Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 014
Guide XI-014

Dargah and temple healing

South Asia
A 38 · L 51 · M 1118 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the Indian shrine-and-clinic arrangements as described by the National Human Rights Commission (NHRC) of India, Indian court reporting and the Dava aur Dua / Dawa-Dua literature (Gujarat programme at the Hazrat Saiyed Ali Mira Datar dargah, Unava, Mehsana district; the Tamil Nadu adaptation at Erwadi), with the NIMHANS temple-healing report (Raguram et al., BMJ 2002) as scholarly context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI, APA core version and DSM-5 supplementary modules).

What it is. "Dargah and temple healing" is not a therapy or a single tradition. It names a widespread South Asian pattern in which people with mental distress, usually brought by their families, stay at or repeatedly visit a Sufi shrine (dargah), a Hindu temple or a Christian shrine known locally for healing, sometimes for weeks. Reported examples include the Mira Datar dargah in Gujarat, the Erwadi dargah in Ramanathapuram district, the Gunaseelam Prasanna Venkatachalapathy temple near Tiruchirappalli, and St Anthony's Shrine at Puliampatti, Thoothukudi, all in Tamil Nadu. Stays of up to 40 days at Mira Datar and 48 days at Gunaseelam are reported [source: Scroll.in 2022; FLAME University report 2018]. Authority over the healing sits with each site's own custodians: at Mira Datar the dargah trust and the mujavars (shrine healers), at Hindu temples the priests and temple administration. Psychiatric services at these sites are run by state health departments and partner NGOs, not by the shrines [source: FLAME 2018; NHRC 2015]. A psychotherapist does not take part in shrine healing. The therapist's work is culturally responsive assessment, collaboration and safeguarding alongside it.

Core idea of how change happens (as each party describes it). Pilgrims and custodians locate healing in the sacred power of the saint, deity or site; this is their belief, to be described, not judged. One dargah trustee is quoted as saying "if it is a disease then the medicine will take care of it" [source: Scroll.in 2022]. The NIMHANS authors suggested that the healing power attributed to such sites may reside in the site itself rather than in a leader or medicines, and reported that a brief temple stay improved objective measures of psychopathology [source: Raguram et al. 2002, BMJ summary page]. The Dava-Dua model aims to bring trained help to the shrine by persuading its healers to encourage medical care alongside prayer, so that faith and treatment run side by side [source: Scroll.in 2022; FLAME 2018].

Why safeguarding is central. On 6 August 2001, 28 residents died in a fire at the Badhusha private mental asylum at Erwadi, primarily because they were chained [source: NHRC press release]. Scroll.in reports 25 shackled people died at once and three later of burns, out of 43 inside [source: Scroll.in 2022]. The Supreme Court of India took suo motu cognisance; the unlicensed homes were closed, more than 500 residents were moved to government care, a commission under district judge N. Ramdas recommended ending chaining, and the Court directed the central government to identify faith-healing centres and make them meet basic standards [source: Scroll.in 2022]. The NHRC asked every state and union territory to certify that no person with mental illness was kept in chains [source: NHRC press release]. Section 95(1)(d) of the Mental Healthcare Act 2017 now bars treatment in which a person is "chained in any manner or form whatsoever" [source: The Leaflet 2019]. Reporters still found people chained at Erwadi and Puliampatti in 2022 [source: Scroll.in 2022].

2. Framework

This is a framework for the psychotherapist's own work with a client (or family) who uses, plans to use, or has returned from shrine or temple healing. It is not a phase model of the shrine practice, which the shrines do not publish as one. Phases, session counts and transition criteria below are [synthesis] unless cited.

Phase A. Engagement and cultural assessment (sessions 1–2, 50–90 min).

  • Goals: understand the problem in the client's and family's terms; learn whether a shrine or temple is part of their help seeking; build trust before any formulation.
  • Tools: core CFI (16 questions, four domains), with the Informant Version for a family member and selected supplementary modules [source: APA CFI PDFs]. The CFI supports, but is not the sole basis for, diagnosis [source: APA CFI].
  • Move on when: the client's explanatory model, help-seeking history (including shrine visits) and main supports are documented, and immediate risk is screened.

Phase B. Formulation and risk (sessions 2–3).

  • Goals: distinguish culturally normative experience (for example possession or trance occurring as part of shrine practice) from disorder, using DSM-5-TR and ICD-11 culture exclusions [source: PMC9199574; ICD-11 6B62/6B63]; identify any restraint, coercion, neglect or interruption of needed care.
  • Move on when: a shared, written formulation exists that the client recognises, and any safeguarding concern has an action plan.

Phase C. Collaborative care planning (sessions 3–6).

  • Goals: agree how therapy, any prescriber's treatment and the client's religious practice will sit together; where a shrine-linked clinic exists, agree with the client whether and how to share information with it. In both Indian models, patients either see shrine healers first and are referred to the clinic, or take clinic medicine and have it blessed at the shrine [source: Scroll.in 2022].
  • Move on when: the client has a plan covering continuity of care across any shrine stay, consent for any contact with others is recorded, and the prescriber (if any) is informed.

Phase D. Continuing therapy and integration (ongoing; typically weekly, then fortnightly).

  • Goals: address the presenting problem with the therapist's usual evidence-based approach, adapted to the formulation; help the client make sense of shrine experiences; work with the family.
  • Move on (step down) when: goals in the formulation are met and relapse signs and help pathways, including faith-based ones the client values, are written into a plan.

Safeguarding runs through all phases. Any report of chaining, tying, beating, deprivation of food or water, sexual abuse, or withholding urgent medical care triggers the safeguarding steps in section 4, whatever the phase.

Typical format. Individual sessions, with planned family sessions (families usually accompany and often stay with the patient at shrines [source: FLAME 2018]); an interpreter or cultural broker where needed; telehealth for clients travelling to a shrine [synthesis].

3. Guiding principles

[source: APA CFI and modules for 1–4; NHRC, Scroll.in, The Leaflet for 8; Shields et al. 2016 for 6; remaining items synthesis]

  1. The client's frame first. Ask what the problem is called and why it happened before naming anything clinically. Practical meaning: open with CFI Cultural Definition questions, not a symptom checklist.
  2. Neither confirm nor dismiss spiritual explanations. Saints' power, spirit affliction or divine displeasure are held by the client and community; you describe them in their words. Practical meaning: write "the family understands this as …" in notes.
  3. Normative experience is not a symptom. Trance or possession that is part of broadly accepted collective religious practice is excluded from dissociative and trance diagnoses [source: PMC9199574; ICD-11]. Practical meaning: diagnose only when the experience is involuntary, unwanted, distressing or impairing, and outside the accepted practice.
  4. Equally, do not miss illness. Families often come to shrines after months or years of psychiatric care [source: Scroll.in 2022]; serious mental illness is common among shrine clients (at Mira Datar, schizophrenia-spectrum, stress-related and mood disorders were each about a quarter of diagnoses) [source: FLAME 2018, citing Shields et al. 2016]. Practical meaning: screen for psychosis, mood disorder, substance use and physical illness in every case.
  5. Know who holds authority. Shrine custodians hold religious authority; clinic staff, psychiatrists and state mental health officers hold clinical authority; courts, the NHRC and the Mental Healthcare Act set legal limits. Practical meaning: never claim to speak for the shrine, and never let religious authority override legal protections.
  6. Collaboration needs trust and is slow. Collaboration "requires trust, rapport-building, and open dialogue" [source: Shields et al. 2016 abstract]; Mira Datar custodians first saw the clinic as surveillance and a threat to livelihoods [source: FLAME 2018]. Practical meaning: approach any faith-based partner respectfully and through the client's own contacts.
  7. Consent governs contact. Practical meaning: contact a shrine-linked clinic, healer, family member or community figure only with the client's explicit consent, except where safeguarding law requires otherwise [synthesis].
  8. Restraint is never treatment. Chaining is prohibited by the Mental Healthcare Act 2017 and has been called inhuman and a violation of Article 21 by the Supreme Court [source: The Leaflet 2019]. Practical meaning: always ask about restraint, and act on it.
  9. Family members are both carers and possible sources of risk. Attenders, mostly mothers in one report, cited violence and fear of running away as reasons for chaining [source: Scroll.in 2022]. Practical meaning: support the carer's burden and address the restraint.
  10. Medicines are the prescriber's domain. Practical meaning: never advise starting, stopping or changing medicines, including around a shrine stay; route all medicine questions to the prescriber [synthesis].
  11. Do not steer clients to or away from shrines. Practical meaning: explore the client's choice; give no endorsement and no ridicule; give information about safety and continuity of care [synthesis].
  12. Self-examination. Your own religious or secular assumptions shape what seems "reasonable". Practical meaning: note your reactions after sessions and bring them to supervision [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them is shrine or temple healing, and this guide gives no account of shrine rituals. Example language is illustrative wording written for this guide, not quoted from any manual.

4.1 Cultural humility and self-examination

  • Purpose: reduce the risk that your own religious, secular or class assumptions turn into contempt for, or romanticising of, shrine healing. Use before the first session and throughout. [synthesis]
  • Steps: (1) Before seeing the client, note what you already believe about shrines, faith healing and families who use them. (2) Note what you know about the client's community and what you do not. (3) After each session, write down any moment you felt judgement, alarm or fascination. (4) Take these notes to supervision, ideally with a colleague who knows the client's religious community.
  • Example language (illustrative): "I don't share your tradition, so I'll be asking a lot of questions. Please correct me whenever I get something wrong."
  • Watch for: feeling a need to "rescue" the client from their faith; equally, not asking about chaining or danger because it might seem disrespectful. It is working when the client corrects you freely and brings up shrine experiences without prompting.

4.2 Core Cultural Formulation Interview

  • Purpose: get the problem, causes, supports, coping, past help seeking and expectations of care in the client's own terms. Use at intake with every client from a community where shrine or temple healing is common. [source: APA CFI]
  • Steps: (1) Explain that you ask everyone about their own understanding of the problem. (2) Work through the four domains in order: cultural definition of the problem; perceptions of cause, context and support (including the role of cultural identity); self-coping and past help seeking, including barriers; current help-seeking preferences and the clinician–patient relationship (for example perceived racism or language barriers) [source: APA CFI]. (3) Paraphrase the questions in plain language; the APA allows clinicians to reproduce the form for use with their patients, but modification or translation needs APA permission [source: APA CFI]. (4) Use the client's own words for the problem in your notes. (5) Mark which subtopics need a supplementary module.
  • Example language (illustrative): "People explain problems like this in many different ways. How would you describe what's been happening, in your own words?" / "Have you or your family already tried anything, at home, with a doctor, or at a temple or dargah?"
  • Watch for: the client giving "medical" answers they think you want; probe gently for other explanations held by them or their family. Time needed is not stated in the APA forms [uncertain: not verified]. It is working when the client's account contains causes, help seeking and expectations you did not anticipate.

4.3 CFI Informant Version with a family member

  • Purpose: families usually bring the person to the shrine and often stay with them [source: FLAME 2018]; their view of the problem shapes what happens. Use when a relative is involved in decisions about care. [source: APA CFI Informant Version]
  • Steps: (1) Get the client's consent to interview the relative, and agree what will and will not be shared. (2) Use the Informant Version (17 questions: the relationship with the patient, then the same four domains) [source: APA Informant Version]. (3) Interview the relative separately if the client agrees; this also creates space to ask about restraint. (4) Compare the client's and the family's explanatory models and note where they differ.
  • Example language (illustrative): "You know your son better than anyone. What do you think is causing this, and what has your family done to help him so far?"
  • Watch for: a family view that the client is spiritually afflicted while the client believes they are ill (or the reverse); signs of carer exhaustion; fear of the client's violence. It is working when the family describes what they have tried, including at a shrine, without defensiveness.

4.4 Spirituality, Religion and Moral Traditions module

  • Purpose: understand the client's religious identity, practice and the meaning of a shrine in their life. Use when religion or a shrine features in the core CFI. [source: APA CFI Supplementary Modules]
  • Steps: (1) Ask about the client's tradition and how important it is to them and their family. (2) Ask how religion helps or makes things harder with the problem. (3) Ask specifically about any saint, deity or shrine connected to the problem. (4) Ask whether going, or not going, to the shrine causes conflict with family. (5) Record attributions in the client's words.
  • Example language (illustrative): "Is there a place, a saint or a temple that matters to your family when someone is unwell? What does going there mean to you?"
  • Watch for: clients from minority faiths fearing they will be judged; religious language for distress (for example being troubled by a spirit) that you should record, not translate into symptoms. It is working when the client explains how faith and treatment fit together for them.

4.5 Exploring the explanatory model (Kleinman; CFI Explanatory Model module)

  • Purpose: map what the client and family call the problem, what caused it and what treatment they expect, so that your plan fits their model rather than fighting it. Use early, and again when engagement falters. [source: Kleinman et al. 1978 via Tanenbaum handout; APA CFI Supplementary Modules]
  • Steps: (1) Ask, in your own wording, the eight areas: the name for the problem; its cause; why it started when it did; what it does to the person and how; how severe it is and how long it will last; what treatment they think is needed; what problems it has caused; what they fear most [source: Tanenbaum handout]. (2) Ask the same of key family members. (3) Write a short summary in the client's terms. (4) Identify points where the client's model and a clinical model can both be true (for example, "the saint's blessing and the medicine both help").
  • Example language (illustrative): "What do you think started this, and why now?" / "What would have to happen for you to feel it has been healed?"
  • Watch for: an expected treatment that needs a long shrine stay away from care, or that involves restraint; a feared outcome (for example being labelled "mad" in the community) that drives avoidance of services. It is working when the client can say how your work fits their idea of healing.

4.6 Asking about shrine and temple visits and healer consultation without judgement

  • Purpose: clients often hide shrine visits from clinicians; knowing about them is essential for safety and continuity. Use at intake and before any holiday or family trip. [source: APA CFI help-seeking domain; synthesis]
  • Steps: (1) Normalise: say many families seek help in several places. (2) Ask which shrines, temples or healers have been consulted, when, and for how long. (3) Ask what helped and what did not. (4) Ask directly, in a neutral tone, whether the person was ever tied, chained or kept from leaving, and whether medicines were stopped. (5) Ask about any plan to go again.
  • Example language (illustrative): "Many families I work with have visited a dargah or temple when someone is unwell. Has your family done that? What was it like for you?" / "Sometimes, when people are very unwell, families feel they have to hold them back or tie them. Has anything like that ever happened to you?"
  • Watch for: shame, minimising or an anxious glance at a relative when restraint is asked about; ask again alone. It is working when the client tells you about shrine visits before they happen.

4.7 Distinguishing culturally normative experiences from disorder

  • Purpose: avoid both pathologising religious experience and missing serious illness. Use whenever possession, trance, voices or spirit affliction is described. [source: PMC9199574; ICD-11 via findacode; APA DSM-5-TR Section III]
  • Steps: (1) Establish whether the experience occurred within a broadly accepted collective cultural or religious practice; trance in such a setting is excluded from dissociative-trance diagnosis in DSM-5 and from ICD-11 trance disorder (6B62) [source: PMC9199574; findacode]. (2) Ask whether it is involuntary and unwanted, recurrent or prolonged, and distressing or impairing; ICD-11 possession trance disorder (6B63) requires replacement of identity by an external "possessing" identity that is involuntary and unwanted [source: PMC9199574]. (3) Ask what the client's community thinks of this experience: is it seen as expected, as part of healing, or as a sign that something is wrong? (4) Screen separately for psychotic, mood, substance and organic causes, including whether symptoms continue outside the shrine context. (5) Consult a cultural broker or community member if you are unsure what is normative. (6) Record both the cultural account and any diagnosis.
  • Example language (illustrative): "When this happened at the shrine, was it something others there expected, or did it feel different and out of your control?" / "Does it happen at home too, when you are not at the dargah?"
  • Watch for: experiences that spread into daily life, command voices, self-neglect, weight loss, or rapid deterioration; these call for medical or psychiatric assessment whatever the cultural frame. DSM-5-TR keeps the DSM-5 point on possession-form identity disruption in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; that it keeps the exact wording is [uncertain: not verified]. It is working when your formulation names both the client's experience and its clinical meaning, and the client accepts it.

4.8 Using DSM-5-TR cultural concepts of distress

  • Purpose: recognise idioms, explanations and syndromes through which distress is voiced. Use when the client's language for distress does not map onto diagnostic terms. [source: APA DSM-5-TR Section III; UNMC slides]
  • Steps: (1) Note that DSM-5-TR groups cultural concepts as idioms, explanations or perceived causes, and syndromes [source: APA DSM-5-TR Section III]. (2) For South Asian clients, be aware that DSM-5-TR lists dhat syndrome among its examples [source: UNMC slides]; possession experiences are addressed under dissociative disorders (4.7). (3) Use the concept to start a conversation, not as a diagnosis; ask what it means for this client. (4) Then assess for any co-occurring disorder.
  • Example language (illustrative): "You said this is like being 'caught' by something. Can you tell me more about what that means in your family?"
  • Watch for: assuming a client from a given region shares a given belief; concepts are examples, not a checklist. It is working when the client's own term is used in your shared formulation.

4.9 Barriers, help-seeking preferences and the clinician relationship

  • Purpose: find out why the family chose a shrine or temple, what they expect of you, and what might make them leave. Use in the first sessions and after any missed appointment. [source: APA CFI domains 3–4; Coping and Help-Seeking and Patient–Clinician Relationship modules]
  • Steps: (1) Ask what has got in the way of care before (cost, distance, stigma, past bad experiences, language). (2) Ask what kind of help they want now and from whom. (3) Ask whether differences between you and the client (religion, caste, class, ethnicity, language) might make it hard to talk; the CFI names perceived racism and language barriers [source: APA CFI]. (4) Agree one adjustment you can make.
  • Example language (illustrative): "Some people find doctors or therapists didn't understand their beliefs. Has that happened to you? What should I know so that doesn't happen here?"
  • Watch for: cost and access as real reasons (the Gujarat clinic's free medicines helped reach poorer patients [source: FLAME 2018]); past coercive psychiatric care. It is working when the client tells you plainly what would make them stop coming.

4.10 Interpreters and cultural brokers

  • Purpose: accurate communication and a check on what is normative in the client's community. Use when language differs, or when you cannot judge whether an experience is expected in the client's tradition. [synthesis]
  • Steps: (1) Use a trained interpreter, not a family member, for assessment and any safeguarding questions. (2) Check the interpreter's community ties and the client's comfort with them (small communities, shrine affiliations). (3) Brief the interpreter on religious terms and on confidentiality. (4) With consent, consult a cultural broker (for example a community worker or religious adviser the client trusts) on the meaning of practices, without sharing identifying detail unless the client agrees.
  • Example language (illustrative): to the client, "The interpreter will translate everything you say and keeps it private. Would you prefer someone from outside your local community?"
  • Watch for: an interpreter softening questions about restraint or adding their own opinion of the shrine. It is working when the client's own religious terms come through in translation.

4.11 Collaboration and referral with shrine-linked services (when the client wishes)

  • Purpose: let faith and clinical care run side by side, as the Dava-Dua and Erwadi models aim to do. Use when a client uses a shrine that has a linked clinic, or when a client wants their healer or custodian informed. [source: Scroll.in 2022; FLAME 2018; NHRC 2015; Shields et al. 2016]
  • What the published models do: At Mira Datar, the Gujarat government conceived the programme, funded by the Department of Health and Family Welfare and monitored by the Hospital for Mental Health, Ahmedabad; the NGO Altruist runs the clinic. Mujavars may refer clients after observing them; referral was designed to be optional. A psychologist assesses, a psychiatrist diagnoses, medicines are free, and social workers and psychologists follow up by phone; clients may continue shrine practice [source: FLAME 2018]. A 2013 Ashoka profile of Altruist's founder adds that psychiatrists from the government mental hospital in Ahmedabad see patients at the clinic in rotation and that the government hospital supplies the medicines [source: Ashoka 2013]. Start dates differ between sources: the FLAME student report gives an official start in 2004, Altruist taking over in 2007 and the clinic opening inside the dargah in 2008 (moving across the street in 2012); the Ashoka profile, written in 2013, says the clinic was founded in the dargah premises nine years earlier; Scroll.in gives 2008 [source: FLAME 2018; Ashoka 2013; Scroll.in 2022] [uncertain: secondary; no government or Altruist document giving the dates is cited here]. If the date matters, say "from the mid-to-late 2000s". At Erwadi, the dargah committee agreed to a clinic in 2013 after its leaders visited the Gujarat programme, and the clinic has run inside the dargah since October 2014 under the Tamil Nadu District Mental Health Programme (Tamil name "Markkam & Maruthuvam"), with faith healers trained to direct clients to it after their religious observances; the state also funded a psychiatric hospital nearby and a rehabilitation centre with vocational work [source: NHRC 2015; Al Jazeera 2015; World Bank blog 2016; Scroll.in 2022]. At Gunaseelam a doctor has visited since 1992; at Puliampatti a psychiatrist holds a Saturday clinic [source: Scroll.in 2022]. The FLAME authors found the two systems worked largely separately, in a relationship of tolerance rather than shared treatment [source: FLAME 2018].
  • Steps for the therapist: (1) Ask whether the client wants any link with the shrine, its clinic or a healer, and what for. (2) Record written consent naming who may be contacted and what may be shared. (3) Contact the shrine-linked clinic (a clinical service) rather than custodians for clinical matters; contact custodians only if the client asks and only about matters the client chooses. (4) Share the minimum: dates, the client's goals, safety needs, the prescriber's name. (5) Never ask a healer to change their practice and never advise the client on shrine rituals. (6) Agree how the client will tell you about the stay afterwards.
  • Example language (illustrative): "Would it help if I spoke to the clinic at the dargah so they know you are seeing me? I'd only tell them what you agree to."
  • Watch for: custodians' mistrust of clinicians (seen at Mira Datar as surveillance and a threat to livelihood) [source: FLAME 2018]; reports of restraint or beating at the site, which override collaboration and move you to 4.14. It is working when the client experiences the two kinds of help as compatible.

4.12 Continuity planning before a shrine or temple stay

  • Purpose: keep the client safe and in care during stays that can last weeks. Use when a client or family plans a stay. [synthesis, informed by stay lengths in Scroll.in 2022 and FLAME 2018]
  • Steps: (1) Ask dates, place, who goes, and where the client will sleep. (2) Ask the client to talk with their prescriber before leaving about any medicine plans; do not advise on medicines yourself. (3) Agree a contact plan (telehealth or phone check-ins) and an emergency plan, including the nearest clinic at or near the site where one exists. (4) Ask the family how they would respond if the client became agitated or tried to leave, and discuss non-restraint options. (5) Agree a session soon after return.
  • Example language (illustrative): "While you're at the temple, how can we stay in touch? And if things get hard there, who would you call?"
  • Watch for: plans for a long stay in a place with no clinical cover; a family expecting to "hold" the client if agitated; physical illness that needs care during the stay. It is working when the plan is written and the family has agreed to it.

4.13 Integrating shrine and temple experiences after return

  • Purpose: help the client make meaning of what happened, keep gains and process anything frightening. Use at the first session after a stay. [synthesis]
  • Steps: (1) Invite an open account in the client's words. (2) Ask what felt healing, what felt frightening, and what changed. (3) Reflect the client's meaning without endorsing or challenging spiritual claims. (4) Ask directly whether anything was done to them that they did not want. (5) Link helpful elements (community, family closeness, routine, hope) to the ongoing plan.
  • Example language (illustrative): "What was the most important thing that happened for you there? Was anything hard or frightening?"
  • Watch for: new shame, fear of spirits or guilt if the stay "did not work"; deterioration; disclosure of restraint or abuse (go to 4.14). It is working when the client can hold the shrine experience and therapy in one story of recovery.

4.14 Safeguarding: restraint, chaining and other harm

  • Purpose: protect a client who is, or may be, chained, tied, beaten, deprived, sexually abused or kept from needed medical care at a shrine, a private "home" near one, or by family. Use at any disclosure or suspicion. [source: NHRC press release; Scroll.in 2022; The Leaflet 2019; synthesis for steps]
  • Legal context in India: chaining in mental health treatment is barred by Section 95(1)(d) of the Mental Healthcare Act 2017; the Supreme Court (PIL by Gaurav Kumar Bensal, as the report spells it, January 2019, a faith-based asylum in Badaun, Uttar Pradesh) called chaining inhuman and a violation of Article 21 [source: The Leaflet 2019]. The NHRC has required states to certify that no one is kept in chains [source: NHRC press release]. Outside India, apply your own jurisdiction's adult and child safeguarding law; harm abroad to a person in your care can still create duties at home [synthesis].
  • Steps: (1) Ask directly and alone (4.6 wording). (2) If restraint is current or imminent, treat it as an emergency: establish where the person is, who is with them, and their physical state (injury, food, water, heat, fire risk; the Erwadi deaths happened because chained people could not escape a fire [source: NHRC press release]). (3) Follow your service's safeguarding procedure and inform the relevant authority (in India, for example, district mental health and police authorities; elsewhere, adult or child protection services) [synthesis]. (4) Arrange urgent medical or psychiatric assessment for the person. (5) Document what was said, by whom, and what you did. (6) Keep the therapeutic alliance with the family where you can: name the harm clearly, and the care need behind it.
  • Example language (illustrative): to a family member, "I can see how frightened you've been that he'll hurt someone or run away. Tying him is not safe and is not allowed, so let's work out right now who can help keep everyone safe."
  • Watch for: restraint described as "for his own good", as tradition, or blamed on others at the site; reports that a ban exists but attenders still restrain (reported at Erwadi and Puliampatti [source: Scroll.in 2022]); practices such as beating presented as removing a spirit [source: Scroll.in 2022, quoting a Banyan clinician]. It is working when restraint stops and the person is in safe care.

4.15 Children and young people

  • Purpose: protect minors taken to shrines or temples for healing. Use whenever a child is the identified patient. [synthesis]
  • Steps: (1) Seek the child's assent and the carers' consent for assessment. (2) Use the CFI School-Age Children and Adolescents module [source: APA CFI Supplementary Modules]. (3) Ask carers about planned stays, schooling and any restraint, beating or deprivation. (4) Apply child protection procedures to any of these, without treating the family's faith itself as abuse. (5) Never name the child in any external communication beyond what safeguarding requires.
  • Example language (illustrative): to a parent, "Many parents take their children to a temple or dargah for blessing. I need to ask everyone: has anything there hurt her, or kept her away from school or from a doctor?"
  • Watch for: missed school during long stays, untreated physical illness, fear in the child. It is working when the child is safe and the family stays engaged.

4.16 Working with families and carers

  • Purpose: families bring people to shrines, stay with them and often do the caring [source: FLAME 2018; Scroll.in 2022]; their exhaustion and fear drive both help seeking and restraint. Use throughout. [synthesis]
  • Steps: (1) Hold a family session to share the formulation in terms both sides accept. (2) Ask about the carer's own health, sleep and supports; use the CFI Caregivers module where useful [source: APA CFI Supplementary Modules]. (3) Plan responses to agitation and wandering that do not involve restraint (who to call, crisis services, calming steps). (4) Discuss stigma and the family's standing in the community. (5) Connect carers to carer support or psychoeducation.
  • Example language (illustrative): "You've been carrying this for years. What would make the next month more manageable for you?"
  • Watch for: one family member making all decisions; the client's wishes being overridden; carer depression. It is working when carers describe a safety plan they believe they can follow.

4.17 Diaspora and migrant clients

  • Purpose: clients abroad may travel home to a shrine, use a local shrine or temple, or be under family pressure to go. Use when migration is part of the story. [source: APA CFI Immigrants and Refugees module; synthesis]
  • Steps: (1) Use the Immigrants and Refugees and Cultural Identity modules. (2) Ask about family expectations to go "back home" for healing. (3) Plan continuity (4.12) and safeguarding (4.14) before any trip. (4) Ask about local religious resources the client values.
  • Example language (illustrative): "Is anyone in your family suggesting you go back home to a shrine for this? How do you feel about that?"
  • Watch for: a trip planned without the client's agreement; loss of contact abroad. It is working when the client makes the decision themselves with a plan.

4.18 Trauma-informed work with people who experienced restraint

  • Purpose: address fear, humiliation and mistrust after being chained or confined. Use when a client discloses past restraint. [synthesis]
  • Steps: (1) Validate that what happened was harmful, while leaving room for the client's mixed feelings about family and faith. (2) Assess for trauma symptoms and offer your usual evidence-based trauma treatment, paced to the client. (3) Separate the harm from the client's faith, if the client wishes to keep it. (4) Work on mistrust of all helpers, including you.
  • Example language (illustrative): "You can love your family and your faith and still say that being tied up was wrong and frightening."
  • Watch for: self-blame, shame, dissociation in session, avoidance of all care. It is working when the client can talk about it without being overwhelmed and stays in care.

5. Handling problems

Sources rarely address therapy problems in this setting; responses below are [synthesis] unless cited.

  • Client or family refuses any psychiatric input, wanting only the shrine. Do not argue. Return to the explanatory model (4.5) and look for overlap; offer psychotherapy and safety planning that fit their frame. Keep the door open: families often move between systems [source: Scroll.in 2022].
  • Client is stuck: "it hasn't worked because of a spirit, so nothing will." Explore what the client's own tradition says about hope and patience; ask who in their community they trust to talk about this. Do not dispute the spiritual cause.
  • Overwhelm during an account of shrine experiences. Slow down, ground the client, and return to the account later in smaller pieces (4.18).
  • Non-adherence to medicines around a stay. Do not advise on medicines; ask the client to speak to the prescriber, and with consent tell the prescriber about the plan. At the Indian clinics, clients may have medicines blessed at the shrine [source: Scroll.in 2022], which some clients find helps them keep taking them.
  • Rupture after you ask about chaining. Acknowledge the offence, explain that you ask every family, and restate your respect for their faith. Do not withdraw the question if risk remains.
  • A custodian or healer is hostile to clinicians. Expect this: custodians at Mira Datar first saw the clinic as surveillance and a threat to livelihoods, and staff tend to defer to them publicly [source: FLAME 2018]. Contact only through the client, keep requests small and clinical, and never criticise the shrine to the client.
  • The client says restraint is "banned" at the shrine, but you hear otherwise. Bans and practice can differ [source: Scroll.in 2022]. Ask specific, concrete questions and act on 4.14.
  • Disagreement inside the family. Hold separate then joint sessions; centre the client's wishes, and do not side with the faction closest to your own views.
  • Unclear whether an experience is possession within practice or psychosis. Hold both possibilities open, consult a cultural broker, observe over time, and arrange psychiatric assessment if there are risk signs (4.7).
  • Your own discomfort. Take it to supervision (4.1).
  • Health claims. Neither shrines nor clinics should be presented as treatment for physical disease; if a client delays urgent medical care for a shrine stay, treat it as a safety issue and encourage medical assessment.
  • Evidence gaps. The figures available for Dava-Dua are service counts, not outcomes: 376 mujavars trained and over 40,000 people treated by 2014, attributed to the National Mental Health Survey, in a student report [source: FLAME 2018] [uncertain: secondary, unverified]; more than 18,000 patients including repeat visits by 2013, in Altruist's founder profile [source: Ashoka 2013]; some 16,000 patients brought to the programme, in a 2014 news report [source: PBS NewsHour 2014]; and, at Erwadi, about 1,000 cases registered by August 2015 and over 3,000 people diagnosed and treated by late 2016 [source: Al Jazeera 2015; World Bank blog 2016]. These reports give only anecdotal accounts of improvement, and the World Bank post is written by a staff member of a funder of the Tamil Nadu programme. Shields et al. 2016 is a case study of the Gujarat collaboration, not an outcome trial [source: Shields et al. 2016, abstract]. No independent outcome evaluation of Dava-Dua is known to this guide [uncertain], so do not tell clients the programme is proven to work; describe it as an arrangement that lets them use prayer and clinical care side by side. Note too that a 2014 report found some shrine attendants telling patients they could stop their medicines [source: PBS NewsHour 2014]; ask about this and route any medicine question to the prescriber. The link between the NIMHANS BMJ report and the Muthuswami shrine at Srivelayuthapalayampudur near the Palani hills, and a NIMHANS study of Gunaseelam, are [uncertain: not verified] [source: Himal 2006; Raguram et al. 2002].

Sources

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