Andean paqo work and despacho (Q'ero)

1. Introduction

Version followed: Q'ero spiritual practice as Peruvian state sources (Ministry of Culture, Cusco; intercultural health policy DS 016-2016-SA) and scholarly ethnography (Wissler 2010; Przytomska-La Civita 2020) describe it, with Hill 2008 on the commercial mystical-tourism industry; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and Kleinman's explanatory-model questions. The ethnographic accounts are outsiders' accounts.

What it is. This is not a psychotherapy. It is a living spiritual tradition of the Q'ero, Quechua-speaking communities of Paucartambo province, Cusco region, Peru, about 200 km east of Cusco, who farm and herd across zones from high puna to valley. The Nación Q'ero was formed in 2005 and groups several communities; Hatun Q'eros is the largest. [source: https://www.redalyc.org/pdf/886/88636918005.pdf] Scholars describe a paqo as a spiritual leader, usually a head of family, who makes offerings to the apus (powerful mountain beings, held to protect the herds) and to Pachamama. A despacho is described as an offering, a food that propitiates these powerful beings. Both sit inside ayni, reciprocity summed up as giving in order to receive, which organises labour exchange and mutual aid among people and also relations with non-human beings. [source: https://www.redalyc.org/pdf/886/88636918005.pdf] [source: https://czasopisma.bg.ug.edu.pl/index.php/etnografia/article/download/6106/5361] These beings and relations are described as the Q'ero hold them, neither stated as fact nor dismissed.

Core idea of change (as attributed). In the ethnography, wellbeing of people, herds and land depends on keeping reciprocal relations with apus and Pachamama in balance; offerings 'feed' these beings and keep vital force flowing, and a broken relation can bring misfortune. [source: https://czasopisma.bg.ug.edu.pl/index.php/etnografia/article/download/6106/5361] For the psychotherapist, change comes from their own culturally responsive work: understanding the client's explanatory model, avoiding both pathologising and missing illness, and supporting the client's chosen healing pathway, including community-sanctioned paqos when the client wishes. [synthesis]

Two client groups. (a) Quechua and Andean clients, in Peru or in diaspora, for whom paqos, apus and ayni are part of their own world. (b) Clients, often non-Andean, who have taken part in commercial 'Inca shamanism' or Andean mystical-tourism workshops in Cusco or abroad. Hill (2008) describes this industry as white and mestizo practitioners and tourists borrowing Quechua cosmology and ritual to build a hybrid New Age Andean spirituality, attributing 'spiritual energy' to Quechua bodies, in ways that reproduce racialised inequality. [source: https://research.usfq.edu.ec/en/publications/inca-of-the-blood-inca-of-the-soul-embodiment-emotion-and-raciali/]

Who holds authority. Within Q'ero communities: paqos, whose knowledge passes from father to son and sometimes to a daughter [source: https://www.redalyc.org/pdf/886/88636918005.pdf]; tertiary sources name two levels, altumisayuq (altomisayoq) and pampamisayuq (pampamisayoq), and scholarship calls the altomisayoq a specialist who makes offerings to an apu [source: https://en.wikipedia.org/wiki/Q%27ero] [uncertain: tertiary source for the level names] [source: https://czasopisma.bg.ug.edu.pl/index.php/etnografia/article/download/6106/5361]; how the community ranks or recognises them today is [uncertain: not verified]. Community councils and the Nación Q'ero authorities decide on outsiders: in 2006 they required permission for groups over ten and turned away unannounced film crews. [source: https://ictnews.org/?p=118353] The Instituto Nacional de Cultura declared the Q'eros Patrimonio Cultural in 2007, reported as the first people in Peru to receive that status [source: https://www.redalyc.org/pdf/886/88636918005.pdf]; the resolution number and exact scope are [uncertain: not verified]. In July 2026 the Ministry of Culture's Cusco office, with the Hatun Q'ero community, presented a cultural and spiritual route that includes 'ceremonias espirituales' within community-coordinated visits. [source: https://www.elperuano.pe/noticia/300309-presentan-ruta-cultural-y-espiritual-hatun-qero] Peru's intercultural health policy (DS 016-2016-SA, 1 April 2016) recognises traditional or ancestral medicine, calls for registering it as intangible cultural heritage, for articulation with conventional medicine, and for protecting collective knowledge under Law 27811. [source: https://busquedas.elperuano.pe/dispositivo/NL/1363166-6] A published Q'ero statement asking outsiders not to perform or reproduce their offerings is [uncertain: not verified]; a commercial seller's title of 'paqo' or 'Q'ero-trained' is not the same as community recognition. [synthesis]

This guide gives no ceremony procedure, offering contents, songs, prayers, sacred objects, initiation steps or divination methods.

2. Framework

The tradition has no therapy phases. The framework below is the psychotherapist's own course of work alongside it. [synthesis, built on the CFI sources cited]

Phase	Goals	Typical format	Move on when
0. Preparation	Examine own assumptions (romantic 'last Inca' imagery, scepticism, spiritual seeking); learn basics of Quechua Andean life and Peruvian history of discrimination	Supervision, reading, consultation	You can name your own biases and the limits of your role
1. Cultural assessment	Core CFI (16 questions, four domains); Informant Version with family; supplementary modules as needed; explanatory model	Sessions 1-3; interpreter where needed	Problem, causes, supports, help seeking and expectations are stated in the client's terms
2. Formulation and differential	Place experiences (relations with apus, dreams, susto or mancharisqa, trance) as normative, distress, disorder or a mix; risk review	Sessions 2-4; cultural consultation	A shared formulation the client recognises; risk documented
3. Collaborative plan	Agree goals; decide with the client whether and how to involve paqos, family or community; consent for any contact	Sessions 3-5	Written consent and a clear division of roles
4. Ongoing therapy and integration	Evidence-based treatment for any disorder, adapted; help integrate healing or ceremonial experience on the client's terms	Weekly or as agreed; length depends on the disorder	Goals met, or a new need appears (return to Phase 1 or 2)
5. Review and ending	Re-check the explanatory model; plan for relapse and continued community support	1-2 sessions	Client has a plan that fits both systems

Safeguarding and risk run through every phase. The CFI is meant to support clinical understanding and decisions, not to be the only basis for a diagnosis, and its modules can be used at first evaluation, later in care, or repeatedly. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] Time for the core CFI: a field trial found later interviews took less time, but a figure in minutes is [uncertain]. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]

3. Guiding principles

You work alongside, not inside, the tradition. Never perform, imitate or 'guide' a despacho or any paqo work; your tools are assessment, formulation, therapy, liaison and safeguarding. [synthesis]
Authority rests with the community. Paqos are recognised within families and communities, and Q'ero authorities decide on outsiders; check standing through the client and community, not a website. [source: https://www.redalyc.org/pdf/886/88636918005.pdf] [source: https://ictnews.org/?p=118353]
Describe beliefs as held. Apus, Pachamama, ayni and offerings are spoken of in the client's terms, never confirmed as fact or dismissed. [synthesis]
Reciprocity matters clinically. Ayni frames obligations to family, community and land; failing in them can break relationships. Ask about duties and debts as well as feelings. [source: https://czasopisma.bg.ug.edu.pl/index.php/etnografia/article/download/6106/5361]
The client leads on spirituality. Ask about healers and offerings openly; never require, recommend or discourage participation. [synthesis]
Neither pathologise nor miss illness. Culturally sanctioned trance or possession is excluded from DSM and ICD-11 dissociative diagnoses; psychosis, depression and PTSD still occur in believers. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
Name the history. Discrimination against Quechua people, and harms such as the 1996-2000 sterilisation programme, shape trust in services. [source: https://crres.indiana.edu/events/speaker-series/lucia-stavig-talk.html]
Do not feed appropriation. Do not refer clients to commercial 'Inca shamanism' or recommend tours; treat the client's experience of them with respect. [source: https://research.usfq.edu.ec/en/publications/inca-of-the-blood-inca-of-the-soul-embodiment-emotion-and-raciali/] [synthesis]
Language is care. Offer Quechua (Runasimi) interpreting where needed; healing work in Runasimi has been central to community-led recovery. [source: https://crres.indiana.edu/events/speaker-series/lucia-stavig-talk.html]
Consent and confidentiality for any contact. No contact with a paqo, family or community member without the client's informed consent. [synthesis]
Medicines and substances belong to the prescriber. Never advise starting, stopping or changing a medicine; route plant-medicine or psychoactive questions to the prescriber (see Domain VII and tab 116). [synthesis]
Touch. Your own work involves no touch beyond ordinary courtesy, with consent, never sexual. [synthesis]

4. Intervention inventory

All interventions below are the psychotherapist's own. None is a paqo practice. Example language is illustrative unless quoted.

4.1 Cultural humility and self-examination

Purpose: to notice what you bring before the first session: admiration for the 'last Inca' image, spiritual seeking of your own, scepticism, or class and race assumptions about Quechua people. Scholars trace the 'last Inca ayllu' image to a 1955 expedition and press coverage [source: https://www.redalyc.org/pdf/886/88636918005.pdf], and tertiary sources note that claims of Q'ero descent from Inca priests are unproven [source: https://en.wikipedia.org/wiki/Q%27ero] [uncertain: tertiary source].
Steps: (1) Write down what you believe about Andean spirituality and where it came from (tours, books, workshops). (2) Note any personal attraction to or rejection of it. (3) Take this to supervision or cultural consultation before and during the work. (4) Re-check after sessions where you felt fascinated or dismissive. [synthesis]
Example language (illustrative, to yourself or a supervisor): 'Am I curious about this client's world for them, or for me?'
Watch for: asking about ceremonies for your own interest; treating a Quechua client as a spiritual teacher; or the reverse, treating their account as superstition. Working if your questions follow the client's priorities. [synthesis]

4.2 Core Cultural Formulation Interview

Purpose: to get the problem, its causes, supports and help-seeking in the client's own terms, at intake and whenever cultural factors seem to shape care. The CFI 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. It may be reproduced by clinicians for use with their patients. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Explain that you ask everyone about their own view of the problem. (2) Go through the four domains in order, using the official form. (3) Record the client's words for the problem (Quechua or Spanish terms included). (4) Under past help seeking, ask about every source of help, including paqos, curanderos, church, family and clinics. (5) Under the clinician-patient relationship, ask directly about discrimination and language. (6) Summarise back and check.
Example language (illustrative): 'People explain troubles like this in many ways. How do you and your family explain what is happening?' / 'Who else have you gone to for help, inside or outside the family or the community?'
Watch for: short or guarded answers about healers, which may reflect past disapproval by services; switching to Quechua words when describing the problem (ask what they mean). Working if the client corrects or adds to your summary. [synthesis]

4.3 CFI Informant Version and supplementary modules

Purpose: to deepen the assessment. The Informant Version (17 questions) is used with a family member or friend. Twelve supplementary modules include Explanatory Model; Social Network; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient-Clinician Relationship; Immigrants and Refugees; and Caregivers. They can be used as add-ons or standalone, at any point in care. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Choose modules from the core interview's gaps: Spirituality module where apus, offerings or church matter; Social Network where community and ayni obligations matter; Immigrants and Refugees for migrants to Lima or abroad; Cultural Identity for clients between Q'ero, Quechua, mestizo or urban identities. (2) Use the Informant Version only with the client's consent. (3) Note where client and informant differ. [synthesis on module choice]
Example language (illustrative): 'You mentioned the mountains and your obligations at home. Can we take some time on what that part of your life means for this problem?'
Watch for: family accounts that override the client's own; spiritual material the client does not want recorded (ask how it should be documented). [synthesis]

4.4 Exploring the explanatory model (Kleinman)

Purpose: to learn what the client calls the problem, what caused it, and what treatment they want, so your plan fits theirs. Kleinman, Eisenberg and Good (1978) set out the explanatory-model approach. [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: Ask, in your own words, eight things: what they call the problem; what caused it; why it started when it did; what it does to them and how it works; how severe it is and how long it will last; what treatment they should get; what the main problems it has caused are; what they fear most. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] Then (1) note causes that involve relations with apus, Pachamama, offerings, envy or broken reciprocity; (2) note causes that involve work, migration, violence or loss; (3) write both into the formulation side by side. [synthesis]
Example language (illustrative): 'Some people say an illness like this comes from a fright, from the land, or from what has happened between people. What do you think brought it on?'
Watch for: layered models (a client may hold a fright, a broken relation with an apu and a work injury as causes at once). Working when the client's own treatment ideas shape the plan. [synthesis]

4.5 Asking about paqos and other healers without judgement

Purpose: to learn the whole help-seeking pathway and any risks, so you can coordinate rather than compete. [synthesis]
Steps: (1) Ask early and normalise. (2) Ask who the healer is to the client (family member, community-recognised paqo, Cusco practitioner, workshop leader) without asking for names unless needed for safety. (3) Ask what the client hopes the healer and you will each do. (4) Ask about any herbs, plant medicines or substances taken, only to route medical questions to the prescriber; never give dose or preparation advice. (5) Record respectfully. [synthesis]
Example language (illustrative): 'Many people from the Andes see a paqo or another healer as well as a doctor. If you have, I would like to understand how it fits with what we do here.'
Watch for: fear that disclosure will lead to ridicule; reports of being charged large sums or pressured, which may signal exploitation (see 4.12). Working when the client mentions healers spontaneously later. [synthesis]

4.6 Working with susto and mancharisqa

Purpose: susto is a DSM-5-TR cultural concept of distress [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. Quechua speakers use mancharisqa ('frightened'); an Andean anthropologist proposes a typology of local meanings [source: https://revistas.pucp.edu.pe/index.php/Kawsaypacha/article/view/22658]. Anthropologist Lucía Stavig presents mancharisqa as soul loss whose symptoms overlap PTSD but whose meaning, an 'illness of the land' that breaks the sociality of the ayllu, clinical trauma definitions miss. [source: https://crres.indiana.edu/events/speaker-series/lucia-stavig-talk.html]
Steps: (1) Ask what event brought the fright and what it did to the client. (2) Ask who usually treats it in their community and whether they have sought that. (3) Screen separately for PTSD, depression and anxiety disorders with standard tools. (4) Formulate both: the client's mancharisqa and any disorder. (5) Offer evidence-based treatment where a disorder is present, alongside, not instead of, the client's own healing. [synthesis]
Example language (illustrative): 'You said you have been mancharisqa since the accident. What does that mean for you, and what usually helps someone with it?'
Watch for: using 'susto' as a diagnosis on its own; missing a treatable disorder. Working when the client sees your treatment as compatible with their own. [synthesis]

4.7 Distinguishing culturally normative experience from disorder

Purpose: to avoid pathologising sanctioned experience (dreams of apus, feeling called to serve as a paqo, trance within accepted practice) and to avoid missing psychosis, mania or other illness. DSM-5 excludes from DID a disturbance that is a normal part of broadly accepted cultural or religious practice, and dissociative trance does not apply to trance within accepted collective practice. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require that the state be involuntary and unwanted and not part of accepted cultural or religious practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html] Exact DSM-5-TR wording is [uncertain].
Steps: (1) Ask whether others in the client's community would see the experience as normal, a calling, or a sign of illness. (2) Ask whether it happens only in its expected context. (3) Check distress, impairment, control and duration. (4) Look for features outside the tradition: disorganisation, decline in self-care, mood episodes, persecutory beliefs about you or family. (5) With consent, consult a cultural broker or family member. (6) Document your reasoning. [synthesis]
Example language (illustrative): 'In your community, would people see what happened to you as something ordinary, as a sign, or as an illness?'
Watch for: beliefs that are extreme for the client's own group; sudden change from usual self. Working if you can state why something is or is not a disorder in terms the client accepts. [synthesis]

4.8 Interpreters and cultural brokers

Purpose: to work in the client's language and with someone who can explain local meanings. Community-led healing has been carried out almost entirely in Runasimi. [source: https://crres.indiana.edu/events/speaker-series/lucia-stavig-talk.html]
Steps: (1) Offer a trained Quechua interpreter; avoid using children or the client's own family. (2) Brief the interpreter on confidentiality and on rendering spiritual terms literally. (3) Ask the client whether they know the interpreter's community, as small networks raise confidentiality issues. (4) Use a cultural broker only with consent and only for meanings, not for decisions. [synthesis]
Example language (illustrative): 'Would you prefer to speak in Quechua with an interpreter? Your words matter for how I understand this.'
Watch for: the interpreter softening or explaining away spiritual content; shame about speaking Quechua in clinics. [synthesis]

4.9 Collaboration and referral with community-sanctioned paqos

Purpose: to coordinate care when the client wishes their paqo or community to be involved. Peru's intercultural health policy calls for articulation between traditional and conventional medicine and for protecting collective knowledge [source: https://busquedas.elperuano.pe/dispositivo/NL/1363166-6]. Trials of collaboration elsewhere give context: in Nigeria and Ghana, collaborative shared care between traditional or faith healers and primary care (COSIMPO, Gureje et al., The Lancet 2020) reduced psychosis symptoms more than usual care and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]; in a Ghanaian prayer camp, adding psychiatric care reduced symptoms but did not significantly reduce days in chains (Ofori-Atta et al., Br J Psychiatry 212(1)) [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. No Andean trial of paqo collaboration is known here [uncertain: not verified].
Steps: (1) Ask whether the client wants any contact; accept a no. (2) Ask how the paqo is recognised (family, community, Q'ero authorities) and do not seek out paqos yourself. (3) Get written consent naming what may be shared, with whom, and for what purpose. (4) If contact happens, ask about the paqo's view of the client's wellbeing and how the two kinds of help can fit; do not ask about or record offering contents, methods or sacred matters. (5) Agree roles: you handle assessment, therapy and risk; the paqo's work is theirs. (6) Share back with the client what was discussed. [synthesis]
Example language (illustrative), to the client: 'If you would like your paqo and me to understand each other's part, I can talk with them, only about what you agree to.' To the paqo, through an interpreter: 'I am not here to learn your work. I want to know how we can both support this person.'
Watch for: pressure from family to involve or exclude a healer; requests for payment for introductions; anyone claiming Q'ero authority whom the client's community does not recognise. Working if the client feels both kinds of help are respected. [synthesis]

4.10 Working with clients from commercial 'Inca shamanism' or mystical tourism

Purpose: to help clients who attended paid workshops, retreats or tours make sense of them, without endorsing or ridiculing. Hill (2008) documents how this industry borrows Quechua cosmology and ritual and reproduces racialised inequality; reports from Q'ero communities describe tourism adding jealousy and division within communities, and outside operators taking advantage of healers who do not speak Spanish. [source: https://research.usfq.edu.ec/en/publications/inca-of-the-blood-inca-of-the-soul-embodiment-emotion-and-raciali/] [source: https://ictnews.org/?p=118353]
Steps: (1) Ask what the client sought and what happened, in their words. (2) Ask about any substances taken, medical events, sleep loss, fasting or exertion, and route medical questions to a doctor; do not advise on substances (see Domain VII and tab 116). (3) Explore meaning and any distress. (4) If the client asks, share in neutral terms that Q'ero communities have their own authorities and that commercial versions differ from community practice. (5) Do not recommend further ceremonies; if the client wants a spiritual path, support them to think it through with their own community or tradition. [synthesis]
Example language (illustrative): 'What were you hoping to find there, and what did you come back with?' / 'What would it mean to you if what you took part in was quite different from how Q'ero families practise?'
Watch for: idealising the leader; financial or sexual exploitation; new psychotic or manic symptoms after a retreat (see 4.15). Working if the client can hold both the meaning they found and a realistic view of the setting. [synthesis]

4.11 Integrating healing or ceremonial experience

Purpose: to help the client connect what happened in their community's healing or ceremony with daily life and therapy goals, on their own terms. [synthesis]
Steps: (1) Ask what the client wishes to share; never ask for ceremony details. (2) Reflect the meanings they name (restored relation with apus, renewed obligations, relief). (3) Link these to goals and supports. (4) Do not interpret the spiritual content with your own theory. [synthesis]
Example language (illustrative): 'You said things feel back in balance after the offering your family made. What do you want to keep doing to stay in balance?'
Watch for: disappointment when symptoms persist, which may need a re-assessment rather than more ceremony; guilt about having sought therapy. [synthesis]

4.12 Safeguarding

Purpose: to act when anyone, inside or outside a tradition, causes harm: physical or sexual abuse, financial exploitation, coercion, delay of urgent medical care, or harm to a child. [synthesis]
Steps: (1) Assess risk as you would with any client. (2) Separate the tradition from the act: harm is addressed as harm, not as a judgement on Q'ero practice. (3) Follow local reporting law and child-protection procedures. (4) If a commercial retreat leader is involved, support reporting to police or consumer bodies as the client wishes. (5) Ensure urgent medical needs are met. [synthesis]
Example language (illustrative): 'Your beliefs are yours, and I respect them. What happened to you there is something different, and you have a right to be safe.'
Watch for: abuse hidden as tradition, and tradition misread as abuse; check with a cultural broker before concluding either. [synthesis]

4.13 Historical, collective and racial trauma

Purpose: to recognise that discrimination and state harms shape distress and trust. From 1996 to 2000 about 314,000 people were sterilised under Peru's family planning programme, most of them Indigenous women; affected Quechua women describe lasting illness and have built a healing centre, Mosoq Pakari Sumaq Kawsay, combining Western medicine and psychology with Runa practices. [source: https://crres.indiana.edu/events/speaker-series/lucia-stavig-talk.html]
Steps: (1) Ask about experiences of discrimination in services (CFI question on the clinician-patient relationship). (2) Name the history plainly when the client raises it. (3) Link the client to community-led and collective resources where they wish. (4) Avoid pressuring disclosure. [synthesis]
Example language (illustrative): 'Some people from the Andes have been treated badly in clinics. If that has happened to you, I want to know, so it does not happen here.'
Watch for: mistrust as a reasonable response, not resistance. [synthesis]

4.14 Family, community and ayni in goals

Purpose: to bring the client's obligations and supports (household, ayllu, land, herds) into goals, since ayni organises mutual aid and broken reciprocity can strain relationships. [source: https://czasopisma.bg.ug.edu.pl/index.php/etnografia/article/download/6106/5361]
Steps: (1) Map who the client gives to and receives from. (2) Identify obligations the illness has disrupted. (3) Set goals that restore valued exchanges. (4) With consent, include family sessions. [synthesis]
Example language (illustrative): 'Who has been helping you, and who are you worried about not being able to help?'
Watch for: guilt about unmet obligations, isolation after migration. [synthesis]

4.15 Acute distress or spiritual crisis

Purpose: to respond when a client is in crisis after spiritual experience, workshop, or community conflict. [synthesis]
Steps: (1) Assess suicide and self-harm risk with standard practice. (2) Screen for psychosis, mania, delirium and substance effects; arrange urgent medical review where needed. (3) Ground, reduce stimulation, involve trusted supports. (4) Once safe, return to the explanatory model and differential (4.4, 4.7). [synthesis]
Example language (illustrative): 'Right now my job is to make sure you are safe. Later we can make sense of what this means for you.'
Watch for: framing a medical emergency as purely spiritual, or the reverse. [synthesis]

5. Handling problems

The sources describe the tradition and the CFI; they do not address therapy problems in this setting. All responses below are [synthesis] unless a source is given.

Client will not talk about paqos or offerings. Respect it. Say once that the subject is welcome and will not be judged, then leave it. Guardedness may reflect past disapproval by services. [synthesis]
Client asks you to take part in, perform or arrange a despacho, or to find a paqo. Decline warmly; explain your role. Suggest the client turn to their own family or community, who hold that authority. Never source a healer from tourist listings. [synthesis] [source: https://ictnews.org/?p=118353]
Client asks whether the apus or an offering are 'real'. Do not rule on it. Reflect what it means to them and how it bears on their goals. [synthesis]
Client believes illness comes only from a broken relation with the apus and refuses other treatment. Explore the explanatory model fully (4.4); look for common ground, such as both helping at once; involve family or a paqo with consent (4.9). If there is serious risk (psychosis with danger, severe depression with suicidality, medical emergency), follow standard emergency procedures and explain them respectfully. [synthesis] COSIMPO is context that collaboration can coexist with medical care. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]
Stuck: symptoms persist despite both ceremony and therapy. Re-run the formulation: missed disorder, substance use, physical illness, ongoing stressors (debt, violence, migration), or loss of community support. Review with a cultural consultant. [synthesis]
Rupture over racism or disrespect. Name it, apologise for your part, ask what would repair it. Use the CFI clinician-patient relationship question to check periodically. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [synthesis]
Non-attendance. Consider distance, cost, farming and herding calendars, travel to community festivals, and family obligations under ayni; offer flexible or remote sessions. [synthesis]
Overwhelm after a commercial workshop or retreat. Prioritise safety and medical review (4.15); delay meaning-making until stable. Do not call the experience fraudulent; help the client weigh it. Route any substance questions to the prescriber. [synthesis]
Client from mystical tourism wants to become a paqo or teach Andean ceremony. Explore motives and meaning. If asked, say that Q'ero knowledge passes within families and communities and that scholars have described the commercial industry as appropriation. [source: https://www.redalyc.org/pdf/886/88636918005.pdf] [source: https://research.usfq.edu.ec/en/publications/inca-of-the-blood-inca-of-the-soul-embodiment-emotion-and-raciali/] [synthesis]
Conflict between the client and a community healer or family over treatment. Stay with the client's own choices; mediate only with consent; check for coercion or harm (4.12). [synthesis]
Your own attraction to the tradition. If you feel drawn to learn or practise it through the client, take it to supervision; never use a client as an access route. [synthesis]
Confidentiality in small communities. Ask how the client wants spiritual matters documented; check interpreter and broker connections (4.8). [synthesis]
Physical or medical issues framed spiritually (or the reverse). No practice is a treatment for physical disease; ensure medical assessment of physical symptoms while respecting the client's spiritual care. [synthesis]
Touch. If a client describes touch by a healer or retreat leader that was non-consensual or sexual, treat it as a safeguarding matter (4.12). Your own work involves no touch beyond ordinary courtesy, with consent. [synthesis]

Sources

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