Okinawan yuta and noro

1. Introduction

Version followed: the psychotherapist's culturally responsive work alongside Okinawan (Ryukyuan) religious practitioners, structured by the DSM-5-TR Cultural Formulation Interview (APA core CFI and supplementary modules) and by the mediation stance described by Okinawan psychiatrists (Naka et al. 1985; Shimoji et al. 1998); the description of yuta and noro follows ethnographic and heritage sources (Sasaki 1984; Prochaska-Meyer 2014 as reviewed by Staemmler 2014; ICOMOS 2000).

What this is. This is not a therapy. It is a living religious tradition of the Ryukyu Islands with two historically distinct kinds of female religious specialist, and this guide covers what a psychotherapist does when a client's life involves them. [source: Staemmler 2014; ICOMOS 2000]

• Noro (祝女) were communal priestesses who performed rites for the kingdom, districts and villages. Under King Shō Shin (r. 1477–1526) Ryukyuan religion was reorganised into a central hierarchy headed by the high priestess, the kikoe-ōgimi (聞得大君), with Sēfa-utaki as one of its most sacred places. Noro were appointed by the royal government, the office passed down within families, and noro also held local political roles; the official system collapsed after Okinawa Prefecture was established in 1879. Some lines have since ended without successors, while the heritage nomination notes that gusuku sites are still used by noro for rites and remain local spiritual centres. [source: ICOMOS 2000; Staemmler 2014; Ryukyu Shimpo 2018]
• Yuta (ユタ) are local spiritual practitioners whom individuals and households consult about illness, misfortune and personal problems; the review of Prochaska-Meyer's study reports that contemporary clients are mainly middle-aged and older women, and that problems are commonly attributed to causes such as soul loss, neglected ancestors or disrespect to sacred places. Some regard the word "yuta" as derogatory; scholars and practitioners also use kaminchu (神人, "person of the deities") as a broader term. [source: Staemmler 2014] The noro role was tied to the belief in onarigami (the sister's spiritual power protecting her brother, and a wife or sister protecting the household). [source: Staemmler 2014]
• Kamidaari (カミダーリ; on Miyako also kamburi) is the state of distress that, within the tradition, precedes or accompanies a person's calling and leads them to consult a practitioner; Okinawan psychiatrists have studied its relation to psychiatric, psychosomatic and neurotic conditions. [source: Sasaki 1984; Shimoji et al. 1998; Ishizu KAKEN report 1990] The related notion sādaka-umari (サーダカウマリ) is treated in Okinawan medical-anthropological work as the basis on which kamidaari arises [source: Ishizu KAKEN report 1990]; its gloss as being "born with high spiritual nature" is [uncertain: not verified].

How change happens (for the therapist's work). Okinawan clinicians on the Miyako Islands argue that where shamanistic and psychiatric medicine coexist, using either system alone forces the clinician to ignore realities that conflict with it; the clinician should instead act as a mediator or negotiator, letting the two explanatory systems form a coalition so care stays continuous across both, without fusing them. [source: Shimoji et al. 1998] Naka et al. (1985) start from the premise that each culture both produces stressors and supplies means of easing them, and argue that psychiatric hospitals should acknowledge yuta when treating patients. [source: Naka et al. 1985] Change, on this view, comes from the client's distress being understood in terms that make sense to them and their family, while any treatable disorder is still recognised and treated. [synthesis]

Who holds authority. Within the tradition, authority over a yuta's or kaminchu's role rests on the calling (kamidaari) and on recognition by clients and community; no state licensing or registration of yuta is described in the sources used here [uncertain: not verified]. Noro authority historically derived from royal appointment and family succession; after 1879 that official authority ended and care of sites and rites in many places rests with families and local communities. [source: Ryukyu Shimpo 2018; ICOMOS 2000] Sacred places (utaki) are protected under Japan's 1950 Law for the Protection of Cultural Properties where designated, and at Sēfa-utaki entry to the innermost area is prohibited to protect the sacred site. [source: ICOMOS 2000; Visit Okinawa Japan] The psychotherapist holds no role in the tradition and does not perform, interpret or advise on its rites or divination.

2. Framework

The framework below organises the psychotherapist's own work; it is not a phase model published by any Okinawan body. [synthesis, built on the CFI structure and Shimoji et al. 1998]

The CFI is meant to deepen clinical understanding and is not a sole basis for diagnosis. [source: APA CFI] Session counts are [synthesis].

3. Guiding principles

• Mediate, do not choose sides. Hold the shamanistic and psychiatric models in dialogue at the boundary where they meet. Practical meaning: never ask the client to pick between "the yuta" and "the doctor". [source: Shimoji et al. 1998]
• Acknowledge yuta in treatment. Naka et al. argue psychiatric services should acknowledge yuta. Practical meaning: ask about consultation routinely and record it as part of help seeking, not as a symptom. [source: Naka et al. 1985]
• Expect consultation to be common. In a 1980s survey of 316 Okinawan psychiatric nursing staff, 22.8% had consulted a yuta and 63.0% including family members; about 36.4% felt yuta had some psychotherapeutic role. Practical meaning: assume nothing from a client's profession or education; staff and clinicians may share the tradition. [source: Ishizu KAKEN report 1990]
• Understand why people consult. The same survey's commonest reasons were repeated accidents or illness, unexplained symptoms, and feeling abandoned by doctors. Practical meaning: a yuta visit can signal unmet need or a rupture with medical care; ask about it with curiosity. [source: Ishizu KAKEN report 1990]
• Attribute, neither affirm nor dismiss. Describe kami, ancestors, soul loss and kamidaari as the tradition and the client hold them. Practical meaning: use phrases such as "in your family's understanding" rather than "the spirits are" or "there is no such thing". [source: tradition as described in Staemmler 2014; stance synthesis]
• Use the community's own words. Some regard "yuta" as derogatory; follow the client's term (kaminchu, kamigutu, the practitioner's name). Practical meaning: ask what word the client uses and mirror it. [source: Staemmler 2014; Ishizu KAKEN report 1990 for kamigutu as a related term]
• Neither pathologise nor miss illness. Kamidaari is socially recognised distress with meaning in the tradition (Sasaki argues its social acceptance relieves frustration and maintains social order), yet psychiatric illness may be attributed to it. Practical meaning: assess both meaning and disorder; one does not exclude the other. [source: Sasaki 1984; Shimoji et al. 1998]
• Cultural conflict is clinically relevant. Tagami (1979) observed that many Okinawan psychiatric patients struggled with identity conflict between shamanic tradition and modern, largely American-influenced culture, and that delusional content reflected this inconsistency. Practical meaning: explore identity and generational conflict, not only belief content. [source: Tagami 1979]
• Remember suppression and stigma. Since the seventeenth century there were attempts to eliminate female spiritual healers and male diviners, with punishments for healers and clients and destruction of sacred sites; since the 1990s the traditions have increasingly been seen as cultural heritage. Practical meaning: clients may expect ridicule from professionals; say explicitly that you will not judge. [source: Staemmler 2014]
• Respect gendered religious roles. Women hold the shamanic and priestly roles in this tradition, while men have held political leadership. Practical meaning: understand a woman's calling or a sister's spiritual responsibility as a role, not as eccentricity. [source: Sasaki 1984; Staemmler 2014]
• The tradition is not yours to practise. No ritual, prayer, divination, offering or visit to sacred sites is suggested or guided by the therapist; access to restricted sacred areas is not sought. Practical meaning: route religious questions to the practitioners and families who hold them. [synthesis; Visit Okinawa Japan on restricted areas]
• Consent governs every contact. Any contact with a practitioner or family member requires the client's informed consent about what is shared. [synthesis]
• Medicines go through the prescriber. Never advise starting, stopping or changing medication, even if the client reports advice to do so. Practical meaning: refer such questions to the prescriber the same day where risk is present. [synthesis]

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them is a yuta's or noro's practice, and none involves ritual, prayer, divination or a sacred site. Example language is illustrative throughout.

4.1 Cultural self-examination and humility

• Purpose / when: before first contact and whenever you notice certainty, amusement or discomfort about the client's religious life. Okinawa's history (annexation in 1879, earlier suppression of healers, wartime destruction, mainland and US influence) shapes how clients read a clinician. [source: Staemmler 2014; Ryukyu Shimpo 2018; Tagami 1979]
• Steps: (1) Write down what you were taught about yuta, noro and "superstition", and by whom. (2) Note your position: Okinawan or not, which island, which generation, mainland Japanese, foreign, diaspora. (3) Identify where your own religious or secular commitments might pull you to affirm or debunk. (4) Bring one case per quarter to consultation with an Okinawan colleague or cultural broker. [synthesis]
• Example language (illustrative): "I am not from your island, and I may get things wrong about what this means in your family. Please correct me."
• Watch for: using "superstition" or "belief" for the client's world but "fact" for yours; humour about yuta. It is working when the client brings religious material spontaneously. [synthesis]

4.2 CFI core interview

• Purpose / when: at intake with any client for whom family religion, ancestors or consultation with practitioners may matter, and whenever diagnosis is unclear. The CFI has 16 core questions across four domains: cultural definition of the problem; cultural perceptions of cause, context and support (including cultural identity); cultural factors affecting self-coping and past help seeking; and cultural factors affecting current help seeking. [source: APA CFI]
• Steps: (1) Introduce it as wanting to understand the problem from the client's point of view. (2) Ask the four domains in order, using the client's words for the problem. (3) Under causes, ask what the client and also family and community think caused it. (4) Under past help seeking, ask openly about every kind of help, naming religious help among others. (5) Under current help seeking, ask what the family thinks should be done and whether anything about you or the clinic makes help harder. (6) Use the informant version with a relative if the client consents. Clinicians may reproduce the APA form for their own patients; it may not be modified without APA permission. [source: APA CFI]
• Example language (illustrative): "Sometimes people see a doctor, a counsellor, and also someone from their family's religious tradition. Have you, or has your family, sought any help like that?"
• Watch for: the client answering in medical terms only when a parent is present, or the reverse. It is working when you can restate the problem in the client's terms and the client agrees with your restatement. [synthesis]

4.3 Explanatory model module

• Purpose / when: when the client or family links the problem to kami, ancestors, soul loss, a neglected obligation, a sacred place, or a calling. [source: Staemmler 2014 for typical attributions; APA CFI for the module]
• Steps: (1) Ask what the client calls the problem and what they think caused it. (2) Ask why it started now. (3) Ask what the family, and any practitioner consulted, said it was. (4) Ask what the client fears most about it and what outcome they hope for. (5) Write the model in the client's words in the record, with attribution ("client and mother understand this as"). [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] Steps 1–4 overlap with Kleinman's eight explanatory-model questions (Kleinman, Eisenberg and Good 1978) [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]; that his approach underlies this module is [uncertain].
• Example language (illustrative): "What does your grandmother think is behind this? And what do you think? They may not be the same."
• Watch for: generational splits (an older relative citing ancestors, the client embarrassed or torn). It is working when you can name agreement and disagreement within the family without the client feeling exposed. [synthesis; Tagami 1979 on identity conflict]

4.4 Religion, spirituality and moral traditions module

• Purpose / when: when the household's relationship with ancestors, family religious duties, or a woman's spiritual role (including onarigami expectations) is part of the problem or of support. [source: Staemmler 2014; APA CFI supplementary modules]
• Steps: (1) Ask which traditions the client and family follow, including Ryukyuan religion, Buddhism, Christianity or none. (2) Ask what role religion plays in coping. (3) Ask about obligations the client feels within the family's religious life and who expects them. (4) Ask whether any religious matter is a source of conflict or guilt. (5) Do not ask about the content of rites, prayers or sacred matters the client does not offer; if offered, listen without recording details beyond what care requires. [APA CFI module; steps 3–5 synthesis]
• Example language (illustrative): "Is there anything your family expects of you as a daughter or sister in religious matters, and how do you feel about that?"
• Watch for: guilt about neglected duties presented as depression, and the opposite, depressive guilt explained as religious failure. It is working when religious obligations can be discussed as part of family life rather than kept secret. [synthesis]

4.5 Cultural identity, social network and older-adult modules

• Purpose / when: for clients caught between island and city, Okinawa and mainland, tradition and modern or American-influenced culture, and for older clients for whom yuta consultation is part of ordinary life. [source: Tagami 1979; Ishizu KAKEN report 1990 on adolescent maladjustment linked to cultural change; Staemmler 2014 on older women clients; APA CFI modules]
• Steps: (1) Ask where the client grew up and moved, and which languages and dialects the family uses. (2) Ask which identities matter (island, Okinawan, Japanese, other). (3) Map the network: who supports, who advises on religious matters, who is consulted when things go wrong. (4) For older adults, ask how ageing has changed roles in the family's religious life. [APA CFI modules; steps synthesis]
• Example language (illustrative): "When something goes wrong in your family, who does everyone turn to first?"
• Watch for: adolescents moving between remote islands and urban schools; identity conflict appearing in symptom content. It is working when the network map includes religious advisers alongside medical ones. [source: Ishizu KAKEN report 1990; Tagami 1979]

4.6 Asking about consultation with yuta or kaminchu without judgement

• Purpose / when: routinely, given how common consultation is, and especially after repeated misfortune, unexplained symptoms, or a sense of being let down by doctors. [source: Ishizu KAKEN report 1990]
• Steps: (1) Normalise: say many families seek several kinds of help. (2) Ask whether anyone has been consulted, using the client's term. (3) Ask what the client was told the problem was and what was suggested, without asking for details of the practitioner's methods. (4) Ask how the client felt afterwards and whether it helped. (5) Ask whether advice touched on medicines or medical care, and if so route that to the prescriber. (6) Record the consultation as help seeking. [source for routine acknowledgement: Naka et al. 1985; steps synthesis]
• Example language (illustrative): "Some people I see have also visited a kaminchu. You can tell me about that here, and I won't think less of it. Did it help?"
• Watch for: the client testing whether you will laugh; disclosures coming only late in therapy. It is working when the client reports both systems' advice freely. [synthesis]

4.7 Distinguishing kamidaari as understood in the tradition from disorders that need treatment

• Purpose / when: when a client, family or practitioner frames current distress (unusual perceptions, dreams, possession-like states, somatic complaints, withdrawal) as kamidaari or a calling. Okinawan psychiatrists have documented psychiatric illness attributed to kamidaari, friction between traditional healing and psychiatry especially around schizophrenia, and links to psychosomatic and neurotic presentations. [source: Shimoji et al. 1998; Tagami 1979; Ishizu KAKEN report 1990] Kamidaari is not among the DSM-5-TR cultural concepts of distress listed by a secondary source [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]; the DSM-5-TR list itself is [uncertain]. DSM-5 states that the identity disruption of dissociative identity disorder "may be described in some cultures as an experience of possession" and requires that the disturbance "is not a normal part of a broadly accepted cultural or religious practice" [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. DSM-5-TR keeps these points in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; that it keeps the exact wording is [uncertain].
• Steps: (1) Hold two questions separately: what does this mean in the client's world, and is there also a disorder? (2) Ask whether family and community recognise the experience as a known pattern, and whether a practitioner has recognised it. (3) Assess course, functioning, sleep, self-care, risk, substance use, and medical causes; arrange psychiatric and medical assessment where psychotic, manic, severe depressive or organic features are present. (4) With consent, consult a cultural broker or an Okinawan clinician on whether the presentation fits local norms. (5) Formulate both explanations in the record, attributed. (6) Re-evaluate over time rather than deciding at one session. [steps synthesis; mediation stance from Shimoji et al. 1998]
• Example language (illustrative): "Your family sees this as a calling. I respect that. I also want to make sure your sleep and health are looked after, because a calling can be hard on the body and mind. Can we do both?"
• Watch for: severe functional decline, not eating or sleeping, danger to self or others, confusion or fever (urgent medical review); and, on the other side, a normative experience being labelled psychotic because of unfamiliar content. It is working when the client accepts assessment without feeling their meaning has been taken away. [synthesis]

4.8 The mediating or negotiating stance

• Purpose / when: throughout care when the client lives within both systems. Shimoji et al. describe the clinician as mediator between shamanistic and psychiatric epistemologies, whose overlap at critical moments forms a clinical "mesh" requiring a coalition for continuous care. [source: Shimoji et al. 1998] Their specific "climatic" stances are illustrated in the full paper [uncertain: not verified].
• Steps: (1) Name both frameworks aloud as legitimate parts of the client's life. (2) Ask what each framework recommends now. (3) Look for overlap (rest, family support, reduced conflict, safety) and build the plan there. (4) Where they conflict (for example, a family wants to stop treatment), slow down, involve the prescriber, and look for a sequence both sides can accept. (5) Keep returning to the client's own goal. [steps synthesis]
• Example language (illustrative): "The kaminchu talked about your family's responsibilities, and your doctor talked about sleep and medication. Where do those two pieces of advice point the same way?"
• Watch for: the therapist drifting into interpreting religious matters (stop and refer back to practitioners and family). It is working when the client stops hiding one system from the other. [synthesis]

4.9 Collaboration and referral with community-recognised practitioners, when the client wishes

• Purpose / when: when the client asks you to coordinate with a yuta or kaminchu, or when a family's religious adviser is central to decisions. Naka et al. argue hospitals should acknowledge yuta in treatment. [source: Naka et al. 1985] No formal Okinawan programme for psychiatry–yuta collaboration, and no registry of practitioners, is documented in the sources used here [uncertain: not verified].
• Steps: (1) Let the client choose the practitioner; never recommend or source one yourself. (2) Obtain written consent specifying what may be shared, with whom, and for how long. (3) Share only what is necessary for safety and coordination. (4) Ask the practitioner what they think helps the client and what concerns them; do not ask them to reveal ritual or divination methods. (5) Agree on how each side responds to a crisis. (6) Document. [synthesis]
• Example language (illustrative): "Would it help if I spoke with the person your family consults, so we are not pulling you in different directions? You decide what I can share."
• Watch for: pressure from family to involve someone the client does not want; confidentiality in small island communities. It is working when the client experiences one coordinated circle of care. [synthesis]

4.10 Working with the family and household

• Purpose / when: when the problem is understood as a household matter (ancestors, succession, a sister's or wife's spiritual responsibility) or when relatives drive consultation. [source: Staemmler 2014 on onarigami and household protection; Tagami 1979 met patients' families]
• Steps: (1) With consent, invite key relatives, including older women who hold religious knowledge. (2) Use the CFI informant version or explanatory-model questions with them. (3) Identify shared goals (the client's wellbeing, family harmony). (4) Address conflicts about succession, obligations or blame directly. (5) Agree what the family will do if the client worsens. [APA CFI for informant version; rest synthesis]
• Example language (illustrative): "Everyone here wants her to be well. Can each of you say what you think she needs most right now?"
• Watch for: blame placed on a relative or the client for neglected duties; pressure on a young woman to accept a calling. It is working when relatives can hold differing views without blame. [synthesis]

4.11 Integrating experiences from religious consultation

• Purpose / when: after the client has consulted a practitioner or taken part in family or community rites, to help them make sense of what they experienced and connect it with their goals. [synthesis]
• Steps: (1) Ask what the client took from the experience. (2) Explore feelings: relief, fear, guilt, hope. (3) Link meaning to concrete life changes the client wants. (4) Note new worries (for example, a feared consequence of not fulfilling an obligation) and work with them as concerns, without endorsing or disputing the religious claim. [synthesis]
• Example language (illustrative): "What did you take away from that visit, and has it changed how you want to deal with things at home?"
• Watch for: fear or guilt rising after consultation; financial strain from repeated consultation. It is working when meaning supports the client's agency. [synthesis]

4.12 Addressing historical suppression, stigma and shame

• Purpose / when: when clients minimise, joke about or conceal their religious life, or describe being ridiculed. Attempts since the seventeenth century to eliminate female healers, criticism shaped by Confucian ethics and modern rationalism, and the later shift towards seeing the traditions as heritage form the background. [source: Staemmler 2014]
• Steps: (1) Acknowledge that professionals have often dismissed these traditions. (2) Invite the client's own view. (3) Explore how shame shapes their help seeking. (4) Correct any sense that you require them to choose. [synthesis]
• Example language (illustrative): "You mentioned people laughed at your aunt for going to a yuta. I'm not here to laugh. What do you make of it yourself?"
• Watch for: your own use of the word "yuta" if the client finds it disrespectful. It is working when the client stops apologising for the tradition. [source for derogatory sense: Staemmler 2014; rest synthesis]

4.13 Interpreters and cultural brokers

• Purpose / when: when older clients or relatives are more at ease in Uchināguchi, Miyako or another Ryukyuan language, or when you lack local knowledge. [synthesis; language names uncertain: not verified in sources used here]
• Steps: (1) Ask which language the client and family prefer for emotional matters. (2) Use a trained interpreter or broker not related to the client where possible. (3) Brief them on confidentiality and on not interpreting religious meaning on your behalf. (4) Debrief after the session. [synthesis]
• Example language (illustrative): "Would you be more comfortable talking about this in the language you use at home?"
• Watch for: brokers who are also religious actors in the same community (conflict of interest). It is working when relatives speak more freely. [synthesis]

4.14 Safeguarding and risk

• Purpose / when: whenever advice or circumstances risk harm: urgent medical care delayed, medication stopped against medical advice, a minor or vulnerable adult under pressure, financial exploitation, or any coercion. The sources used here do not report specific harms by Okinawan practitioners [uncertain: not verified]; this section is general safeguarding practice. [synthesis]
• Steps: (1) Assess suicide and self-harm risk with standard practice. (2) Where a client reports advice to stop medication or avoid hospital, involve the prescriber promptly and do not advise on medicines yourself. (3) For minors, follow local child-protection procedures; never name minors in records shared outside care. (4) Document concerns and consult before reporting where time allows. [synthesis]
• Example language (illustrative): "I'm worried about your safety right now. Whatever the cause, I need to make sure you're seen by a doctor today."
• Watch for: the family hiding deterioration to avoid hospitalisation. It is working when safety is secured without the client feeling their tradition was attacked. [synthesis]

5. Handling problems

Unless a source is tagged, the responses below are [synthesis].

• The client will not discuss religious matters. Respect it; say the door stays open; return to it if the formulation stalls. Shame rooted in historical ridicule is common. [source for background: Staemmler 2014] Language (illustrative): "You don't have to talk about this. If it ever feels relevant, I'm interested."
• The family insists the problem is purely kamidaari and refuses psychiatric assessment. Do not argue about the cause. Name shared goals (sleep, eating, safety), propose assessment as caring for the body and mind during a hard time, and, if the client consents, ask whether the family's adviser would support it. If risk is high, follow emergency procedures. [mediation stance: Shimoji et al. 1998]
• The client is told to stop medication. Do not advise on the medicine. Acknowledge the dilemma, involve the prescriber promptly, and help the client bring both views to that conversation.
• The client feels abandoned by doctors and has turned to a practitioner. Treat this as a rupture in care, not as non-adherence; this was a common reason for consultation in Okinawan survey data. [source: Ishizu KAKEN report 1990] Repair: acknowledge what went wrong, and re-establish what you can offer.
• Stuck: symptoms persist and each system blames the other. Convene (with consent) a meeting or parallel conversations to agree a sequence; refocus on the client's goals; consider a second psychiatric opinion.
• Overwhelm during exploration of the calling. Slow down, ground in the present, attend to sleep and supports; defer meaning-making until the client is stable. Never induce or deepen altered states.
• Rupture over a word or stance. If the client hears "yuta" or "belief" as dismissive, apologise, ask what term they prefer, and repair. [source for derogatory sense: Staemmler 2014]
• A young woman is pressured to accept a calling, or to give up schooling or work. Explore her own wishes; work with the family on her choices; if coercion or harm to a minor arises, follow child-protection procedures.
• Identity conflict between tradition and modern or American-influenced culture. Make the conflict itself the focus rather than taking a side. [source: Tagami 1979]
• The therapist feels drawn to interpret signs, ancestors or the calling. Stop; this belongs to practitioners and families. Take it to supervision.
• A client from outside Okinawa wants to seek out a yuta or sacred sites for personal spiritual growth. Explore what they seek; do not encourage consultation or visits outside legitimate community pathways; note that sacred areas such as Sēfa-utaki's innermost part are closed to visitors, and that interest from spiritual tourism since the 1990s is described in scholarship. [source: Visit Okinawa Japan; Staemmler 2014]
• Small-community confidentiality. Clinicians, staff and practitioners may know the family. Agree explicitly who may know what; consider referral if dual relationships cannot be managed.
• Financial strain from repeated consultation. Explore the client's own view and choices without judging the practitioner; help with budgeting and decision-making if wanted.
• Non-adherence to homework. Check whether tasks conflict with family religious duties or calendars; adapt timing.

Sources

Web pages:

• Mediation between the shamanistic model and the psychiatric model in a shamanistic climate (Fujita Health University research portal)
• Yuta (Shaman) and Community Mental Health on Okinawa (IDEAS/RePEc record)
• 沖縄における比較文化精神医学的研究 (Kobe University Repository)
• KAKENHI 61480173: 沖縄における心身症の様態とその治療方略に関する研究, 1988 report
• SASAKI Yuji researcher record (NRID)
• Sasaki 1984, Spirit Possession as an Indigenous Religion in Japan and Okinawa (eHRAF record)
• Staemmler, review of Prochaska-Meyer, Kaminchu (Japanese Journal of Religious Studies)
• ICOMOS evaluation No 972: Gusuku Sites and Related Properties of the Kingdom of Ryukyu (UNESCO)
• Sefa Utaki (Visit Okinawa Japan)
• 「祝女」だった母、記憶の中に (Ryukyu Shimpo, 2018)
• 『沖縄の精神医療』書評 (Ryukyu Shimpo, 2016)
• APA DSM-5-TR Cultural Formulation Interview
• APA DSM-5 Cultural Formulation Interview Supplementary Modules
• Tanenbaum: Explanatory Models of Illness (handout of Kleinman's eight questions)
• Szepe and Fritson, DSM-5-TR webinar slides (UNMC BHECN), listing DSM-5-TR cultural concepts of distress
• PubMed Central PMC9199574: DSM-5 and ICD-11 possession and trance criteria
• Lewis (2023). Study guide citing APA (2022) DSM-5-TR on dissociative identity disorder and dissociative trance (University of Missouri System Pressbooks; paraphrase, not APA text)

Publications cited:

• Shimoji, A., Eguchi, S., Ishizuka, K., Cho, T., Miyakawa, T. (1998). Mediation between the shamanistic model and the psychiatric model in a shamanistic climate: a viewpoint of medical anthropology. Psychiatry and Clinical Neurosciences, 52(6), 581–586. doi:10.1046/j.1440-1819.1998.00456.x
• Naka, K., Toguchi, S., Takaishi, T., Ishizu, H., Sasaki, Y. (1985). Yuta (shaman) and community mental health on Okinawa. International Journal of Social Psychiatry, 31(4), 267–273. doi:10.1177/002076408503100404
• Tagami, S. 田頭政三郎 (1979). 沖縄における比較文化精神医学的研究 [Transcultural psychiatry in Okinawa]. 神戸大学医学部紀要, 40(1), 73–90.
• Ishizu, H. 石津宏 (1990). KAKENHI project 61480173 research report (University of the Ryukyus).
• Sasaki, K. (1984). Spirit possession as an indigenous religion in Japan and Okinawa. Senri Ethnological Studies, 11, 75–84.
• Prochaska-Meyer, I. (2014). Kaminchu: Spirituelle Heilerinnen in Okinawa. Vienna: Praesens (cited through Staemmler's review).
• Staemmler, B. (2014). Review of Prochaska-Meyer, Kaminchu. Japanese Journal of Religious Studies, 41(2), 422–426.
• ICOMOS (2000). Evaluation No 972, Gusuku Sites and Related Properties of the Kingdom of Ryukyu.
• American Psychiatric Association (2013/2022). Cultural Formulation Interview and Supplementary Modules (DSM-5 / DSM-5-TR).
• Ogura, R. 小倉力 (2015). 『沖縄の精神医療』. Nakayama Shoten (background on Okinawan psychiatric services; content on folk belief [uncertain: not verified]).