Coptic and Ethiopian holy-water healing (tsebel)

1. Introduction

Version followed: holy-water (tsebel) practice of the Ethiopian Orthodox Tewahedo Church (EOTC) as described by the Church's Sunday School Department (Mahibere Kidusan), by the ethnography of Ethiopian Orthodox holy-water sites in Addis Ababa (Wright 2023, University of Bergen dissertation, as summarised in its published abstract and a scholarly review), and by the clinical-collaboration studies at the St Michael's and St Mary's holy-water sites in Addis Ababa (Baheretibeb, Wondimagegn & Law 2021) and the St Mary's Clinic at Entoto (Asher et al. 2021). The Coptic Orthodox blessing of water is noted only briefly. This guide covers a religious rite, not a therapy: sections 2–5 set out the psychotherapist's own work alongside it.

What it is. Tsebel (Amharic ፀበል; transliterated ṣäbäl, also spelled "Tebel" by Mahibere Kidusan) is water blessed by a bishop or priest. In the Church's teaching it is "more than a symbolic ritual": through sanctification the water is held to carry the grace of the Holy Spirit, to purify, bless and repel evil, and to be used in prayer for physical and spiritual well-being and in exorcism [source: Mahibere Kidusan, "Holy Water"]. Holy-water sites (ṣäbäl bota), estimated at roughly 100–150 in and around Addis Ababa and mostly at springs or taps in church compounds, are places both of veneration and of dealing with illness [source: Wright 2025 abstract; Wilkens 2024 review]. Spring water at the St Michael's and St Mary's sites is regarded as holy because of historically recorded healing miracles [source: Baheretibeb et al. 2021].

How change is understood (attributed). In the tradition, illness can be caused by demons, malignant forces, harmful magic or envy, often within broken relationships; these are fought off through holy water, prayer, faith and liturgical blessing, and healing chiefly means restoring relationships, above all with God [source: Wright 2025 abstract; Wilkens 2024 review]. These are the tradition's beliefs, described here neither as fact nor dismissed. Many users combine tsebel with biomedicine: in the Addis Ababa collaboration, 92.2% of clinic users were comfortable combining holy water, prayer and medication, while 73.6% attributed their illness to possession [source: Baheretibeb et al. 2021]. Health claims: the Church and users attribute healing to tsebel; there is no controlled evidence that it treats physical disease, and the collaboration study could not measure clinical effectiveness [source: Baheretibeb et al. 2021]. The therapist's role is to understand the rite's meaning, keep the client safe, coordinate physical-health questions with the doctor, and collaborate with clergy when the client wishes [synthesis].

Coptic note. In the Coptic Orthodox Church a special prayer over water (often called the Lakkan) is held at Epiphany, Holy Thursday and the Feast of the Apostles [source: St-Takla.org glossary]. Details of Coptic holy-water healing at shrines are [uncertain: not verified] here.

2. Framework

The rite has no therapeutic phases or session counts. The structure below describes (A) the observance as sources describe it and (B) the therapist's work alongside it. No source gives session numbers for B; the steps are [synthesis].

A. The observance as described

Blessing. Holy water is made by liturgical blessing performed by a bishop or priest, often during scripture reading [source: Mahibere Kidusan; Wilkens 2024]. At Timket (Epiphany) holy water is used in public celebration, and priests bless homes, especially around Theophany [source: Mahibere Kidusan; Wikipedia, [uncertain: secondary, unverified]].
Who leads and authorises. Priests perform all holy-water activities: blessing, chanting, prayer, and a light ceremonial touch or smack with a religious cloth that symbolises exorcising evil spirits; they also offer religious counselling [source: Baheretibeb et al. 2021]. Priests regard holy water as part of the sacrament [source: Baheretibeb et al. 2021]. Formal rules on how the Church hierarchy licenses individual sites are [uncertain: not verified].
Daily practice at a site. Rituals are typically daily and involve drinking, immersing or washing in the water, which can be cold, especially early in the morning [source: Baheretibeb et al. 2021]. Water may be drunk in large amounts to induce vomiting of harmful substances; scripture passages are read aloud and touched to the afflicted part of the body; dietary instructions, liturgical fasting and personal vows form part of the process [source: Wilkens 2024]. People also take water home to wash with, bless objects or drink in small amounts [source: Wilkens 2024]. Healing is both individual and collective, including in the religious association (maḫbär) [source: Wright 2025 abstract].
Residential stays and attendants. At the two Addis Ababa sites studied, about 1,000 people lived in simple dwellings nearby; services were free; families paid attendants who gave daily care, supervised residents, accompanied them to rituals and mediated with priests [source: Baheretibeb et al. 2021]. Of clinic users, 68% stayed under a year (typically 2–5 months), 24% stayed 1–5 years and 8% more than 5 years [source: Baheretibeb et al. 2021]. Attendants at Entoto run group houses and are paid by families [source: Asher et al. 2021].
Return home. Water is carried home in containers [source: Wilkens 2024].

B. The therapist's work alongside (phases) [synthesis]

Engagement and cultural assessment. Goal: understand what tsebel means to the client and family, who decides, and current safety. Tools: CFI core plus supplementary modules (section 4). Move on when the client's explanatory model, help-seeking pathway and family decision-makers are mapped and any restraint or acute risk has been addressed.
Joint plan. Goal: a care plan the client and family accept, often a combination model of holy water plus medical and psychological care, as the Addis Ababa clinic aimed for [source: Baheretibeb et al. 2021]. Move on when roles of doctor, therapist, family and (if wished) priest are agreed.
Coordination during the observance. Goal: continuity during a pilgrimage or stay at a site, physical-health monitoring by the doctor, and contact with the clinic or priest where consented.
Follow-up and reintegration. Goal: support after return home, relapse planning, caregiver support, and repair of stigma or family rupture. Patients leaving the Addis Ababa sites were referred to local health centres or hospitals [source: Baheretibeb et al. 2021].

Format: individual sessions with the client, family sessions with the client's consent, and liaison with doctor and clergy [synthesis].

3. Guiding principles

Attribute, do not adjudicate. Describe demons, possession and divine healing as the client's tradition holds them. In practice: "In your Church, holy water is understood to..." (illustrative), never "that isn't real" or "that will cure you" [synthesis].
Open-minded respect is a precondition. The collaboration authors call "open-minded acceptance" of traditional healing's strengths "a prerequisite" [source: Baheretibeb et al. 2021]. In practice: begin by asking what tsebel has given the client before asking about problems.
Both-and, not either-or. Most users accept combining holy water and medicine; priests in the collaboration study saw biomedicine as one part of an eclectic approach [source: Baheretibeb et al. 2021; Baheretibeb et al. 2024]. In practice: build plans that include the rite rather than compete with it.
Humility earns collaboration. Priest-healers valued the humility and respect shown by biomedical practitioners [source: Baheretibeb et al. 2024]. In practice: approach clergy as colleagues with their own expertise.
Referral runs both ways. Priests' main complaint was that they referred patients to the clinic but the clinic did not refer back [source: Baheretibeb et al. 2024]. In practice: when the client wishes, refer for spiritual care too, and tell the priest how the client is doing.
Families often have the final say. Family members often had the "final say" on clinic attendance and sometimes resisted psychiatric care [source: Asher et al. 2021]. In practice: engage family early, with consent, and use the CFI Caregivers module.
Dignity and liberty are non-negotiable. Restraint is a human-rights violation whose underlying cause is lack of access to treatment [source: Asher et al. 2017]. In practice: screen for restraint, never endorse it, and act on safeguarding duties (see Harm account).
Physical health goes to the doctor. No practice here is treated as a remedy for physical disease. In practice: route cold immersion, induced vomiting, fasting, stopped medication and physical illness to the client's doctor; never advise on medicines [synthesis].
The therapist is not the priest. In practice: do not bless, pray over or prescribe holy water; do not act as confessor; refer to clergy for religious questions [synthesis].
Client-led integration. In practice: the client chooses whether faith enters sessions and whether clergy are contacted; record consent [synthesis].
Watch for OCD masquerading as devotion. IOCDF notes OCD "can masquerade as religion" [source: IOCDF]. In practice: when washing, confession or ritual exceed what the Church asks and impair life, assess for scrupulosity.

4. Intervention inventory

These are the psychotherapist's own interventions alongside the rite. The rite itself (blessing, prayer, exorcism, sprinkling) belongs to priests and is not performed by the therapist. Steps are [synthesis] unless a source is tagged.

4.1 Exploring the meaning of tsebel in the client's life

Purpose / when: At intake, and whenever the client mentions holy water, a pilgrimage, a stay at a site or a priest. It shows what the rite gives (hope, relationship with God, community, belonging) before any risk is assessed.
Steps:
1. Ask which site, which saint or church, and whether this is a one-day visit, Timket celebration, home use of bottled water, or a residential stay.
2. Ask what the client hopes for, using their words (healing, protection, forgiveness, release from a spirit, reconciliation).
3. Ask who suggested it (self, family, priest, attendant) and who pays.
4. Ask what has helped and what has been hard there.
5. Reflect the meaning back in the client's terms and record it in the formulation.
Example language (illustrative): "When you go to the tsebel, what are you hoping God will do for you?" "Who in your family thought it would help, and what do you think?"
Watch for: The client relaxing and offering detail (working); guarded answers, which may mean fear of being judged or that something at the site was frightening. Note signs that attendance was not voluntary.

4.2 Cultural Formulation Interview: core and the Spirituality, Religion and Moral Traditions module

Purpose / when: Structured cultural assessment early in treatment, or when a religious explanation is central [source: APA CFI Supplementary Modules].
Steps:
1. Give the core CFI (DSM-5-TR version).
2. Add the Spirituality, Religion and Moral Traditions module (16 questions). Its domains: identity and affiliation, including community and family background; the tradition's role in daily and family life; home and community practices; how the tradition helps coping (through leaders, texts, media, personal practice); and whether it has contributed to the problem, caused distress or conflict, or led to discrimination [source: APA CFI Supplementary Modules].
3. Use the client's own name for the tradition (for example "the Tewahedo Church", "Orthodoxy", "the tsebel") as the module instructs [source: APA CFI Supplementary Modules].
4. Explore each tradition the client names; some Ethiopian clients also refer to other healers or spirit beliefs.
5. Summarise in the cultural formulation and share the summary with the client.
Example language (illustrative): "Can you tell me how the Church is part of your everyday life and your family's?" "Has anything about your faith or the holy-water site ever made this harder for you?"
Watch for: Over-long administration that feels like interrogation (use questions selectively); answers that show both support and harm, which are both clinically relevant.

4.3 Explanatory Model and Coping and Help-Seeking modules

Purpose / when: To map how the client and family explain the problem (possession, harmful magic, envy, sin, illness) and the path that led to the site and to you [source: APA CFI Supplementary Modules; Wright 2025 abstract].
Steps:
1. Explanatory Model module (14 questions): the client's understanding of the problem, prior experience of it, causal explanations and how they changed, effects on body, mind and spirit, expected course, and views of the best help, including family's and community's [source: APA CFI Supplementary Modules].
2. Coping and Help-Seeking module (13 questions): self-coping including spiritual practice; help from family and friends; help from religious communities, doctors, mental-health clinicians and other healers; what led to current care and what help is hoped for [source: APA CFI Supplementary Modules].
3. Hold more than one explanation at once; do not ask the client to choose.
4. Note medication history: in the Addis Ababa clinic, 89.2% of those previously treated had stopped medication, mainly because of side effects (55%) and cost (23%) [source: Baheretibeb et al. 2021]. Pass this to the prescriber; do not advise on medicines.
Example language (illustrative): "Some people feel a spirit is involved, some feel it is an illness, some feel it is both. How do you see it?" "What made you stop the tablets before?"
Watch for: Shame when disclosing spirit beliefs; fear that the clinician will forbid holy water. Working: the client volunteers both religious and medical ideas.

4.4 Engaging the family: Caregivers module, Informant version and Social Network module

Purpose / when: When a family brought the client to a site, decides on attendance, or pays an attendant. Families often have the "final say" [source: Asher et al. 2021]; 54% of clinic users in Addis Ababa were brought by families [source: Baheretibeb et al. 2021].
Steps:
1. With the client's consent, invite the key family member(s).
2. Use the CFI Informant version for collateral information, and the Caregivers module (14 questions, given to the caregiver, not the patient) when the client cannot answer, for example during severe psychosis, or to hear the caregiver's own burden [source: APA CFI Supplementary Modules].
3. Use the Social Network module (15 questions) to identify whom the client trusts, including people met through worship, and their preferences for involving others [source: APA CFI Supplementary Modules].
4. Ask directly and non-judgementally about restraint at home or at the site (see 4.8).
5. Agree what the family will do if the client becomes agitated, as an alternative to restraint.
Example language (illustrative): "Caring for someone who is this unwell is exhausting. What has been hardest for you?" "What do you do when things become frightening at home?"
Watch for: Caregiver hopelessness and powerlessness, which drive restraint [source: Asher et al. 2017]. Working: the family names alternatives and agrees to a crisis plan.

4.5 Building a combination care plan

Purpose / when: After assessment, when the client wants both holy water and medical or psychological care. The Addis Ababa clinic's stated goal was for patients and referrers to consider "a combination model of treatment" [source: Baheretibeb et al. 2021].
Steps:
1. Write down what the client will continue at the site (prayer, holy water, counselling from a priest).
2. Write down medical and psychological care: prescriber review, psychoeducation, psychotherapy.
3. Agree how they fit together in time (for example appointments that do not clash with early-morning rituals).
4. Name who to contact in a crisis.
5. Review the plan with the family and, if the client wishes, with the priest or attendant.
Example language (illustrative): "Many people use both the tsebel and the clinic. Some priests describe medicine as part of God's gift too. How would you like to combine them?" (The phrase echoes the title of Asher et al. 2021, "Medical treatments are also part of God's gift".)
Watch for: The client hiding one side from the other; a priest or family member opposing medicine. Working: open discussion of both in session.

4.6 Accommodation in scheduling and treatment

Purpose / when: When the client attends a site, keeps fasts, celebrates Timket, or plans a residential stay.
Steps:
1. Ask about the liturgical calendar and planned visits; book around them.
2. For a planned stay, agree contact (phone or video if possible), a review date and a named local clinic or health centre near the site.
3. Provide a short written summary (diagnosis, plan, prescriber contact) the client can take with them, with consent.
4. Offer sessions at times compatible with early-morning rituals.
5. Respect wishes about religious objects or water brought into sessions.
Example language (illustrative): "When will you be at the site, and how can we keep in touch while you're there?"
Watch for: Long, open-ended stays without review. 8% of clinic users had stayed more than five years [source: Baheretibeb et al. 2021]. Check whether the client still chooses to be there.

4.7 Physical-health liaison with the client's doctor

Purpose / when: When the observance involves cold early-morning immersion, drinking large amounts of water to induce vomiting, dietary instructions, liturgical fasting or vows [source: Baheretibeb et al. 2021; Wilkens 2024]; when the client has stopped medication; or when the client hopes holy water will heal a physical illness. Ethnography reports people bringing conditions such as typhus, cancer and gastritis to sites [source: Wilkens 2024].
Steps:
1. Ask what the client actually does (qualitatively) and how they feel physically.
2. Name conditions where these practices may need medical advice (for example heart, kidney or eating problems, pregnancy, diabetes, frailty) and suggest the client discuss them with their doctor [synthesis].
3. With consent, inform the doctor of fasting, vomiting or medication stopping.
4. Never advise starting, stopping or changing medicine; refer to the prescriber.
5. Ask the client how their priest views illness and medicine; many priests accept medicine alongside holy water [source: Baheretibeb et al. 2024].
Example language (illustrative): "It sounds as if the holy water matters a great deal to you. Because you have diabetes, would you be willing to talk with your doctor about the fasting and the drinking so they can keep you safe while you take part?"
Watch for: Dehydration, electrolyte problems, weight loss, cold exposure in a frail or psychotic client, abandoned treatment for serious physical illness [synthesis]. Working: the client keeps the observance and medical follow-up.

4.8 Screening for restraint, coercion and abuse

Purpose / when: Every client with severe mental illness who has stayed at, or is going to, a holy-water site, and every family who brought a relative there. Treatment at sites is sometimes involuntary; attendants may hold people in place; in extreme cases people are chained to their residence to prevent escape; beatings have been reported [source: Baheretibeb et al. 2021]. Restraint in Ethiopian homes and at sites is documented [source: Asher et al. 2017]. Risk flag: see Harm account.
Steps:
1. Ask the client privately whether they were ever held, tied, chained, locked in, beaten or forced to bathe, drink or fast.
2. Ask the family separately and without blame what they did when the person was most unwell, including during transport to a site or clinic.
3. Look for wrist or ankle scars, wounds, contractures or nerve injury and refer to a doctor for examination [synthesis; harms listed by HRW 2020].
4. Assess trauma symptoms related to the experience.
5. If restraint is current or planned, act on safeguarding and local legal duties (see Harm account), and build an alternative crisis plan with the family.
Example language (illustrative): "Some families tell me that when things were very bad, they had no choice but to tie their relative, or that it happened at a holy-water site. Has anything like that happened to you?"
Watch for: Minimising ("only for a few days"), fear of getting family or priests into trouble, shame. Working: honest disclosure and a family crisis plan without restraint.

4.9 Distinguishing religious experience from illness

Purpose / when: When the client describes possession, spirits speaking, or visions. At holy-water sites evil spirits are described as everywhere, and ethnographers have transcribed speech attributed to spirits [source: Wright 2025 abstract]. 73.6% of clinic users believed possession caused their illness [source: Baheretibeb et al. 2021], and schizophrenia (40%), substance use (24%), bipolar I (18%), major depression (12%) and seizure disorders (6%) were common diagnoses [source: Baheretibeb et al. 2021].
Steps:
1. Ask how the client's community and priest understand the experience; normative religious experience is shared and accepted by the community [synthesis].
2. Assess for features of psychosis, mania, depression, substance use, dissociation and seizures, including functioning, sleep and duration.
3. Refer to a psychiatrist or neurologist for diagnosis where indicated; do not decide spiritual questions.
4. Where the problem is religious or spiritual rather than a disorder, DSM-5-TR provides a code for a religious or spiritual problem (Z65.8).
5. Share the formulation in language that leaves room for the client's faith.
Example language (illustrative): "I can't tell you what is happening spiritually. That is for you and your priest. What I can check is whether there is also an illness that medicine or therapy could help."
Watch for: Pathologising normal devotion; missing psychosis or seizures behind a possession explanation. Working: the client accepts assessment without feeling their faith is dismissed.

4.10 Scrupulosity and religious OCD

Purpose / when: When washing, drinking holy water, confession, fasting, vows or prayer become repetitive, driven by fear of sin, impurity or possession, exceed what the Church asks, and impair life. IOCDF lists fear of possession, fear of having sinned, excessive confession, reassurance-seeking from religious leaders, repeated cleansing rituals and repeated prayer as scrupulosity features [source: IOCDF].
Steps:
1. Assess OCD symptoms and functioning.
2. Explain scrupulosity as OCD that can "masquerade as religion" [source: IOCDF].
3. Offer CBT with exposure and response prevention (ERP), the primary psychological treatment named by IOCDF; refer for medication assessment, which is the doctor's decision [source: IOCDF].
4. With consent, consult the client's priest or confessor to clarify what the Church actually requires, so that exposures stay within the client's faith [source: IOCDF].
5. Build exposures that target the fear (for example resisting extra washing or repeat confession) and never ask the client to break a genuine obligation of their faith [synthesis].
Example language (illustrative): "Your priest has said one confession is enough. The urge to go back again is the OCD, not your faith. Shall we practise letting that urge pass?"
Watch for: Reassurance-seeking redirected to the therapist; the priest's guidance being reinterpreted by OCD. Working: less time on rituals, more freedom in worship.

4.11 Moral injury and guilt

Purpose / when: With caregivers who restrained a relative, people who were restrained or beaten, and (in collaboration settings) priests or attendants who now regret practices. In the Addis Ababa workshops some priests and attendants said they regretted beating patients and wanted to change their practice [source: Baheretibeb et al. 2021]. Caregivers described distress at restraining relatives and feeling they had no choice [source: Asher et al. 2017].
Steps:
1. Invite the account without judgement.
2. Separate responsibility from circumstance (lack of services, burden, fear) while not excusing harm.
3. Explore the client's tradition's resources for repentance and reconciliation, with clergy if the client wishes.
4. Plan concrete repair: changed practice, apology, ongoing care.
Example language (illustrative): "You did what you believed would keep your son alive, and you also wish it had been different. Both can be true."
Watch for: Self-punishment, depression or suicidal thoughts in caregivers; assess risk following current standards. Working: guilt turns into commitment to care.

4.12 Grief, ritual and community support

Purpose / when: When illness, long stays or stigma have cut the client off from family and community, or when the rite is a source of belonging. Healing in the tradition centres on restoring relationships, including in the religious association (maḫbär) [source: Wright 2025 abstract]. Stigma towards people with schizophrenia was widespread [source: Asher et al. 2017].
Steps:
1. Map losses: work, marriage, years at a site, community standing.
2. Identify supportive relationships, including parish, maḫbär, godparents.
3. Support the client to use rituals they find meaningful for grief and return home.
4. Address stigma with the family and, if wished, with community leaders.
Example language (illustrative): "Who at church would be glad to see you back?"
Watch for: Isolation after return; rejection by community. Working: renewed participation by the client's own choice.

4.13 Collaboration with priests and attendants

Purpose / when: When the client wishes, and when working in or near a holy-water site. The Addis Ababa model built trust through five workshops (at the church, at the hospital, on stigma, on abuses, and to agree a clinic), then opened a clinic near the churches in 2012, run fortnightly by a psychiatrist, resident, clinical psychology student, mental-health nurse and clerk, with free essential medicines funded by a family-founded NGO (Ethiopian Mental Health Society) and Addis Ababa University's psychiatry department [source: Baheretibeb et al. 2021]. Priests and attendants referred patients; attendance rose from about 15 to 39 patients per day between 2012 and 2019 [source: Baheretibeb et al. 2021]. At Entoto, attendants acted as partial gatekeepers, selecting clients and supporting attendance and medication [source: Asher et al. 2021].
Steps (individual clinician):
1. Get written consent stating what may be shared.
2. Contact the priest respectfully, ask about their view and role, and share only what the client agreed.
3. Agree shared goals (safety, dignity, care) and how to refer in both directions [source: Baheretibeb et al. 2024 on one-way referral].
4. Keep roles distinct: the priest gives spiritual care, the clinician gives clinical care.
Steps (service developing a partnership) [synthesis from Baheretibeb et al. 2021]: relationship-building meetings at the church and the clinic; joint sessions on stigma and on abuses; an agreed clinic near the site open to anyone wanting biomedical consultation; referral to local health services on leaving.
Example language (illustrative): "Your guidance matters a great deal to this family. I'd value your view on how we can support them together."
Watch for: Clergy feeling used as referral sources only; clinicians dismissing spiritual care. Working: referrals and feedback flow both ways.

4.14 Psychoeducation and brief psychotherapy in a site-linked clinic

Purpose / when: For clinicians working in a clinic linked to a site. At the Addis Ababa clinic, 41.3% of patients received counselling from priests, 34.3% received psychoeducation and brief eclectic psychotherapy from the clinic, and 24.4% received both [source: Baheretibeb et al. 2021]. The content of the brief psychotherapy is not specified in that source [uncertain: not verified].
Steps [synthesis]: brief, practical sessions covering the illness in the family's words, medication questions routed to the prescriber, early-warning signs, sleep and substance use, alternatives to restraint, and plans after leaving the site.
Example language (illustrative): "Let's write down the early signs that things are getting worse, and who you will call."
Watch for: Overloading people who are acutely unwell; involve attendants and family with consent.

4.15 Professional boundaries and self-disclosure

Purpose / when: Throughout. The psychotherapist is not a priest, confessor or spiritual director.
Steps [synthesis]: decline to bless or prescribe holy water; keep personal religious views private unless disclosure clearly serves the client; avoid dual relationships with a client's parish; seek consultation when your own beliefs (Orthodox, other faith or none) colour reactions; follow your profession's ethics code. Professional spiritual and religious competency frameworks (for example Vieten et al. 2013) are relevant [uncertain: not verified].
Example language (illustrative): "My role is to help with the illness and the stress. Questions about the faith itself are best taken to your priest."
Watch for: Being pulled into theological arguments; over-identifying with or against the tradition.

4.16 Safeguarding children and young people

Purpose / when: When minors are taken to sites for exorcism, fasting, cold immersion or residential stays. HRW reports shackling worldwide of children as young as 10 [source: HRW 2020].
Steps [synthesis]: ask about the child's experience directly and age-appropriately; seek the child's assent and the parents' consent; route health concerns to a paediatrician; follow local child-protection procedures if the child is restrained, beaten or deprived.
Example language (illustrative): "What was it like for you at the holy water? Did anything there scare you?"
Watch for: Physical signs of restraint, malnutrition, fear of returning. Never name the child in correspondence beyond what procedures require.

5. Handling problems

Sources describe the collaboration context; most responses below are [synthesis] unless tagged.

Client wants holy water only and refuses clinical care. Respect a capable adult's choice. Keep the door open, agree warning signs that would prompt a review, and offer contact with a clinician who works alongside priests. Note that many priests accept medicine as part of an eclectic approach [source: Baheretibeb et al. 2024]. If capacity is in doubt and risk is high, follow local mental-health law, not family pressure.
Family insists on a long stay or opposes medicine. Families often decide [source: Asher et al. 2021]. Use the Caregivers module to hear their fears and burden; ask what would make medicine acceptable; offer a combination plan; agree a review date for any stay. Check the client's own wish privately.
Client wants to leave the site but is kept there. Treat as a safeguarding question. Ask about restraint, document, and follow local adult-protection and legal routes (see Harm account).
Stopping medication (non-adherence). In the Addis Ababa clinic, side effects and cost were the main reasons [source: Baheretibeb et al. 2021]. Explore reasons without blame and send them to the prescriber; do not advise on medicines. Ask whether a priest or attendant could support attendance, as at Entoto [source: Asher et al. 2021].
Stuck between "spirit" and "illness". Stop debating causes. Shift to shared goals (sleep, safety, getting back to church or work) and to what has helped. Hold both explanations side by side.
Distress or overwhelm after an exorcism or ritual. Ground the client, assess for trauma, psychosis or dissociation, and ask whether anything was done against their will. Ethnographic work notes ethical questions about perceived violence in exorcism [source: Wilkens 2024]. Offer to discuss with their priest if wished.
Rupture: the client fears you are against their faith. Name it, apologise for any dismissive moment, restate that you are not asking them to give up holy water, and return to their goals. Rupture the other way (you seem to endorse a spiritual cure) is repaired by restating role limits (4.15).
Physical illness managed only with holy water. Respect the faith practice and urge medical review in the same breath. With consent, involve the doctor. Health claims for tsebel are the tradition's; there is no controlled evidence of physical cure [source: Baheretibeb et al. 2021 could not measure effectiveness].
Priest declines contact or the client refuses it. Respect the refusal; continue with the client's account of their faith. Never contact clergy without consent.
Scrupulosity resists ERP. Return to the client's values; with consent, seek the priest's clarification of what the Church requires [source: IOCDF].
Diaspora clients. They may use holy water brought from Ethiopia, attend Timket locally, or plan a trip home to a site. Ask about the trip, safety plans abroad, contact while away, and local clinics near the site.
Therapist's own reaction to a restraint disclosure. Expect anger or shock; seek supervision; keep the family engaged while meeting safeguarding duties. Caregivers often felt they had no alternative [source: Asher et al. 2017].

Harm account

This account concerns restraint, chaining and abuse of people with severe mental illness documented at some holy-water sites and in Ethiopian community settings. It does not describe the rite as a whole, and priests interviewed in the sources did not condone restraint. No victims or private individuals are named.

What was actually done

Involuntary residence and holding during rituals. At the St Michael's and St Mary's holy-water sites in Addis Ababa, treatment was sometimes involuntary. Families brought relatives when overwhelmed and paid attendants to supervise them; attendants might hold people in place during rituals of drinking, washing or immersion, sometimes in cold early-morning water [source: Baheretibeb et al. 2021].
Chaining to a dwelling. In extreme cases residents were chained to their residence to prevent escape, and attendants used restraints on people seen as involuntary or violent [source: Baheretibeb et al. 2021].
Beatings. Beatings of patients by priests and attendants were raised and addressed in a workshop held before the clinic opened in 2012 [source: Baheretibeb et al. 2021].
Restraint during transport to sites and clinics. In rural Sodo and Butajira (fieldwork 2013), restraint was used to transport people with schizophrenia to health facilities or holy-water sites, and to force medication [source: Asher et al. 2017]. One person reported restraint at a holy-water site; another reported being tied and beaten there [source: Asher et al. 2017].
Restraint at home, typically. Most restraint in that study happened in the family home, using chains, shackles, handcuffs or ties. Some people were restrained for long periods; others were restrained repeatedly depending on behaviour. Restraint was sometimes used as punishment [source: Asher et al. 2017].
Wider pattern. Human Rights Watch documented shackling in about 60 countries: people chained or locked in confined spaces, sometimes for long periods and in degrading conditions, and in some healing centres forced to fast, take herbal concoctions, and endure physical and sexual violence [source: HRW 2020]. The HRW summary cited here describes church and faith-healing sites in Kenya, Nigeria and Liberia; it does not single out Ethiopia.

How it caused harm

Physical. Injuries that could be permanent, and beatings, sometimes by family members [source: Asher et al. 2017]. Shackling more broadly is linked to post-traumatic stress, malnutrition, infections, nerve damage and cardiovascular problems [source: HRW 2020].
Psychological. Community leaders and health workers said restraint could worsen illness, increase hopelessness and raise the risk of violence [source: Asher et al. 2017].
Rights. Restraint violates dignity, freedom from violence and abuse, equal legal capacity and liberty, and discriminates against people with severe mental illness [source: Asher et al. 2017].
Delayed treatment. Over half of the Addis Ababa clinic's users had their first ever contact with biomedical care there; some had stayed at sites for years [source: Baheretibeb et al. 2021].
Harm to families. Caregivers described hopelessness, distress, feeling trapped, financial hardship, and becoming unwell themselves [source: Asher et al. 2017].
Most at risk. People with schizophrenia and other psychoses, people seen as violent or likely to run away, those whose families have no access to services, and rural families far from centralised care [source: Asher et al. 2017; Baheretibeb et al. 2021]. Children are also shackled in some countries [source: HRW 2020].

Recognising it today

Rationales. Restraint framed as protecting the person (from wandering, traffic, animals, floods, fights), protecting others or property, getting the person to treatment, or punishing misbehaviour [source: Asher et al. 2017]; or as stopping escape from a site [source: Baheretibeb et al. 2021].
"Humane" restraint. Guidance on safer ways to restrain can normalise it, a risk the researchers flag for community workers [source: Asher et al. 2017].
Red flags at a site or in a service [synthesis]: residents unable to leave; chains, ropes or locks near dwellings; open-ended stays without review; attendants paid by families with no outside oversight; no access to a doctor; forced bathing, drinking or fasting; injuries explained away; refusal to let clinicians or relatives visit.
Red flags in a family [synthesis]: scars on wrists or ankles; a relative kept in one room or outbuilding; reports of "keeping him safe" without a crisis plan.
How legitimate practice differs. Voluntary attendance; freedom to leave; prayer, blessing and religious counselling without force; priests who do not condone restraint (one priest released a woman brought to his site restrained) [source: Asher et al. 2017]; access to a clinic and referral both ways [source: Baheretibeb et al. 2021; 2024].

What to do instead and how to help those harmed

Treatment access is the main alternative. All participant groups named increased access to treatment as the most effective way to reduce restraint; suggestions included free antipsychotics and social health insurance [source: Asher et al. 2017]. Medication decisions are the prescriber's.
Collaboration clinics. The Addis Ababa model (workshops, including one on abuses; a clinic near the churches; free essential medicines; referral on leaving) and the Entoto clinic show feasibility and acceptability to some attendants and priests [source: Baheretibeb et al. 2021; Asher et al. 2021]. Outcome data are not yet available [source: Baheretibeb et al. 2021].
Community-based rehabilitation. Home-based support with caregiver education, adherence support and community awareness, as in the RISE project; programmes elsewhere (Indonesia's Bebas Pasung; an intensive programme in China in which 92% of 271 unchained people remained unrestrained after seven years) are cited as models [source: Asher et al. 2017].
Policy. HRW urges governments to ban shackling, reduce stigma, develop community mental-health services, and inspect institutions [source: HRW 2020].
Assessing a person who was restrained [synthesis]: physical examination by a doctor for injury and nerve damage; trauma assessment; explore shame, fear of sites, and trust in family; ask whether they still want holy water on their own terms; trauma-focused care when stable.
Helping families [synthesis, informed by Asher et al. 2017]: acknowledge burden and powerlessness; build a crisis plan without restraint; link to services and peer support; address guilt (4.11).
Ethical, reporting and legal duties [synthesis]: current restraint or abuse of an adult or child triggers safeguarding procedures under local law; document injuries and disclosures; inform the client of limits to confidentiality; consult supervisors and legal advisers; do not confront a site or family in ways that increase risk to the person.

Sources

Further works: Wright MC (2023), Saved and Healed: Illness, Illness Causation and Healing among Ethiopian Orthodox Christians at Holy Water Sites in Addis Ababa, PhD dissertation, University of Bergen (cited through its abstract and review). Vieten C et al. (2013), spiritual and religious competencies for psychologists [uncertain: not verified].

ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances

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