Traditional bone-setters

1. Introduction

Version followed: there is no single manual for traditional bone-setting. This guide draws on three bodies of work: the orthopaedic and public-health literature on traditional bone-setters (TBS) in Nigeria, Ghana and Tanzania (2015–2025); historical and ethnographic accounts of hereditary bonesetters in Wales, England and Ireland; and the DSM-5-TR Cultural Formulation Interview (CFI) with Kleinman's explanatory-model questions, which make up the psychotherapist's own work. [source: https://www.panafrican-med-journal.com//content/article/30/189/full] [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

What it is. Traditional bone-setting is hands-on care for fractures, dislocations, sprains, and back and joint complaints. It is given by practitioners who are trained within a family, an apprenticeship or a community, not within formal medicine. It is found worldwide. In Ashanti, Ghana, bone-setters treat leg, arm and rib fractures, joint dislocations, and waist and spinal problems. They combine plant- and animal-based materials, spirituality and physical therapy with some orthodox procedures. Over 60% of those interviewed attributed their healing power to God, and the rest did not discount spiritual therapy. [source: https://ajod.org/index.php/ajod/article/view/97] In Ireland, practitioners describe bone-setting as a hereditary "gift" tied to a family line. One family's account traces the gift's origin to a priest in the penal era. [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf] In Nigeria, one study cites a figure of up to 85% of fracture patients going first to a bone-setter. [source: https://www.panafrican-med-journal.com//content/article/30/189/full]

Who holds authority. Authority rests with the family line or lineage that holds the skill or gift, and with communities that recognise the practitioner. Increasingly it also rests with practitioners' associations. In Ghana, regional bone-setter associations were formed by June 2022 through a training programme run by AO Alliance with Komfo Anokye Teaching Hospital (Kumasi) and Tamale Teaching Hospital. Over 200 practitioners had joined. Association leaders trace practitioners linked to recorded complications and offer them prevention training. [source: https://edit.aofoundation.org/who-we-are/about-ao/news/2022/ao-alliance-ghana] Nigerian orthopaedic authors call for education, certification and "legislative control of TBS practice", which implies no such statutory control existed where they worked. [source: https://www.panafrican-med-journal.com//content/article/30/189/full] Current statutory regulation in any country is [uncertain: not verified].

History in Britain and Ireland. The "bonesetters of Anglesey" were a hereditary family line founded by Evan Thomas (d. 1814). His son Richard Evans (1771–1851) farmed and also ran a regular bone and joint clinic. A later Evan Thomas (1804–1884) practised full time in Liverpool from 1830. Local doctors resented him for lacking qualifications, and he was acquitted in several legal challenges. He had all five sons qualify in medicine. One of them, Hugh Owen Thomas (1834–1891), designed the Thomas splint. His nephew Robert Jones (1857–1933) is called "the father of orthopaedics". [source: https://www.rjah.nhs.uk/media/o1ybnyqt/bonesetters-of-anglesey-and-hugh-owen-thomas.pdf] In 1867 James Paget lectured on the cases bone-setters cure, and Wharton Hood published On Bone-Setting, So Called (1871). Physicians "frequently rebuked their trade; or sought to acquire the skills for themselves." The London bonesetter Herbert Barker was knighted in 1922. [source: https://history.physio/manipulation-setting-the-record-straight/] (The source spells Barker's name inconsistently [uncertain].) In Ireland, practice declined in the later twentieth century. Osteopaths, chiropractors and physical therapists are replacing it, though hereditary practitioners still work. [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf] Historians treat charmers as a tradition distinct from cunning-folk. [source: https://uhra.herts.ac.uk/handle/2299/10170] How far British bonesetters overlapped with charming is [uncertain: not verified].

Core idea of change. Within the tradition, change comes from the practitioner's skill, gift or God-given power applied by hand [source: https://ajod.org/index.php/ajod/article/view/97]. The psychotherapist does not set bones, judge bone-setting technique or give manual treatment. The therapist's own work is different. It is to understand the client's explanatory model and reasons for choosing a bone-setter, to support safe, informed choices (including timely medical review, because serious complications are documented), to support collaboration where the client wishes it, and to help with the psychological consequences of injury, pain, disability or amputation. [synthesis]

2. Framework

Bone-setting has no psychotherapy protocol. The framework below is the psychotherapist's own sequence, built from the CFI and the complication literature. Phases overlap, and an acute physical concern overrides the order. [synthesis]

Phase A: Engagement and cultural assessment (usually sessions 1–2). Goal: understand the problem in the client's terms, including the injury, pain, meaning, help-seeking and the role of family. Tools: the core CFI (16 questions in four domains), selected supplementary modules, and the explanatory-model questions. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Time needed for the CFI: [uncertain]. The DSM-5 field trial reports only that later interviews took 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 own account of the injury, who they consulted and why, and what they want from you.
Phase B: Physical-safety screening and medical routing (at once if any warning sign; otherwise within Phase A). Goal: make sure a current injury or treatment has medical oversight. Documented complications include non-union, malunion, gangrene leading to amputation, compartment syndrome, infection and pressure sores, unreduced dislocations and nerve injury. [source: https://www.panafrican-med-journal.com//content/article/30/189/full] A systematic review found limb- and life-threatening complications, including death. [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543] Move on when medical review is arranged or done, or the client's informed choice is documented and safeguarding duties are met.
Phase C: Collaborative planning (if the client wishes). Goal: agree how traditional and medical care will coexist. Agree what is shared with whom, under what consent, and with which programme or association where one exists. Move on when the client has a care plan they endorse and the therapist's role in it is clear.
Phase D: Psychological work on consequences (variable length; typical weekly 50-minute sessions [synthesis]). Goal: address pain-related distress, loss of function or role, grief after amputation, guilt, decisional regret, family conflict, trauma symptoms, or conflict between the client's tradition and services. Move on when the agreed goals are met or reviewed.
Phase E: Integration and review. Goal: help the client make sense of the whole experience in terms that fit their own tradition, and plan for future injuries, for example who to see first and when to go to hospital.

Session count: no source gives one. Phases A–C can often be done in 2–4 sessions, and Phase D follows the treatment chosen for the presenting problem. [synthesis]

3. Guiding principles

The therapist works alongside the tradition and never performs it. In practice: no manipulation, splinting, poultices or advice on technique. Your work is talk-based assessment, support, collaboration and referral. [synthesis]
Describe beliefs as the client and tradition hold them. In practice: say "you see this skill as a gift from God" or "your family's gift". Neither affirm nor dispute the spiritual claim. [source: https://ajod.org/index.php/ajod/article/view/97] [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf]
Physical safety comes before cultural exploration. In practice: any current injury with warning signs is routed to medical care in the same session. Gangrene leading to amputation in children and compartment syndrome are documented. [source: https://www.panafrican-med-journal.com//content/article/30/189/full]
Understand reasons before responding. In practice: ask what led to the choice. In Makurdi, Nigeria, reasons were relatives' and friends' advice (29.2%), lower cost (25%), sociocultural beliefs (14.2%), accessibility (12.5%), fear of amputation (10.8%) and fear of surgery (8.3%). [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA]
It is not either/or. In practice: support care that combines both when the client wishes. Bone-setters have been shown willing to engage with orthodox services and training. [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543]
Avoid stigmatising language. In practice: some medical sources call clients' beliefs "erroneous". Do not adopt that framing with clients. Name specific risks instead. [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA] [synthesis]
Touch must be consented to and never sexual. In practice: the client has the right to agree to, refuse and stop any hands-on treatment. Any genital or sexual touch is a safeguarding matter, whatever rationale is given. The therapist does not touch the client. [synthesis]
Never advise on medicines, herbs or applied preparations. In practice: questions about poultices, plant or animal materials, painkillers or prescribed drugs go to the prescriber or treating doctor. [synthesis]
Children and dependent adults need extra protection. In practice: delay of urgent care for a child's injury is a safeguarding matter. [synthesis]
Remember the history. In practice: hereditary practitioners in Britain faced professional hostility and prosecution, and medicine absorbed some of their skills. Clients from these traditions may expect contempt from services. [source: https://www.rjah.nhs.uk/media/o1ybnyqt/bonesetters-of-anglesey-and-hugh-owen-thomas.pdf] [source: https://history.physio/manipulation-setting-the-record-straight/]
Consent governs collaboration. In practice: share nothing with a bone-setter, association, family member or medical team without the client's explicit agreement, except where safeguarding law requires it. [synthesis]

4. Intervention inventory

Every intervention below is the psychotherapist's own work. None is a bone-setting procedure. The CFI and explanatory-model items come from the sources cited, and the way they are applied to bone-setting is [synthesis] unless a source is given.

4.1 Cultural humility and self-examination

Purpose / when: before and during work with any client who uses or practises traditional bone-setting. It lets you notice your own assumptions, such as "quackery" or, at the other extreme, romanticising the practice, before they shape the assessment. [synthesis]
Steps:
1. Before the session, write down what you assume about bone-setters, and where the assumption came from: training, media, family.
2. Note any professional allegiance, such as physiotherapy, orthopaedics or osteopathy, that may colour your view.
3. Recall the history. Medicine in Britain both rebuked bonesetters and absorbed their skills. [source: https://history.physio/manipulation-setting-the-record-straight/] Many clients in West Africa also report satisfaction with their bone-setter. [source: https://ajod.org/index.php/ajod/article/view/97]
4. After the session, check whether you asked about risks in a way that sounded like blame.
Example language (illustrative): "I'm not an expert in bone-setting, and I'd like to understand how it works for you and your family."
Watch for: your own tone tightening when the client mentions the bone-setter. Clients who become guarded or vague about who treated them may be sensing judgement. It is working when the client volunteers details of traditional care without being asked.

4.2 Core Cultural Formulation Interview, focused on the injury

Purpose / when: the first session, with any client whose presenting problem involves injury, pain, disability or a healing choice. The CFI clarifies the problem from the perspective of the client and their social network: what it means, sources of help, and what the client expects from services. It supports clinical understanding. It is not the sole basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: cover the four CFI domains in your own words. Clinicians may reproduce the APA form for use with their own 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]
1. Cultural definition of the problem: how the client and family describe the injury or pain, and what troubles them most.
2. Cause, context and support: what caused it, including any spiritual or social cause the client names, what stressors and supports are present, and how cultural identity bears on it.
3. Self-coping and past help-seeking: what they did first, including the bone-setter, family remedies and the hospital, what helped, and what got in the way, such as cost, distance, fear or past treatment.
4. Current help-seeking: what help they want now, and any concerns about you or the service, including language and perceived racism.
Example language (illustrative): "When you hurt your arm, who did you go to first, and what made that the right choice?" "Was there anything that made the hospital hard to go to?"
Watch for: fear of amputation or of surgery, cost, and relatives' advice as the drivers of the choice [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA]. Watch also for any current physical warning sign (go to 4.6 at once). It is working when the client's story of the injury includes their own reasons, not just a list of treatments. An Informant Version (17 questions) exists for interviewing a relative. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]

4.3 Selected CFI supplementary modules

Purpose / when: to go deeper where the core CFI points. The modules can be used as add-ons, as standalone tools, at first evaluation, or repeatedly during treatment. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: choose from the 12 modules according to need. Modules that are often relevant here [synthesis]:
- Explanatory Model: when the client holds a spiritual or social account of the injury or of healing.
- Coping and Help-Seeking: when the client delayed or mixed treatments.
- Spirituality, Religion and Moral Traditions: when healing is framed as God-given or as a family gift.
- Social Network: when relatives directed the choice.
- Level of Functioning: after malunion, non-union or amputation.
- School-Age Children and Adolescents or Older Adults: when relevant.
- Immigrants and Refugees: for diaspora clients who used a bone-setter abroad or within their community.
- Caregivers: for the family member caring for an injured person. This module is given to the caregiver.
Example language (illustrative): "You said your grandmother insisted on the bone-setter. Can you tell me more about who in the family usually decides about health matters?"
Watch for: module fatigue. Use one or two modules per session. It is working when the formulation explains why the client chose as they did and what would make medical review acceptable to them.

4.4 Kleinman explanatory-model questions

Purpose / when: a brief alternative or complement to the CFI Explanatory Model module, useful in a single consultation or with interpreters. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] (Kleinman, Eisenberg and Good, 1978, Annals of Internal Medicine 88; page range varies across sources [uncertain].) [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: ask, in your own words, about eight areas: what the client calls 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 whether it will be short or long; what treatment they think they should receive; the chief problems it has caused; and what they fear most about it.
Example language (illustrative): "What do you fear most about this injury?" "What kind of treatment do you think would be right for it?"
Watch for: the answer to "what do you fear most". Fear of amputation or of losing work is common, and it often explains avoidance of hospital. [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA] It is working when you can state the client's model back to them and they agree with it.

4.5 Non-judgemental inquiry about consulting a bone-setter

Purpose / when: whenever there is an injury, chronic musculoskeletal pain, or a family bone-setting tradition. Clients often do not mention traditional care unless asked. [synthesis]
Steps:
1. Normalise the question, and ask it of everyone with an injury.
2. Ask who, when, how many visits, and what the client was told.
3. Ask about the client's experience of the treatment, including pain and touch (see 4.8).
4. Ask what the client wants to keep from that care.
5. Do not ask for, record or evaluate techniques or materials. Record only that traditional care was received and whether any applied material or splint is still in place. [synthesis]
Example language (illustrative): "Lots of people see a bone-setter, a family healer or a doctor, or a mix of these. Who has been helping you with this?"
Watch for: shame or secrecy, especially if a doctor has previously scolded the client. Watch also for a splint or binding still in place on a painful limb, which needs prompt medical review (4.6). It is working when the client discloses traditional care readily in later sessions.

4.6 Physical-safety screening and medical routing

Purpose / when: at once, whenever a client has a current or recent injury treated outside medical care, or worsening symptoms after any treatment. Documented complications include non-union (40.8% of complications in one Nigerian series), malunion (24.5%), gangrene requiring amputation (including in two children), compartment syndrome, infection, pressure sores, chronic unreduced dislocations and nerve injury. [source: https://www.panafrican-med-journal.com//content/article/30/189/full] A review of 12 studies (833 participants, 691 complications) reports limb- and life-threatening complications, including death. [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543]
Steps:
1. Ask the client whether pain is increasing, whether the limb is cold, pale, dark or swollen, whether there is numbness or inability to move fingers or toes, whether there is a smell, discharge or open wound, or fever, and whether a binding feels too tight. These are general warning signs for a medical assessment, not a diagnosis by you. [synthesis]
2. If any is present, advise same-day emergency medical care, help arrange it, and document it.
3. If none is present but the injury was never imaged or reviewed, or is not improving, recommend medical review and explore barriers (4.7).
4. Do not advise removing, loosening or changing any splint, binding or applied material yourself. That is for the treating clinician. [synthesis]
5. If the client declines, document the information you gave and their capacity and choice, and follow safeguarding rules for children and adults at risk (4.13).
Example language (illustrative): "Some of what you're describing, like the coldness and the darker colour, needs a doctor to look at it today. That isn't about whether the bone-setter did well; it's about protecting your arm. Can we work out how you get there?"
Watch for: minimising ("it always hurts at first") and fear of amputation stopping attendance. It is working when the client attends review and returns to tell you the outcome.

4.7 Working with fears and barriers that keep the client from medical care

Purpose / when: when the client avoids hospital because of cost, distance, fear of amputation or surgery, past bad experiences, or family pressure. [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA]
Steps:
1. Name each barrier in the client's words.
2. Separate fears from facts the client can check. Have the medical team explain options. Do not give orthopaedic information yourself beyond what you know reliably. [synthesis]
3. Use a motivational style: look at what the client gains and risks either way, and their own reasons for seeking review. [synthesis]
4. Problem-solve practical barriers such as transport, cost, an interpreter or a companion.
5. Frame medical review as compatible with the client's tradition, where the client sees it so (4.9).
Example language (illustrative): "It sounds like the biggest worry is that the hospital will want to cut. Would it help to ask the doctor directly what the options are, with me or a relative there?"
Watch for: pushing too hard, which can lead to drop-out from therapy. It is working when the client shifts from "never" to "maybe if…".

4.8 Consent, touch and boundaries review

Purpose / when: whenever a client describes hands-on treatment by any practitioner, traditional or not. It confirms that touch was consented to, that the client could stop it, and that it was never sexual. [synthesis]
Steps:
1. Ask whether the practitioner explained what they would do and asked permission first.
2. Ask whether the client felt able to say stop, and what happened if they did.
3. Ask whether any touch felt sexual or involved the genitals or breasts. Ask in plain, clinical, non-explicit terms.
4. If touch was non-consensual or sexual, follow your safeguarding and reporting duties, offer support, and do not investigate the details beyond what is needed for safety.
5. For future care, help the client plan how to state limits, for example bringing a companion or agreeing a stop word with the practitioner.
Example language (illustrative): "With any hands-on treatment, you have the right to know what will happen, to say yes or no, and to stop it at any point. Was that how it felt for you?"
Watch for: normalising pain as part of being cured, and reluctance to criticise a respected elder. It is working when the client can name their own limits for future treatment.

4.9 Collaboration and referral with bone-setters and programmes

Purpose / when: when the client wants to keep traditional care alongside medical care, or comes from a community where bone-setters are the first point of care. Training and collaboration programmes exist:
- In Ghana, AO Alliance with Komfo Anokye Teaching Hospital and Tamale Teaching Hospital trained 197 bone-setters from 2021. Referrals rose, and the programme reports a 57% fall in bone-setter-related amputations. [source: https://edit.aofoundation.org/who-we-are/about-ao/news/2022/ao-alliance-ghana]
- In rural Tanzania (Rorya district), a joint three-day course for formal health workers and bone-setters was run in November 2024. Participants reported changed fracture care and greater mutual respect. [source: https://doaj.org/article/6672bce4cc084b07bface5c585ca0916] [source: https://www.globalsurgeryfoundation.org/news/tanzania-bonesetters-surgeons-collaboration]
- The review authors note that bone-setters are willing to engage with orthodox services. [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543]
- In mental health, collaboration between healers and primary care has trial support: COSIMPO (Gureje et al., The Lancet 2020) [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306], and the Ghana prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), where symptoms fell but days in chains were not significantly reduced [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. These are analogies, not bone-setting evidence. [synthesis]
Steps:
1. Ask whether the client wants their bone-setter involved, and in what way.
2. Find out whether a local association, training programme or hospital liaison exists. Where one exists, work through it rather than informally.
3. Get explicit, specific written consent for any information sharing, and agree what is shared.
4. Keep your role to coordination and psychological care. Leave decisions about physical treatment to the medical team, working with the bone-setter where they collaborate.
5. Review the plan with the client after each change in physical condition.
Example language (illustrative): "Would it help if your doctor and your bone-setter knew about each other's care? We'd only share what you agree to."
Watch for: the client feeling pressed to choose sides, and a practitioner opposed to any hospital involvement (see section 5). It is working when the client reports that both carers know the plan and no urgent care is delayed.

4.10 Working with family and relatives

Purpose / when: when relatives directed or opposed the choice. Relatives' and friends' advice was the most common reason given for using bone-setters in Makurdi. [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA]
Steps:
1. With consent, invite key relatives, or use the CFI Informant Version. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
2. Elicit each person's explanatory model.
3. Find shared goals, such as "keep the limb" or "get back to work".
4. Agree who decides what, and how warning signs will be acted on.
5. After a bad outcome, address blame within the family. [synthesis]
Example language (illustrative): "Everyone here wants your brother to walk again. Let's hear how each of you sees the best route there."
Watch for: a relative speaking over the client, and the client's own wishes getting lost. It is working when the family has one agreed plan for warning signs.

4.11 Distinguishing cultural explanation from clinical concern

Purpose / when: when the client gives a spiritual, moral or social account of the injury, of their recovery or of the practitioner's gift. Also when distress is expressed through bodily idioms. DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] (A secondary list of DSM-5-TR examples includes ataque de nervios, khyâl cap, kufungisisa, nervios and susto [uncertain: list not verified against the manual]. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf])
Steps:
1. Treat beliefs about divine gift, family gift or spiritual causation as culturally held explanations, and record them in the client's words.
2. Assess mood, anxiety, trauma symptoms and pain-related distress with your usual methods. A cultural explanation does not rule out a disorder, and a disorder does not invalidate the explanation.
3. Where unsure whether an experience is normative in the client's community, consult a cultural broker or community member with the client's consent.
4. Avoid both pathologising the belief and missing depression, PTSD or suicidality. [synthesis]
Example language (illustrative): "You see the healing as God's work through the bone-setter. Alongside that, I'd like to ask how your sleep and mood have been since the accident."
Watch for: guilt framed spiritually ("I was punished") that hides depression or suicidal thinking; follow standard risk assessment. It is working when the client feels the explanation was respected and the symptoms were taken seriously.

4.12 Psychological care after complications, amputation or chronic pain

Purpose / when: after malunion, non-union, amputation, nerve injury or persistent pain, whatever the treatment route. [source: https://www.panafrican-med-journal.com//content/article/30/189/full] Specific psychological outcomes after bone-setter complications are not described in the sources [uncertain: not verified]. The steps are [synthesis].
Steps:
1. Assess grief, depression, trauma symptoms (including medical-procedure trauma), anger, guilt and decisional regret.
2. Allow ambivalence. The client may still value the bone-setter and also feel harmed.
3. Use the evidence-based treatment that fits the presenting disorder, such as trauma-focused therapy, behavioural activation, or acceptance-based pain work, and adapt its examples to the client's model.
4. Address role loss (work, farming, caregiving) and practical rehabilitation goals with the rehab team.
5. Address any family blame (4.10).
Example language (illustrative): "You made the best choice you could with what you knew and what you feared then. Can we look at the anger and the sadness about how it turned out, without either of us having to decide who was to blame?"
Watch for: self-blame, and anger at services that dismissed the client. It is working when the client can talk about the injury without being flooded and re-engages with valued roles.

4.13 Safeguarding

Purpose / when: when a child or an adult at risk has an untreated or worsening injury, when urgent care is being delayed, when treatment involved non-consensual or sexual touch, or when there is physical harm. Gangrene leading to amputation in children is documented. [source: https://www.panafrican-med-journal.com//content/article/30/189/full]
Steps:
1. Act on warning signs at once (4.6).
2. Follow local safeguarding procedures and consult your safeguarding lead.
3. Tell the family what you are doing and why, unless that would increase risk.
4. Separate the practice from the harm: the concern is the delay or injury, not the tradition.
5. Document facts, not judgements about the tradition. [synthesis] Do not name the child in any external communication beyond what the procedure requires.
Example language (illustrative): "I can see how much you trust the bone-setter. My job is to make sure your daughter's hand is seen by a doctor today, and I have to make sure that happens."
Watch for: families concealing care for fear of blame, and practitioners being scapegoated. It is working when urgent care happens and the family stays engaged.

4.14 Interpreters and cultural brokers

Purpose / when: when the client's preferred language differs from yours, or local knowledge of the bone-setting tradition is needed. [synthesis]
Steps:
1. Use a trained interpreter, not a family member, for consent and safety questions.
2. Brief the interpreter on the respectful, non-judgemental stance.
3. With the client's consent, consult a cultural broker or a community health worker who knows local practitioners.
4. Debrief with the interpreter after sessions involving distressing injury material.
Example language (illustrative): "Please translate the questions about the bone-setter just as I say them, without softening or adding warnings."
Watch for: the interpreter's own views on bone-setting colouring the translation. It is working when the client's answers become fuller and more specific.

4.15 Integration and meaning-making

Purpose / when: at review or end of therapy, or when a client has had a good experience of traditional care and wants it acknowledged. Users in Ashanti reported warm reception, prompt attention and satisfaction. [source: https://ajod.org/index.php/ajod/article/view/97] Irish bone-setters often treated without fixed charge, and patients paid what they could. [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf]
Steps:
1. Invite the client's own story of healing, including what the relationship with the practitioner meant to them.
2. Link it to the client's values and identity.
3. Agree a plan for future injuries: who to see, and when to go to hospital.
Example language (illustrative): "What would you want to remember from how you were cared for, and what would you do differently next time?"
Watch for: the therapist taking the role of judge of the tradition. It is working when the client has a coherent account that includes both forms of care.

4.16 When the client is a bone-setter or from a bone-setting family

Purpose / when: when the client holds, or is expected to inherit, the family skill or gift. In Ireland the gift is described as passed through family lines, sometimes carrying community expectation to practise, though holding it does not oblige a person to practise. [source: https://www.ucc.ie/en/media/research/corkfolkloreproject/folkloredept/KingstonATaleofTwoBone-setters.pdf] Clients may also carry the family memory of professional hostility. [source: https://www.rjah.nhs.uk/media/o1ybnyqt/bonesetters-of-anglesey-and-hugh-owen-thomas.pdf]
Steps:
1. Explore identity, duty, burden and pride around the gift.
2. Explore the relationship with medicine, and any legal or reputational stress, such as an adverse outcome or a complaint.
3. Explore role strain, for example treating patients late into the night.
4. Support the client's own decisions about training, association membership or stopping practice, without directing them. [synthesis] Do not ask the client to describe or demonstrate techniques.
Example language (illustrative): "What does it mean to you to carry this gift, and what does it ask of you?"
Watch for: guilt after a patient's bad outcome, and isolation. It is working when the client can weigh their choices about practice in their own terms.

5. Handling problems

The sources describe the barriers and complications. The responses below are [synthesis] unless a source is given.

The client refuses hospital despite warning signs. Check understanding and capacity. Name the specific risk calmly: limb loss and life-threatening complications are documented. [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543] Explore the feared outcome, often amputation or cost. [source: https://www.dovepress.com/patronage-of-traditional-bonesetters-in-makurdi-north-central-nigeria-peer-reviewed-fulltext-article-PPA] Offer a trusted companion and practical help. If the client is a child or an adult at risk, or lacks capacity, follow safeguarding procedures. Otherwise document the advice and the informed choice, and leave the door open. [synthesis]
The client feels judged and disengages. Repair the rupture explicitly. Acknowledge that services have often dismissed traditional practitioners. [source: https://history.physio/manipulation-setting-the-record-straight/] Separate concern about a specific risk from any view of the tradition, and return to the client's goals. Example (illustrative): "I think I came across as criticising your choice. That wasn't fair to you. Can we start again from what you want for your leg?"
The bone-setter or family opposes any medical involvement. Do not argue against the tradition. Seek a shared goal, such as keeping the limb, and, with consent, use any association or hospital liaison that exists. In Ghana, associations include complication tracing and prevention training. [source: https://edit.aofoundation.org/who-we-are/about-ao/news/2022/ao-alliance-ghana] Where no channel exists, keep the client's safety plan independent of others' agreement. [synthesis]
The client wants your opinion on the bone-setter's method or materials. Decline kindly. You are not qualified to assess technique, splints, poultices or plant and animal materials, and questions about medicines go to the prescriber. Redirect to the medical team and to the client's own observations of their recovery. [synthesis]
The client wants you to recommend a bone-setter, or to rule one out. Do not refer to individual practitioners outside a sanctioned programme or association. Explain what collaboration routes exist and let the client choose. [synthesis]
The client is stuck in blame or regret after amputation or disability. Slow down. Validate both the loss and the reasons for the original choice. Use grief- and trauma-focused work as indicated (4.12), and watch for depression and suicidality with standard risk assessment. [synthesis]
Non-adherence to medical follow-up or rehabilitation. Re-run the explanatory-model questions. The client may believe healing is complete once the practitioner has finished, or that further care conflicts with their faith. Negotiate small, specific next steps. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [synthesis]
Disclosure of non-consensual or sexual touch. Believe and support the client. Follow reporting and safeguarding duties. Do not question the client in ways that require explicit detail. Offer trauma-informed follow-up. [synthesis]
Overwhelm during injury or medical-trauma material. Pause, ground and pace the work. Return to safety and stabilisation before further detail. [synthesis]
The clinician's own conflict, such as an allied-health background or strong views. Seek supervision or consultation. Revisit 4.1, and refer on if you cannot hold a non-judgemental stance. [synthesis]
The client is a practitioner facing a complaint or legal action. Offer support with distress and decision-making. Do not give legal advice; signpost legal and professional-association help. Nigerian authors call for certification and legislative control of practice, so the legal context may be changing [source: https://www.panafrican-med-journal.com//content/article/30/189/full]. Current law: [uncertain: not verified]. [synthesis]
Conflicting information across sources. Some studies of users report no adverse experiences [source: https://ajod.org/index.php/ajod/article/view/97]. Hospital-based series and the review document serious complications [source: https://www.panafrican-med-journal.com//content/article/30/189/full] [source: https://journals.sagepub.com/doi/ref/10.1177/00494755221122543]. Both can be true. Hospital series see the complications, while user samples may not. Hold both views when talking with clients. [synthesis]

Sources

Books and papers cited:

Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88. (Page range differs between sources [uncertain].)
Hood W (1871). On Bone-Setting, So Called. Macmillan. Cited via MacDonald 2020 [uncertain: not verified].
Paget J (1867). Clinical lecture on cases that bone-setters cure. Cited via MacDonald 2020 [uncertain: not verified].

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