesis]
No advice on plants, snuffs or medicines. Route questions about combining plant medicines with prescribed drugs to the prescriber. Bahserikowi's founder states its plant medicines have no side effects. Treat that as the centre's claim, and leave interaction questions to the prescriber. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [synthesis]
Name discrimination. Barreto's account of a hospital refusing joint care and Indigenous specialists' exclusion from institutions show that services can enact racism. Ask about it and own your service's part. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
Avoid both pathologising and missing illness. Culturally normative experience is not disorder. Neither is a cultural explanation proof that no disorder exists. Assess both. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
Safety overrides. Delay of urgent medical care, violence linked to accusations, and harm to children are safeguarding matters whatever their cultural framing. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions. None reproduces or substitutes for the work of Tukanoan or Piaroa specialists. Steps and example language are [synthesis] unless a source is tagged. All example wording is illustrative.

4.1 Cultural humility and self-examination

Purpose / when: Use before and throughout the work. It surfaces assumptions drawn from popular images of the "Amazonian shaman", from "ecological Indian" romanticism, or from dismissal. Barreto names the exoticised pajé image circulating in media, textbooks and science as a source of misunderstanding. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679]
Steps: (1) Write down what you think you know about these peoples and where it came from (films, ethnography, retreat marketing). (2) Mark which parts come from outsiders. Reichel-Dolmatoff's energy-balance model, for example, is contested. [source: https://www.redalyc.org/pdf/1050/105015287009.pdf] (3) Check your language: "specialist", "kumu", or the client's own term, not pejorative labels for healers or "primitive"; "Indigenous medicine", not "superstition". (4) Note your reactions to sorcery or spirit explanations and keep them out of your questions. (5) Take it to supervision or consultation, ideally with an Indigenous colleague.
Example language (illustrative): "I know very little about Tukano medicine except what outsiders have written. I'd rather learn from you how you and your family see this, and what words you use."
Watch for: romanticising the client as an "ecological" or "spiritual" person, or expecting "ceremonial display" (Barreto reports doctors held such stereotypes). [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] It is working when the client corrects you freely and introduces their own terms.

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

Purpose / when: At intake for any client from these peoples, or any client whose care involves their specialists. The CFI clarifies the problem from the perspective of the person and their social network: what it means, sources of help and expectations of services. 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; Cultural Factors Affecting Current Help Seeking. APA describes it as usable "by any clinician" in "any care setting". Clinicians may reproduce it for use with their patients, but modifying or translating it needs APA permission. [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) Download the official form and use it as published. (2) Introduce it as a way to understand the problem in the client's terms. (3) Work through the four domains in order, following the client's words. When the cause is placed in relations with waimahsã, food or another person, record it verbatim. (4) In the domain on cultural identity, ask about people, language, clan or sib affiliation as the client chooses to describe it, and about life between village and city. (5) In past help seeking, ask about Indigenous specialists, health posts, hospitals, churches and pharmacies alike. (6) In the clinician-patient relationship domain, ask directly about racism and language barriers. (7) Summarise back and check.
Example language (illustrative): "People explain problems in many ways. What do you call what is happening, and how would your family describe it?" "Have you seen a kumu or anyone else about it? What did they say?"
Watch for: short, guarded answers. These may reflect earlier dismissal by services; slow down. Do not rush to symptom checklists. It is working when the client gives an explanation in their own terms and names who else is involved in their care. Administration time is [uncertain].

4.3 CFI supplementary modules

Purpose / when: To go deeper when the core CFI shows a domain matters. There are 12 modules: Explanatory Model; Level of Functioning; Social Network; Psychosocial Stressors; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient-Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; Caregivers. They can be used at 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 modules from what the core CFI showed. Typical choices here: Explanatory Model; Social Network (kin, in-laws, community); Coping and Help-Seeking; Cultural Identity (village/city, languages); Psychosocial Stressors (displacement, land conflict). Use Immigrants and Refugees for clients displaced across borders. (2) For the Spirituality, Religion and Moral Traditions module, say first that you will not assume the client sees their medicine as "religion". Barreto rejects that framing. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf] Many clients also take part in Catholic or evangelical churches, so ask openly. [synthesis] (3) Use the Caregivers module with a caregiving relative. (4) Repeat a module when circumstances change.
Example language (illustrative): "Some people don't think of their own medicine as religion at all, more as knowledge. How would you put it?"
Watch for: module fatigue, so spread modules over sessions. It is working when new information changes the plan, for example a relative's role or a church conflict.

4.4 CFI Informant Version with kin

Purpose / when: When the client consents and kin carry the illness narrative or decide on care. This fits Piaroa accounts in which health means living well with relatives. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf]
Steps: (1) Get the client's consent, including what may and may not be shared. (2) Use the 17-question Informant Version, which opens with the informant's relationship to the client. (3) Interview separately if the client prefers. (4) Compare the two explanations and note agreements and tensions.
Example language (illustrative): "Your son said I could talk with you. How do you and the family understand what has been happening to him?"
Watch for: the relative's account overriding the client's. Also watch for a relative's explanation that blames another person (see 4.17). It is working when you can describe where the family agrees and where it differs.

4.5 Kleinman explanatory-model questions

Purpose / when: A brief alternative or complement to the CFI Explanatory Model module, from Kleinman, Eisenberg and Good (1978). [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: Ask, in your own words, the eight areas: what the client calls the problem; its cause; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment the client thinks is right; the main problems it has caused; what they fear most. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] Record answers verbatim. Note where the client places the illness: in the body, among kin, between people, or in relations with places, animals or waimahsã.
Example language (illustrative): "Why do you think it started then, rather than at another time?" "What worries you most about where this is going?"
Watch for: answers about timing that point to a move, a hunt, a food, a trip to a particular place, or a conflict. They often carry the explanation. It is working when you can state the client's model back and they agree.

4.6 Mapping the client's account of cause without asking for restricted knowledge

Purpose / when: When the client links distress to categories their people recognise. Barreto lists four broad Tukano causes: attacks by waimahsã when people use resources or enter their places without permission; food-related causes; illnesses linked to women's vulnerable periods (menstruation, pregnancy, postpartum); and interpersonal aggression, which he translates as witchcraft. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Freire and Zent report that Piaroa link most illnesses to eating or seeing certain animals. Serious illnesses are often attributed to enemy shamans or spirits, and forest beings (märimü) concentrate at important places that people avoid. They also describe de'a ituna, a common form of madness associated with not knowing how to live in harmony with kin. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf]
Steps: (1) Let the client name the category; never offer one first. (2) Ask about consequences, not mechanisms: what changed in their life, relationships and sleep, and what the specialist advised in general terms. (3) Do not ask for the specialist's methods, words or materials. Barreto notes that specialists withhold sensitive knowledge and are reluctant to discuss witchcraft openly. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] (4) Link the account to what you will both work on, such as sleep, conflict with in-laws or grief.
Example language (illustrative): "You don't need to tell me anything that should stay with the kumu. What I'd like to understand is how this has affected you and the people around you."
Watch for: relief when the client realises you will not probe secrets. Note a de'a ituna-type framing, which points the work toward kin relations. [synthesis] It is working when the client volunteers more context over time.

4.7 Diagnostic caution: cultural concepts of distress, trance and possession

Purpose / when: Whenever diagnosis is in play. No DSM-5-TR glossary entry names a Tukanoan or Piaroa concept. [uncertain: not verified] The manual treats cultural concepts of distress as "idioms, explanations or perceived causes, and syndromes". The client's terms (for example de'a ituna, or an illness attributed to waimahsã) should be recorded as idioms and explanations, not mapped onto a DSM label. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: (1) Record the client's idiom and explanation in the formulation. (2) Assess DSM-5-TR disorders on their own criteria. (3) For trance or identity-alteration presentations, apply the cultural exclusions. DID Criterion D excludes disturbance that is a normal part of broadly accepted cultural or religious practice, and dissociative trance (other specified dissociative disorder) does not apply to trance that is part of accepted collective practice. In ICD-11, 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted and outside accepted cultural or religious practice. [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] (4) Exact DSM-5-TR wording is [uncertain]; check the manual. (5) Seek a cultural broker's view before diagnosing psychosis where the content concerns other beings, sorcery or specialists.
Example language (illustrative): "In your community, would people see what you've been experiencing as expected, or as something that has gone wrong?"
Watch for: both errors, labelling an accepted experience as psychosis and dismissing psychosis as "cultural". It is working when your formulation holds both the client's idiom and a careful diagnostic opinion, and the client and a cultural broker find it fair.

4.8 Distinguishing normative experience from disorder

Purpose / when: When the client reports experiences that their people may treat as meaningful: dreams, encounters with beings at particular places, an illness read as an attack, or the demands of training as a specialist. Barreto describes specialist training as beginning in childhood and continuing for years with seclusion, dietary and sexual restrictions under a senior teacher. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679]
Steps: (1) Ask whether others in the community would recognise the experience and how they would understand it. (2) Ask whether a specialist has been consulted and what kind of matter they judged it to be. Freire and Zent report that Piaroa distinguish illnesses of "magical" origin from those doctors can treat, and this decides which specialist acts. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] (3) Assess function, distress, safety, and the course over time: sleep, eating, self-care, disorganisation, risk. (4) If a client is in specialist training, distinguish expected rigours (described by the client and their teacher) from deterioration, such as weight loss, inability to function or suicidal ideas. (5) With consent, consult a cultural broker or the client's specialist through the client.
Example language (illustrative): "If your grandfather heard about this dream, what would he say it means? And apart from what it means, how have you been sleeping and eating?"
Watch for: distress the client experiences as unwanted and outside what their people expect, which points toward disorder. Also watch for an accepted experience causing no impairment, where no diagnosis is needed. It is working when the client feels the experience was respected and risk is clear. [synthesis]

4.9 Asking about Indigenous specialists without judgement

Purpose / when: At intake and at reviews. Clients often use several systems at once and may hide this after past dismissal. Barreto describes a hospital refusing a kumu access to a patient. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [source: https://news.mongabay.com/2020/04/shamans-in-the-city-brazil-clinic-offers-traditional-amazonian-treatments]
Steps: (1) Ask routinely, as you would about any other provider. (2) Ask what the specialist found and advised, in general terms, and whether the client plans to continue. (3) Ask about any dietary or conduct restrictions the client is keeping. Barreto notes that consultations may involve them, and they may affect sleep, mood, appointments or medication timing. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] (4) Ask about plant medicines only so that you can tell the prescriber with consent. Give no advice on them. (5) Record it neutrally.
Example language (illustrative): "Many people I see also go to a kumu or another specialist, and that's fine with me. Is anyone else helping you with this?"
Watch for: hesitation or a change of subject, which suggests the client is testing whether you will disapprove. It is working when they tell you about all their care.

4.10 Collaboration and referral with community-sanctioned specialists

Purpose / when: When the client wants their Indigenous care and your work coordinated, or wants a specialist they cannot reach. Colombian law gives Indigenous people the right to choose biomedical, traditional, intercultural or combined care. It places Indigenous health within SISPI under traditional authorities and requires coordination with the general health system. [source: https://sidn.ramajudicial.gov.co/SIDN//NORMATIVA/TEXTOS_COMPLETOS/5_DECRETOS/DECRETOS%202025/Decreto%20Ley%200480%20de%202025.pdf] SISPI's earlier implementation was audited as still incomplete in 2020. Local pathways may therefore be uneven. [source: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/OCI/auditoria-sistema-indigena-salud-propio-intercultural-sispi.pdf] Trials in West Africa support collaboration in general: COSIMPO (Gureje et al., The Lancet, 2020) found greater symptom reduction and fewer harmful practices with collaborative care between healers and primary care. In Ghana, adding psychiatric care to prayer-camp care reduced symptoms but did not significantly reduce days in chains (Br J Psychiatry 212(1)). Neither involved Amazonian peoples. [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 what the client wants: coordination, referral, or simply that you know. (2) Find the sanctioned pathway, not a private contact. In Colombia this means the people's own authorities or Gobierno Propio health structures. In Brazil, it means the DSEI or Indigenous-run centres such as Bahserikowi in Manaus, which works with specialists from several peoples and with COIAB and the Federal University of Amazonas. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] For Piaroa clients, it means community leadership as the client directs. (3) Obtain written consent specifying what is shared, with whom and for what purpose. (4) Agree roles: the specialist's matters, your matters, and the physician's or prescriber's matters. Barreto describes a hospital agreement in which specialists treated alongside nursing care. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] (5) Do not attend or observe ceremonies. (6) Review the arrangement regularly with the client.
Example language (illustrative): "Would it help if I could speak with the person treating you through your own community, so we're not pulling in different directions? Only if you want that, and only what you agree I can share."
Watch for: referral to unsanctioned "shamans" or retreat businesses using these peoples' names. Do not make or endorse such referrals. [synthesis] It is working when the client reports the two kinds of care fitting together.

4.11 Interpreters and cultural brokers

Purpose / when: When the client's first language is Tukano, Desana, another Tukanoan language or Piaroa, or when Spanish or Portuguese is a second language. Indigenous researchers name Portuguese as a second language as a barrier. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
Steps: (1) Offer a trained interpreter. Ask the client's preference about using someone from their own community, because of confidentiality and kin and sib ties. (2) Brief the interpreter on confidentiality and on not softening explanations. (3) Use a cultural broker, with the client's consent, for advice on norms. The broker is not a diagnostician. (4) Debrief after sessions.
Example language (illustrative): "Would you prefer to speak in your own language? Is there anyone you would not want interpreting, because of family or community ties?"
Watch for: the interpreter answering for the client, or a relative-interpreter filtering content. It is working when the client's answers lengthen and include their own terms.

4.12 Supporting informed choice and the right to cultural objection

Purpose / when: When the client is weighing biomedical against Indigenous care, or declines a recommended treatment on cultural grounds. Decreto Ley 480 de 2025 recognises choice of treatment and cultural objection. [source: https://sidn.ramajudicial.gov.co/SIDN//NORMATIVA/TEXTOS_COMPLETOS/5_DECRETOS/DECRETOS%202025/Decreto%20Ley%200480%20de%202025.pdf]
Steps: (1) Elicit the client's priorities and fears. (2) Give your own clinical view honestly, including risks of delay. (3) Explore combined options; Barreto describes conditions he sees as better suited to each system. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] (4) Route all medicine questions, including any combination with plant remedies, to the prescriber. (5) Document the choice and the information given. (6) Where the choice risks serious harm (see 4.17), follow safeguarding and capacity law.
Example language (illustrative): "It's your decision, and many people use both. My concern is X. Could we look at a way to keep both going?"
Watch for: the client agreeing with you to please you, and then disengaging. It is working when the client states the plan in their own words.

4.13 Kin-centred and convivial work

Purpose / when: When distress is tied to relationships. Piaroa accounts locate health in "living well" with kin and value a peaceful life and self-restraint in eating, speaking and acting. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] Overing describes Piaroa communities' valuing of trust, conviviality and good humour and their dislike of coercion. [source: https://peacefulsocieties.uncg.edu/?p=58]
Steps: (1) Map kin, in-law and community relationships with the client (a genogram if acceptable). (2) Identify where tranquillity has broken down. (3) Use your usual relational or family methods. Keep the stance non-coercive and avoid confrontational techniques that clash with these values. (4) Invite relatives only with consent.
Example language (illustrative): "When things are going well in your family, what does that look like? What has made it harder to live well together lately?"
Watch for: shame about conflict, and a client who stays silent rather than criticise relatives. It is working when the client describes relationships repairing in their own terms. [synthesis]

4.14 Territory, place and environmental loss

Purpose / when: When distress is tied to land, places, food or displacement. Both peoples' accounts tie wellbeing to territory, and Indigenous health is described as "intrinsically linked to territory". [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf] The Pirá Paraná safeguarding project names young people's emigration as a threat to the knowledge system. [source: https://ich.unesco.org/en/assistances/safeguarding-of-the-traditional-knowledge-for-the-protection-of-sacred-natural-sites-in-the-territory-of-the-jaguars-of-yurupari-vaupes-province-colombia-01224]
Steps: (1) Ask about the client's relationship to their home territory and what has changed: moves to cities, land conflicts, environmental damage, loss of access to places or foods. (2) Treat grief, dislocation and identity strain as real clinical targets. (3) Support the client's own links to community, language and specialists. (4) Do not interpret environmental events through Reichel-Dolmatoff's model. [synthesis]
Example language (illustrative): "What is it like being in the city, far from your river? What do you miss, and what helps you stay connected?"
Watch for: loss presented as physical symptoms, and guilt about leaving. It is working when the client names a way to maintain connection.

4.15 Integrating Indigenous healing experiences

Purpose / when: After a client has received treatment or protection from a specialist and wants to make sense of it alongside therapy.
Steps: (1) Invite the client to share only what they wish. (2) Ask what changed, what they were advised to do or avoid, and how it fits with your work. (3) Help the client carry advice into daily life where it bears on mental health, such as relationships, routines and conduct. (4) Do not interpret the ritual's meaning for them.
Example language (illustrative): "You saw the kumu last week. How have you been since? Is there anything from that you'd like us to keep in mind here?"
Watch for: conflict between advice from the two systems (for example on food, or on missing appointments during restrictions). Plan around it. It is working when the client experiences the systems as complementary. [synthesis]

4.16 Addressing discrimination and colonial harm in services

Purpose / when: When the client has faced dismissal of their medicine, refusal of joint care or racism. Barreto describes a doctor asserting authority from years of training, and a family proposal of joint care rejected until prosecutors intervened. Clinicians are quoted on strong resistance among health professionals to Indigenous knowledge. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
Steps: (1) Ask directly, using the CFI clinician-patient relationship domain. (2) Validate the experience without defending services. (3) Repair within your service: advocate, document, and support complaints if wanted. (4) Address intergenerational and historical trauma when the client raises it. Specific histories of mission schooling or extraction in the client's region are [uncertain: not verified] here; let the client lead.
Example language (illustrative): "Some people have been treated badly by hospitals when they wanted their own medicine too. Has that happened to you or your family?"
Watch for: missed appointments or silence that reflect mistrust of services rather than "non-adherence". It is working when trust and attendance improve.

4.17 Safeguarding

Purpose / when: When any practice or conflict carries a risk of harm. Barreto lists interpersonal aggression, translated as witchcraft, among Tukano illness causes. He also notes that specialists' roles can include causing harm within the same cosmopolitical system. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Freire and Zent report that serious illness is often attributed to enemy shamans. [source: https://www.flacsoandes.edu.ec/sites/default/files/agora/files/1360945535.fa_agora_2013_gfreire2.pdf] Such attributions can fuel conflict between people. [synthesis] COSIMPO measured harmful practices as an outcome, showing that they occur in healing contexts generally. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]
Steps: (1) Screen for violence, threats, or retaliation linked to an accusation; for delay of urgent medical care (for example snakebite, infection, pregnancy complications); for harm to children; and for coercion. (2) Assess suicide risk in the usual way. Colombia has intercultural guidance on suicide prevention (2016). [source: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/OCI/auditoria-sistema-indigena-salud-propio-intercultural-sispi.pdf] (3) Act under your jurisdiction's safeguarding and reporting law, and involve Indigenous authorities where appropriate and safe. (4) Keep the client's cultural explanation in the record without letting it delay protective action.
Example language (illustrative): "When people believe someone has caused an illness, things can get dangerous between families. Is anyone at risk of being hurt, including you?"
Watch for: a child named as the cause of misfortune, which is high-risk. Also watch for refusal of urgent physical care. Protection is working when risk is reduced and the client stays engaged.

4.18 Boundaries around ceremony, plants and knowledge

Purpose / when: Always. Especially relevant when a non-Indigenous client seeks "Amazonian shamanism" for self-development, or a colleague proposes adopting it.
Steps: (1) Do not recommend, broker or attend ceremonies, and do not suggest plant or snuff use. (2) For non-Indigenous clients, explore what they hope for. Tell them the knowledge belongs to specific peoples and is held by their specialists. Barreto stresses that becoming a specialist takes long training. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] (3) No explicit public statement from Tukanoan or Piaroa bodies asking outsiders not to take part was found. Whether one exists is [uncertain: not verified]. Do not treat that as permission. (4) Refer psychedelic questions to the relevant clinical services and the client's prescriber. Psychedelic-assisted therapy is a separate field.
Example language (illustrative): "That knowledge belongs to particular peoples and their specialists. I can't offer it or point you to it, but I'd like to understand what you're looking for."
Watch for: retreat marketing that uses these peoples' names, and psychiatric red flags after plant-medicine use. Assess these clinically. It is working when the client's underlying need becomes the focus. [synthesis]

5. Handling problems

The sources do not address psychotherapy process with these clients. Everything below is [synthesis] unless tagged.

Client will not discuss their own medicine. Likely causes are past dismissal or the fact that the knowledge is restricted. Say that you do not need details. Ask only about effects on the client's life, and return to it later. Barreto notes sensitive knowledge is intentionally withheld. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Example (illustrative): "You don't have to tell me about that. I only want to know whether it's helping."
Stuck: the client sees the problem as entirely an attack or a breach with other beings, and therapy feels irrelevant. Do not argue causation. Agree a parallel focus within your competence, such as sleep, fear, conflict, grief or practical stressors, while the specialist addresses the cause. Ask what the client would notice if things improved.
Stuck: you and the client disagree about a diagnosis such as psychosis. Revisit 4.7–4.8, consult a cultural broker with consent, and use the Informant Version. Keep the shared description in the client's words, and put your diagnostic opinion separately and transparently in the record.
Overwhelm. This can come from discussing sorcery accusations, displacement or historical harm. Slow the pace, use grounding methods the client finds acceptable, and keep content general. Check whether the client has community support or specialist care in place.
Non-adherence that is really a conflict between systems. Missed sessions or medicines may coincide with specialist restrictions or a treatment period. Ask about this before labelling it non-adherence, and reschedule around it. Route medicine timing or combination questions to the prescriber.
Ruptures. Common triggers include using "shaman", "belief" or "spirits" in a way the client hears as dismissive, a colleague's racism, or breaching confidentiality with kin or community. Name the rupture, apologise specifically, and repair. Barreto's critique of these terms is the touchstone. [source: https://revistapesquisa.fapesp.br/wp-content/uploads/2023/04/080-083_conceitos-indigenas_326.pdf]
The client asks you to take part in, recommend or arrange a ceremony, or to give an opinion on a plant remedy. Decline warmly. Explain that this belongs to their specialists and community, and offer to coordinate through a sanctioned pathway (4.10). Route any medicine question to the prescriber.
A non-Indigenous client is engaged with commercial "Amazonian shamanism". Explore needs and risks. Assess for psychiatric effects of any substance use and liaise with the prescriber. Do not endorse the provider. Psychedelic-assisted therapy is outside this guide.
Conflict between a specialist's advice and urgent medical need. Examples are snakebite, sepsis, pregnancy complications and severe psychiatric risk. Prioritise safety, explain your concern honestly, and seek a combined solution like the shared-care agreement Barreto describes. [source: https://periodicos.ufpa.br/index.php/amazonica/article/download/5665/4679] Use safeguarding and capacity law if needed.
Accusations between families. If the client fears being harmed or accused, or accuses someone, assess risk to all parties, including children. Involve authorities as the law requires, and the people's own authorities where safe.
Pathways do not exist or are unclear. For example, SISPI may not yet be operational locally, or a Piaroa client in a third country may lack community access. [source: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/OCI/auditoria-sistema-indigena-salud-propio-intercultural-sispi.pdf] Ask the client whom they trust in their community. Help them reach their own organisations, and do not substitute an unsanctioned contact.
Your own pull to romanticise or to dismiss. Use supervision. Remember that the "ecological shaman" image is an outsider construct that is disputed in the scholarship. [source: https://www.redalyc.org/pdf/1050/105015287009.pdf] [source: https://www.lasillavacia.com/?p=28244]

Sources

Community, Indigenous-authored and official sources

Scholarship (outsider accounts, attributed)

Cayón, L. (2001). En la búsqueda del orden cósmico: sobre el modelo de manejo ecológico tukano oriental del Vaupés. Revista Colombiana de Antropología 37: 234–267 (abstract page: In Search of Cosmic Order)
Ecocosmología y chamanismo en el Amazonas: variaciones sobre un tema (Revista Colombiana de Antropología; author and year not shown on the page) [uncertain]
Overing, J. (1994). O Xamã como construtor de mundos: Nelson Goodman na Amazônia. Idéias 1(2): 81–118
Peaceful Societies: review of Overing (2006), The Backlash to Decolonizing Intellectuality, Anthropology and Humanism 31(1)
Freire, G. and Zent, S. Los Piaroa (book chapter; year and volume [uncertain])
Ospina, L. (2012). La pureza de Erasmus Gerardo Reichel-Dolmatoff. La Silla Vacía
Reichel-Dolmatoff, G. (1971). Amazonian Cosmos; and (1976). "Cosmology as ecological analysis". Cited from the reference lists of the Revista Colombiana de Antropología articles above; publication details [uncertain: not verified].
Barreto, J. P. L. (2021). Kumuã na kahtiroti-ukuse (doctoral thesis, Universidade Federal do Amazonas; published by IEB), as reported by Pesquisa FAPESP; details [uncertain: not verified].

Clinical assessment and collaboration

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