Romani healing

1. Introduction

Version followed: Romani healing and protective practice as described in Romani-studies scholarship (Council of Europe Factsheets on Romani Culture, especially factsheet 2.3 by Markéta Hajská on jakhendar, the evil eye), the Patrin Web Journal page on Romani beliefs, historical work on Roma and health care (Szabóné Kármán), and the 2024 Roma Support Group and Friends, Families and Travellers report on mental health. The therapist's own work follows the APA DSM-5-TR Cultural Formulation Interview (CFI) and Kleinman's explanatory-model questions.

What it is. There is no single Romani healing system. Roma are many groups across Europe and beyond (for example Vlach Rom, Sinti, Kaale, Servika Roma, Romanichal), and beliefs and practices differ by country, group and family [source: https://www.oocities.org/~patrin/beliefs.htm] [source: https://www.coe.int/en/web/roma-and-travellers/factsheets-on-romani-culture]. Sources describe the following elements:

A purity code. Romaniya is described as the system of standards that keeps Roma apart from gadje (non-Roma). Things and acts are pure (vujo or wuzho) or polluted (marimé). Marimé also names the exclusion imposed for breaking the rules. Many groups treat the lower body as polluting, which shapes dress, washing, the separation of men and women and contact with non-Roma. How strictly the code is kept varies [source: https://www.oocities.org/~patrin/beliefs.htm] [source: https://www.ccjm.org/content/60/6/427.full.pdf].
Ideas about illness and misfortune. Sources describe illness as an unnatural condition (prikaza), bad luck (bibaxt), curses (amria), the dead (mulé) and, very widely, the evil eye. The evil eye is called jakhendar among Slovak Roma, and Krainova's article records yakhaló [source: https://www.oocities.org/~patrin/beliefs.htm] [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373] [source: https://romi.hr/features/print/traditional-roma-medicine]. Historical sources also record named disease-demons. By the 20th century these survived mainly in curses [source: https://btk.pte.hu/sites/btk.pte.hu/files/romologia_folyoirat/16-17.%20Health%20Care%20And%20Roma%20people%20Rom.%20foly.pdf]. These concepts are described here as Romani traditions hold them. They are neither presented as fact nor dismissed.
Healers and herbal knowledge. The drabarni (also drabengi) is a woman healer who gives traditional cures, from drab, meaning herb or medicine. Herbal knowledge itself may be held by men or women [source: https://www.oocities.org/~patrin/beliefs.htm]. Most healing knowledge sat in families and mostly with women, and some communities also had specialist healers [source: https://btk.pte.hu/sites/btk.pte.hu/files/romologia_folyoirat/16-17.%20Health%20Care%20And%20Roma%20people%20Rom.%20foly.pdf]. Knowledge passed down by word of mouth. Remedies used plants, roots and sometimes metals; Kelderash groups, for example, regarded gold as healing. Remedies came with words the healer kept secret [source: https://romi.hr/features/print/traditional-roma-medicine]. The Patrin page separates fortune-telling for gadje, which it describes as a livelihood, from healing advice given among Roma themselves [source: https://www.oocities.org/~patrin/beliefs.htm].
Protection. Charms, amulets and talismans are carried against misfortune and illness. Sources mention a red ribbon on a child's wrist, small cloth pouches (bayero) for children, and bread kept in a pocket [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373] [source: https://romi.hr/features/print/traditional-roma-medicine] [source: https://www.oocities.org/~patrin/beliefs.htm]. Today the evil-eye cleansing practice is widely kept among Slovak Roma and in families who moved to Czech towns, in a simpler form than older accounts describe. It is usually led by the affected person or an older woman of the family [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373].
On the word "chovihani". The term chovihani, rendered as "witch" in popular usage, appears with "herbs and amulets for protection" in a Wikipedia article. That article cites a popular herbal-magic book (Dunwich 2019), not Romani scholarship [source: https://en.wikipedia.org/wiki/Romani_folklore]. None of the Romani-studies or Romani community sources cited here use the term. Treat it as an outsider's label unless the client uses it [uncertain: not verified].

Who holds authority. Healing authority sits in families and communities, not in any licensing body. Older women lead protective practices for children, and recognised healers (drabarni) give remedies [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373] [source: https://www.oocities.org/~patrin/beliefs.htm]. Purity rules are enforced by community norms. Some groups have a Romani court (kris romani), led by elders [source: https://www.ccjm.org/content/60/6/427.full.pdf] [source: https://www.coe.int/en/web/roma-and-travellers/factsheets-on-romani-culture]. Roma also follow the faiths of their host countries, and Pentecostal and evangelical churches have spread among Roma [source: https://www.oocities.org/~patrin/beliefs.htm]. How these churches view traditional practices is [uncertain: not verified]. On health access, Roma-led and Gypsy, Roma and Traveller organisations and Roma health mediators speak for communities [source: https://www.coe-romed.org/romed1] [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].

The therapist's role. A psychotherapist does not practise Romani healing and does not perform protective or cleansing practices. Your work runs alongside it. You assess culturally (CFI, explanatory model), respect the purity code in how you deliver care, ask about family remedies and protection without judgement, tell normative belief apart from disorder, work with mediators, advocates and family, and attend to discrimination, coercive medical history and safeguarding.

How change happens (therapist side) [synthesis]. Change comes through trust. The client's own account of illness (bad luck, the evil eye, nerves, a curse) is taken seriously and brought into a shared plan. The plan respects purity and family structures and reduces the barriers that discrimination has built. Protective and family practices can stay in place as sources of coping while therapy proceeds.

2. Framework

This is not a therapy with phases. Romani healing has no published treatment structure, and none of the sources sets session counts. The structure below is the therapist's own culturally responsive process, drawn from the CFI and from the practitioner recommendations of the Roma Support Group and Friends, Families and Travellers report (RSG/FFT 2024) [synthesis].

Preparation (before contact). Goals: check your own assumptions about "Gypsies" and anti-Gypsyism; learn which Romani groups live locally; find the local Roma organisation, health mediator or advocate; book a professional interpreter in the client's language (Romanes, or the national language they prefer); offer the client a male or female clinician. RSG/FFT recommend cultural awareness training, finding out about the local population and avoiding assumptions that all Gypsy, Roma and Traveller people share the same needs [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Move on once access barriers are dealt with: contact by phone or in person, no reliance on post, an interpreter booked.
Engagement and trust (sessions 1–2, often longer) [synthesis]. Goals: safety, a clear account of confidentiality, especially regarding social services, and practical help where needed (housing, debt, registration). RSG/FFT advise addressing non-health needs and keeping promises [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Move on when the client returns and can say what they want help with.
Cultural assessment (1–3 sessions) [synthesis]. Goals: the core CFI with the relevant supplementary modules and Kleinman's questions. Map family remedies, protection practices, healers consulted and purity constraints. The CFI has 16 questions in four domains, and its modules can be used at the first evaluation or later [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]. How long the CFI takes is [uncertain]. The field trial found 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 explanatory model in their own terms and they agree with your summary.
Formulation and differential. Goals: decide whether the presentation is culturally normative belief or practice, distress that needs psychological help, or a disorder that needs psychiatric or medical assessment. The CFI supports clinical understanding but is not the only basis for diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Move on once a shared formulation is reached and medical or psychiatric referral has been made if needed.
Shared plan and collaboration (ongoing) [synthesis]. Goals: an evidence-based psychological treatment adapted for literacy, gender, purity and family. Agree roles for family, mediator or advocate and prescriber. Family protective practices continue if the client wishes. Run safeguarding and risk review throughout.
Integration and review [synthesis]. Goals: review the explanatory model again, keep continuity through travel or moves (hold their place on waiting lists, arrange phone follow-up), plan endings with the community organisation. RSG/FFT advise against discharging after missed appointments without notice and recommend drop-in options [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].

Format [synthesis]. Individual sessions, with family members present only at the client's request and never as interpreters. Use in-person or phone contact rather than digital-only, and plain spoken language with teach-back instead of leaflets [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].

3. Guiding principles

Plurality, not a stereotype. Practices vary by group, country and family. Ask the client rather than applying a checklist [source: https://www.oocities.org/~patrin/beliefs.htm]. Practical meaning: never assume purity rules, beliefs or language from the word "Roma".
Ask about naming. Some people call themselves Roma, Romani, Sinti, Kaale or Gypsy (for example British Romany Gypsies), and some reject "Gypsy" [synthesis]. Practical meaning: ask which name the client uses and use it.
Cultural humility and self-examination. Anti-Gypsyism is pervasive [source: https://fra.europa.eu/en/publication/2022/roma-survey-findings]. Practical meaning: check whether you are reading poverty, mistrust or family loyalty as pathology.
Describe and attribute; never practise. The therapist does not do evil-eye cleansing, give herbal remedies, make amulets or speak charms. Practical meaning: you discuss these practices only as the client's own resources.
Neither fact nor dismissal. The evil eye, curses, bibaxt and the dead are described as the client's tradition holds them. Practical meaning: explore what they mean and what they do in the client's life without arguing about whether they are real.
Purity-aware care. Marimé rules can shape dress, touch, washing, gender and contact with non-Roma [source: https://www.oocities.org/~patrin/beliefs.htm] [source: https://www.ccjm.org/content/60/6/427.full.pdf]. Practical meaning: offer gender choice, ask before raising bodily topics, and accommodate dress and setting.
Trust before technique. Trust is the main enabler in services, and good experiences spread through communities [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Practical meaning: keep promises, keep continuity, and do not discharge without notice.
Rights-based mediation. ROMED frames mediation as a duty to secure access to rights, not as charity [source: https://www.coe-romed.org/romed1]. Practical meaning: use mediators and advocates to open access, not to manage or persuade the client.
History-informed, trauma-informed. Coercive public-health measures and forced sterilisation of Romani women are documented [source: https://btk.pte.hu/sites/btk.pte.hu/files/romologia_folyoirat/16-17.%20Health%20Care%20And%20Roma%20people%20Rom.%20foly.pdf] [source: https://www.hhrjournal.org/?p=8270]. Practical meaning: treat fear of services as reasonable, make consent explicit, and never pressure.
Consent and confidentiality, including within the family. Practical meaning: agree with the client what family members, mediators and interpreters may hear, given fears that a mental-health label could affect marriage prospects [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
No advice on remedies or medicines. Practical meaning: never advise starting, stopping or changing herbal or prescribed medicines. Send interaction questions to the prescriber or a pharmacist [synthesis].
Physical illness goes to medicine. No Romani practice is presented here as a treatment for physical disease. Practical meaning: make sure medical assessment happens alongside family remedies [synthesis].
Safeguarding is non-negotiable and non-stereotyping. Practical meaning: act on actual risk to the person, never on ethnicity or tradition alone [synthesis].
Touch. Psychotherapy here involves no touch. Any physical contact a client describes from a healer is explored only with consent, and touch is never sexual [synthesis].

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a Romani healing practice. Example language is illustrative throughout.

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout work with any Romani client. It counters the effects of anti-Gypsyism. The FRA 2021 survey found that a quarter of Roma had felt discriminated against in the past year in areas of daily life that include health care [source: https://fra.europa.eu/en/publication/2022/roma-survey-findings]. RSG/FFT report that over 90% of Gypsy, Roma and Traveller people report racism and discrimination in everyday life [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps [synthesis]:
1. List the images of "Gypsies" you carry: fortune-telling, theft, "witches", romantic nomads. Notice which ones reach into clinical judgement.
2. Learn the local context: which groups live locally, which languages they speak, whether they are long-settled, recent EU migrants or Traveller families. The Council of Europe factsheets describe this variation [source: https://www.coe.int/en/web/roma-and-travellers/factsheets-on-romani-culture].
3. Check your notes and referral letters for loaded words such as "superstitious", "chaotic" or "non-compliant".
4. Take this to supervision or peer consultation, ideally with someone who has worked with Roma organisations.
Example language (illustrative): "I don't know everything about how your family does things, and I'd rather ask than guess. Tell me if I get something wrong."
Watch for: Surprise or relief when you ask instead of assuming is a good sign. Formulations that mention ethnicity without saying what it means for this client are a warning sign. You know it is working when the client corrects you.

4.2 Building access and trust

Purpose / when: From first contact, because mistrust, fear of social services, low literacy, digital exclusion and having no fixed address all block care [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps (adapted from RSG/FFT 2024 recommendations):
1. Offer in-person or phone contact as well as digital. Do not rely on letters.
2. Use plain spoken language. Repeat key points and ask the client to explain them back (teach-back). Use visual aids rather than leaflets.
3. Respond to missed sessions with a call, not automatic discharge. Hold the client's place on the waiting list during travel or eviction.
4. Help with practical needs (housing, debt, registration) or refer for them.
5. Keep every promise, including small ones such as calling back on time.
6. Say clearly what confidentiality means and when social services would be involved.
Example language (illustrative): "If you miss a session, I'll phone you, I won't just close your file. If you're travelling, tell me and we'll keep your place." / "Nothing you tell me goes to social services unless someone is at serious risk, and if that happens I'll tell you first."
Watch for: Returning for a second session, bringing a relative to the waiting area, or referring a cousin are signs of growing trust. RSG/FFT note that good experiences travel through communities. Repeated no-shows after a letter-based contact point to a system barrier, not low motivation [synthesis].

4.3 Working with interpreters, advocates and Roma health mediators

Purpose / when: When language, literacy or trust limits communication. RSG/FFT report that family interpreters can filter information through gender, age and stigma; for example, a mother may not disclose symptoms through her son. NHS England guidance favours professional interpreters [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. The Council of Europe's ROMED programme trained about 1,479 mediators, roughly 90% of them Roma and over half women, to act between Roma and public institutions including health care [source: https://www.coe-romed.org/romed1].
Steps:
1. Book a professional interpreter in the client's preferred language (a Romani variety or the national language). Ask the client whether gender or community membership of the interpreter matters.
2. Brief the interpreter: mental-health vocabulary may be missing in Romanes [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf], so ask for meaning rather than word-for-word rendering.
3. If the client wants a Roma advocate or mediator, agree in writing what the advocate may hear and pass on [synthesis].
4. Debrief with the interpreter or advocate after the session about any cultural meanings you might have missed [synthesis].
Example language (illustrative): "Would you prefer a woman or a man interpreting, and someone from inside or outside the community?" / to the advocate: "Your role today is to help us understand each other, not to speak for her."
Watch for: The client looking at the advocate before answering, or answers getting shorter when a relative is present. Rising disclosure after you switch to a professional interpreter suggests the change has helped.

4.4 The core Cultural Formulation Interview

Purpose / when: At assessment, to get the client's own definition of the problem, its causes, supports, coping, past help-seeking and expectations. The APA describes the CFI as usable by any clinician in any setting [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps:
1. Introduce it as questions about how the client and their people understand the problem.
2. Work through the four domains in your own words: (1) cultural definition of the problem; (2) perceived causes, context and supports, including the role of cultural identity; (3) self-coping and past help-seeking, including barriers; (4) current help-seeking preferences and the clinician–patient relationship, including perceived racism and language [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
3. In domain 3, ask specifically about family remedies, protective practices, the evil eye, and older women or drabarni consulted (see 4.7) [synthesis].
4. In domain 4, ask directly about experiences of discrimination in services.
5. Use the Informant Version (17 questions) with a relative only with the client's consent [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
6. Clinicians may reproduce the CFI for use with their own patients. Translating or modifying it needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Ask the interpreter to convey meaning in session rather than producing a written translation.
Example language (illustrative): "How would you describe what's been happening, in your own words, the way you'd say it to your family?" / "Has anything about being Roma made it harder to get help, here or anywhere?"
Watch for: Terms such as "nerves" or "bad nerves", bad luck, the eye, or a curse. Keep the client's words in your notes. The field trial found the CFI feasible and acceptable, and clinicians grew faster after the first use [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].

4.5 CFI supplementary modules

Purpose / when: For depth on specific topics, at the first evaluation or later in care. There are 12 modules [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps (choose by need) [synthesis on selection]:
- Explanatory Model: when the client links symptoms to the eye, a curse, bad luck or impurity.
- Spirituality, Religion, and Moral Traditions: for Orthodox, Catholic, Muslim or Pentecostal faith, pilgrimages and the meaning of purity rules.
- Cultural Identity: for group, language, a settled or travelling background, and how the client relates to gadje society.
- Coping and Help-Seeking: for family remedies, protective items, healers, clergy.
- Social Network: for extended-family ties and obligations.
- Immigrants and Refugees: for recent EU or other migrant Roma.
- Patient-Clinician Relationship: when mistrust or past coercion is present.
- Older Adults, School-Age Children and Adolescents, Caregivers: as relevant. The Caregivers module is given to the caregiver.
Example language (illustrative): "You said your mother thought it might be the eye. Can I ask a few more questions about what that means in your family?"
Watch for: Module fatigue. Use one module per session. If the client asks why you want to know, it is a cue to explain the purpose, not to stop.

4.6 Exploring the explanatory model (Kleinman)

Purpose / when: When the client's view of cause and cure differs from a biomedical or psychological one, for example illness from the evil eye, a curse, bad luck, impurity or "nerves".
Steps: Ask, in your own words, Kleinman's eight areas: the client's name for the problem, its cause, why it started when it did, what it does, how severe it is and how long it will last, what treatment it needs, the main problems it causes, and what the client fears most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Then summarise back and look for overlap with your own model [synthesis].
Example language (illustrative): "What do you call this?" / "Why do you think it came now?" / "What do you think would help, from your family's side and from ours?" / "What worries you most about it?"
Watch for: The client may hold several models at once, for example the eye and stress and a medical illness. Do not force a choice. Fear that mental illness is hereditary and could affect a family's marriage prospects is reported among some Roma [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf], so ask gently. The model is working as a bridge when the client accepts a plan that includes both family and clinical help.

4.7 Asking about family remedies, healers and protection without judgement

Purpose / when: At assessment and when symptoms change. Clients may use family herbal remedies, protective items or family-led cleansing, or consult an older woman or drabarni [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373] [source: https://www.oocities.org/~patrin/beliefs.htm]. Hajská notes that well-integrated Roma may deny these practices while still following them.
Steps [synthesis]:
1. Treat it as normal: say many families have their own ways of protecting and healing.
2. Ask what has been tried, by whom, and with what effect. Do not ask for recipes, words or methods; these may be secret by tradition [source: https://romi.hr/features/print/traditional-roma-medicine].
3. Ask whether anything is being swallowed or applied, so that you can tell the prescriber or GP (see 4.12).
4. Record practices respectfully, in the client's terms.
Example language (illustrative): "Lots of families have their own ways of protecting children or treating illness. Has your family done anything like that for this? You don't need to tell me the details, just whether it helped."
Watch for: Hesitation or denial followed by later disclosure, which is common where practices have been mocked. Never ask the client to remove a protective item. If an item is visible, a neutral question is enough.

4.8 Purity-aware and gender-aware delivery

Purpose / when: In every contact where marimé rules may apply. These rules can shape dress, washing, the separation of upper and lower body, men and women, and contact with gadje [source: https://www.oocities.org/~patrin/beliefs.htm]. A clinician writing from an outsider's view reported that standard hospital clothing was experienced as degrading [source: https://www.ccjm.org/content/60/6/427.full.pdf]. RSG/FFT report that a postnatal "purity period" may affect engagement with postnatal services, and they secured a female therapist for a client uncomfortable with a male therapist [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps [synthesis]:
1. Offer a therapist of the client's preferred gender at the outset.
2. Before discussing sex, menstruation, pregnancy, childbirth or bodily symptoms, ask permission. Use non-explicit clinical language and offer a same-gender clinician or interpreter.
3. In inpatient or group settings, raise clothing, washing and shared-space concerns with the team.
4. Plan postnatal mental-health follow-up so it fits any purity period the client keeps (for example phone contact).
5. Do not assume rules: ask what applies in this family.
Example language (illustrative): "Some people prefer to talk about body or women's matters with a woman. Would that be better for you?" / "Is there anything about this room or how we do things that is uncomfortable for you?"
Watch for: Silence or shame when bodily topics arise. Discomfort with mixed-gender groups. Gratitude when you ask first shows the accommodation is landing.

4.9 Distinguishing normative belief and practice from disorder

Purpose / when: When symptoms are explained by the evil eye, a curse, bad luck, the dead or impurity, or when unusual experiences are reported. Neither pathologise belief nor miss illness. Hajská lists symptoms that communities attribute to the evil eye: weakness, irritability, sudden sleepiness, listlessness, vomiting, dizziness, headache and stomach ache; and in children fever, poor sleep and poor appetite [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373]. These overlap with depression, anxiety and physical disease.
Steps:
1. Establish whether the belief is shared in the client's family or group. Ask the client, and with consent a relative or a Roma advocate [synthesis].
2. Check function and distress: is the belief held in proportion and does it fit the community's view, or is it fixed, idiosyncratic, escalating and impairing? [synthesis]
3. Use the diagnostic culture provisions. DSM-5 notes that identity disruption in dissociative identity disorder may be described in some cultures as possession, and excludes disturbance that is a normal part of broadly accepted cultural or religious practice. Dissociative trance (other specified dissociative disorder) carries the same exclusion [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. A DSM-5-TR study guide paraphrases these points as retained [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; the exact DSM-5-TR wording is [uncertain]. ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary, unwanted and outside accepted cultural or religious practice [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574].
4. Explore idioms of distress such as "bad nerves", which RSG/FFT report Gypsy and Traveller people often use instead of mental-health terms [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Do not equate it with DSM "nervios"; DSM-5-TR's list of cultural concepts of distress is [uncertain] and none of the concepts is Romani-specific [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf].
5. Arrange medical assessment for physical symptoms, and psychiatric assessment where psychosis, mania or severe depression is possible. RSG reported high rates of psychosis (23%) and depression (55%) among its mental-health project beneficiaries, a service sample and not a population rate [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
6. Whether DSM-5-TR still states that culturally sanctioned beliefs should not be counted as psychotic symptoms is [uncertain]. Rely on clinical judgement and cultural consultation [synthesis].
Example language (illustrative): "In your family, how would people usually know someone has the eye? Does what's happening to you look like that to them, or does it feel different?" / "Let's ask the doctor to check your body too, so we're not missing anything while your family does what they do."
Watch for: Relatives saying "this is not the eye, this is something else" is a strong signal of illness. Watch for beliefs spreading beyond what the family shares, and for loss of function, self-neglect or command experiences. Over-pathologising shows up as mistrust and the client not returning.

4.10 Working with the family and community

Purpose / when: Extended family is central. Several generations may live together, and many relatives may come at times of illness [source: https://www.ccjm.org/content/60/6/427.full.pdf]. Healing for children is usually led by the mother or grandmother [source: https://rm.coe.int/factsheets-on-romani-culture-2-3-the-evil-eye-jakhendar/1680aac373].
Steps [synthesis unless cited]:
1. Ask the client who in the family should be involved, and in what.
2. Agree one family contact person for practical updates. An outside clinician suggests this approach for hospital care [source: https://www.ccjm.org/content/60/6/427.full.pdf].
3. Keep individual time with the client for topics that carry stigma or purity concerns.
4. With the client's consent, explain to relatives what therapy is and is not, in plain language.
5. Do not seek to involve, or comment on, a Romani court or other community dispute process. Those are the community's own institutions.
Example language (illustrative): "Who in your family do you want to know about our work, and what can I tell them?" / to relatives: "This is a place for her to talk. It doesn't replace what your family does, and it doesn't involve social services."
Watch for: Family pressure to end therapy, or marriage-related stigma fears [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Relatives answering for the client. Family support for attendance is a sign the work is accepted.

4.11 Collaboration and referral with community-sanctioned resources

Purpose / when: When the client wishes to combine family or community healing, faith support and therapy, or needs advocacy. Romani healing has no formal licensing or referral register. Practitioners such as drabarni and older women are recognised within families and communities, and the therapist does not refer to them unless the client asks and arranges it [synthesis]. Community-led organisations and mediators are the main institutional partners [source: https://www.coe-romed.org/romed1] [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps:
1. Map local Roma and Gypsy/Traveller organisations, health mediators and advocates. Examples in England are the Roma Support Group and Friends, Families and Travellers. RSG's work with Newham Talking Therapies included bilingual advocates, translated forms, visual prompts and tailored groups [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
2. With written consent, share only what the client agrees to share [synthesis].
3. If the client wants to consult family healers or clergy, support their choice. Ask how it fits with therapy, and make sure physical symptoms still reach medical care [synthesis].
4. Evidence for collaborative models comes from other settings and is not Romani-specific. In Ghana and Nigeria, collaborative shared care between traditional and faith healers and primary care (COSIMPO; Gureje et al., The Lancet 2020) reduced psychotic symptoms more than control care and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]. In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric care reduced symptoms, but days in chains did not fall significantly [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. WHO's traditional medicine strategy supports safe integration within health systems [source: https://www.who.int/activities/implementation-of-the-WHO-traditional-medicine-strategy-2014-2023]. No collaboration trial with Romani healers was identified [uncertain: not verified].
Example language (illustrative): "Would it help if someone from the Roma support organisation came with you next time?" / "If your grandmother is helping in her way, that's fine with me. Is there anything she'd want me to know or not do?"
Watch for: The advocate becoming the gatekeeper. Clients feeling they must choose sides. Coordinated care looks like the client attending both and reporting no conflict.

4.12 Herbal remedies and medicines: the safety conversation

Purpose / when: When family herbal remedies, roots, metals or other preparations are used alongside prescribed medicines or instead of medical care [source: https://romi.hr/features/print/traditional-roma-medicine] [source: https://www.oocities.org/~patrin/beliefs.htm].
Steps [synthesis]:
1. Ask neutrally what is taken or applied and how often. Do not ask for recipes.
2. Do not advise starting, stopping or changing any remedy or medicine.
3. With consent, tell the prescriber, GP or a pharmacist, who can judge interactions.
4. If remedies are replacing urgent medical care, especially for a child, see 4.17.
Example language (illustrative): "I can't advise on herbs or medicines, but your doctor or pharmacist should know what you're taking so they can check it's safe together. Can I let them know?"
Watch for: Fear that disclosure will bring ridicule. Physical symptoms getting worse. The conversation is working when the client lets you or the GP know about remedies.

4.13 Addressing discrimination and historical and intergenerational trauma

Purpose / when: When mistrust, fear of services, anger or shame relate to racism or coercive care. Documented history includes coercive public-health measures against Roma settlements in Hungary: forced inspections, washing and delousing under the 1876 Public Health Act, which continued into the 1970s–80s, and quarantines and the burning of a settlement in 1935 [source: https://btk.pte.hu/sites/btk.pte.hu/files/romologia_folyoirat/16-17.%20Health%20Care%20And%20Roma%20people%20Rom.%20foly.pdf]. It also includes coercive sterilisation of Romani women in Czechoslovakia and the Czech Republic: state policy until 1993, with cases documented as late as 2007 and examined in an ERRC report [source: https://www.hhrjournal.org/?p=8270]. Details of Czech compensation legislation are [uncertain: not verified]. Persecution of Roma under Nazism is part of collective memory for many families [uncertain: not verified]. RSG/FFT recommend trauma-informed practice that recognises intergenerational trauma [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps [synthesis]:
1. Ask about discrimination using CFI domain 4 (see 4.4).
2. Validate fear of services as grounded in documented history.
3. Make consent explicit at every step, especially around reproductive health, children and social services.
4. Formulate distress in relation to racism, eviction, poverty and housing as well as individual factors. The FRA 2021 survey found 80% of Roma below the at-risk-of-poverty threshold and an 11-year (women) and 9-year (men) life-expectancy gap [source: https://fra.europa.eu/en/publication/2022/roma-survey-findings].
5. Use evidence-based trauma treatment when it is indicated and the client chooses it.
Example language (illustrative): "Many Roma families have had bad experiences with doctors and authorities. If anything like that has happened to you or your family, it makes sense to be careful with me."
Watch for: Disclosure of reproductive coercion; refer for legal or advocacy support if the client wishes. Testing behaviour, such as missing a session to see whether you call. Trust growing after a rupture is repaired.

4.14 Suicide and self-harm risk

Purpose / when: At every assessment and review. RSG/FFT report a suicide rate seven times higher for Traveller men than for settled men, suicide in an estimated 11% of Irish Traveller deaths, and roughly twice the national suicide risk for carers. These figures concern Travellers and carers and are not Roma-specific; Roma data are thinner [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Steps: Follow your service's current standard risk assessment and safety planning [synthesis]. Ask directly, through a professional interpreter, and avoid family interpreters for this. Include lethal-means counselling (safe storage and removal). With consent, involve trusted family and the community organisation in the safety plan. RSG/FFT ask commissioners to treat these communities as a high-risk group even where local data are lacking.
Example language (illustrative): "Sometimes when people feel this bad they think about ending their life. Has that happened to you?" / "Who in your family could help keep you safe this week?"
Watch for: Bereavement, eviction, family conflict, and shame about mental illness. The stigma around mental health may suppress disclosure, so recheck risk at later sessions.

4.15 Integrating protective practice and meaning into therapy

Purpose / when: When protective items, family cleansing, faith or purity observance are part of how the client copes. Szabóné Kármán notes that ethnobotanical and psychological studies suggest some folk therapies have real effects, such as relieving stress [source: https://btk.pte.hu/sites/btk.pte.hu/files/romologia_folyoirat/16-17.%20Health%20Care%20And%20Roma%20people%20Rom.%20foly.pdf].
Steps [synthesis]:
1. Ask what the practice gives the client: safety, connection, feeling cared for.
2. Treat it as a coping resource in the formulation.
3. Build therapy tasks that sit beside it. For example, the client continues family protection while doing graded activity or problem-solving.
4. Never prescribe, adapt or perform the practice, and never use it as a therapeutic exercise.
Example language (illustrative): "When your mother does that for you, what changes for you inside?" / "Let's keep what helps from home, and add something from here."
Watch for: Over-reliance that delays urgent care, or protective rituals growing into compulsive checking, which needs separate assessment. Integration is working when the client describes both as helping.

4.16 Death, the dead and bereavement in care settings

Purpose / when: At deaths in hospital or care, and in grief work. Beliefs about the dead (mulé) and death omens are described for some groups [source: https://www.oocities.org/~patrin/beliefs.htm]. An outsider clinician's account describes intense, demonstrative grief, families asking for brief rites at the bedside, and mourning observances over the following year [source: https://www.ccjm.org/content/60/6/427.full.pdf].
Steps [synthesis]:
1. Ask the family what they need at the time of death. Support space and privacy for their rites without taking part or directing them.
2. Treat intense expressions of grief as normative, not as a crisis in themselves.
3. In grief therapy, explore what the dead and the mourning period mean to the client, including any fears about the dead.
4. RSG/FFT ask bereavement services to work with Gypsy, Roma and Traveller organisations [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf].
Example language (illustrative): "Is there anything your family needs to do for him now that we should make room for?" / "What does your family believe happens after someone dies?"
Watch for: Fear of the dead disrupting sleep or functioning beyond what the family expects. Complicated grief. Suicide risk after bereavement.

4.17 Safeguarding

Purpose / when: When any practice, or its use in place of care, puts someone at risk. Examples are a child's serious illness treated only with home remedies, coercion or violence, or exclusion that leaves someone destitute. Safeguarding guidance specific to Romani traditional practices is [uncertain: not verified], so this section is [synthesis].
Steps [synthesis]:
1. Assess the actual risk to a specific person. Ethnicity, travelling or tradition is never a risk factor in itself.
2. Consult your safeguarding lead before acting, and where safe tell the client first (see 4.2).
3. Distinguish practices that are harmless, such as a ribbon or a protective pouch, from risk to health.
4. Involve a Roma advocate or mediator in explaining processes, if the client agrees.
5. Document carefully and without stereotyping language.
Example language (illustrative): "I respect what your family does. I'm worried because she has had a high fever for days, and I need to make sure a doctor sees her today."
Watch for: Your own bias, such as over-reporting Roma families or under-reporting through fear of seeming racist. A family's fear of child removal can drive avoidance, so watch for that too.

5. Handling problems

Responses below are [synthesis] unless cited.

Missed appointments and "non-adherence". Travel, eviction, missed post and digital exclusion are the usual causes, not low motivation [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Response: phone rather than write, hold the client's place on waiting lists, offer drop-in or phone sessions, and never discharge without contact. Illustrative: "I noticed you couldn't come. Are you still nearby, and would a phone session be easier?"
Mistrust and testing. The client is guarded, asks who will see the notes, or misses a session to see whether you call. Response: name the history (4.13), explain record access concretely, keep small promises, and call as promised.
"It's the eye, not my mind". The client rejects a psychological frame. Response: do not argue. Use the explanatory model (4.6) and agree shared goals around sleep, worry or functioning that fit both views. Ask whether family protection is already being done and say you are not replacing it. Illustrative: "Whatever the cause, you're not sleeping. Can we work on that while your family does what they do?"
Shame and taboo about mental illness. RSG/FFT describe mental health as the greatest taboo among health problems, with fears about marriage prospects [source: https://www.gypsy-traveller.org/wp-content/uploads/2024/08/Tackling-Mental-Health-Inequalities-for-Gypsy-Roma-and-Traveller-People-final-May-2024.pdf]. Response: use the client's words ("nerves", "worry"), avoid labels until needed, agree confidentiality within the family, and normalise help-seeking.
Family takes over sessions or interprets. Response: book a professional interpreter, keep part of each session for the client alone, and give the family a defined role (4.10). Illustrative: "I'd like a few minutes with her alone, which is how I work with everyone."
Gender or purity rupture. You raised a bodily topic without asking, or the room or seating breached a norm. Response: acknowledge it directly, offer a same-gender clinician or interpreter, and ask what would make it right. Do not over-apologise or avoid the topic for good.
Overwhelm in the CFI or history work. Memories of coercion or loss come up. Response: slow down, ground in the present, move to stabilisation, and return to detail only with consent. Use one supplementary module per session.
Conflict between remedies and medical care. A child or adult is getting worse on home remedies alone. Response: state your concern respectfully, bring in the GP or prescriber, and follow 4.12 and 4.17. Do not ridicule the remedy.
Advocate or mediator conflict of interest. The advocate is a relative or part of a community dispute. Response: offer an alternative advocate or a professional interpreter, and confirm the client's choice alone.
Church and tradition in tension. A client in an evangelical church may reject family practices, or feel guilty for keeping them. How Romani Pentecostal churches view traditional practices is [uncertain: not verified]. Response: explore with the CFI spirituality module and do not take sides.
Exclusion from the community (marimé as sanction). Exclusion for breaking purity rules is described in the sources [source: https://www.oocities.org/~patrin/beliefs.htm]. Response: treat it as a serious loss and a possible suicide risk factor, assess risk, support the client's own choices about reconciliation, and never intervene in the community's process.
Requests for the therapist to take part. A client asks you to join or endorse a cleansing practice, or to supply herbs. Response: decline warmly, affirm their family's role, and keep therapy separate. Illustrative: "That belongs to your family. My part is here, talking with you."
Clinician over-culturalising. Everything gets read as "cultural" and illness is missed. Response: do a structured differential (4.9), arrange medical and psychiatric review, and consult a cultural colleague.
Clinician stereotyping in the team. Colleagues use slurs or the "Gypsy witch" trope, or assume dishonesty. Response: challenge it, offer training resources such as the Council of Europe factsheets [source: https://www.coe.int/en/web/roma-and-travellers/factsheets-on-romani-culture], and escalate where care is affected.
Ending and continuity. The client is moving. Response: plan handover to a service in the next area or to the community organisation, give phone follow-up, and keep the file open for a planned period.

Sources

Web sources:

Cultural assessment, diagnosis and collaboration:

Books cited: Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258 (journal article; questions used via the Tanenbaum handout). Dunwich G (2019). Herbal Magick, Weiser Books. This is a popular book, cited only as the source Wikipedia gives for "chovihani"; it is not a Romani-studies source.

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