Thai traditional medicine and mor phi

1. Introduction

Version followed: Thai traditional medicine (TTM) as Thai law and the Department of Thai Traditional and Alternative Medicine (DTAM) define and regulate it, under the Thai Traditional Medical Professions Act B.E. 2556 (2013), as summarised in DTAM's 2023 BIMSTEC report. Spirit healing (mor phi, mor tham) and phi pob beliefs follow Thai-language ethnographic studies from Isan (northeastern Thailand). The psychotherapist's own methods follow the DSM-5-TR Cultural Formulation Interview (CFI). [source: DTAM BIMSTEC 2023 report pp. 108, 111, 116]

What it is. This entry covers two different things. Neither is a psychotherapy.

TTM is a codified, state-regulated medical system. It is not a single therapy. Its official components are Thai traditional pharmacy, nuad Thai (massage), Thai traditional midwifery and Thai indigenous (folk) medicine. Indigenous medicine is described as "a part of local health wisdom and community health care." [source: DTAM BIMSTEC 2023 p. 108] One Mahidol University account holds that TTM recognises a physical and a spiritual part of the person, and that "the basis of treatment is holistic approach." [source: Vallisuta, Mahidol Faculty of Pharmacy]
Mor phi (roughly "spirit doctor") is a broad, informal term for local healers who deal with illness or misfortune attributed to spirits (phi). In Isan the best-documented figure is the mor tham (หมอธรรม, "dharma doctor"). The mor tham is a mostly male healer, lay or monastic, who learns from a teacher (khru tham), keeps the Buddhist five precepts and the teacher's prohibitions, and is respected by villagers in a way "comparable to respect for monks." [source: Phraaphichat Buddhayano et al. 2018] The exact boundaries between mor phi, mor tham and other healer types vary by locality. [uncertain: not verified]
Phi pob (also spelled phii pob or phi pop) is a feared spirit in Isan belief. It is believed to possess a living person, cause illness or misfortune in others, and pass through families. [source: Bangkok Post, "A village haunted by superstition"; Suwanlert 1976]

How change is understood within the systems (attributed). In TTM, health is the balance of four elements (dhatu): earth, water, wind and fire. Illness reflects imbalance, assessed against age, season and time of day. Treatment restores balance through herbs, manual therapy and other means. [source: Vallisuta; UNESCO Nuad Thai listing] In Isan spirit healing, illness without a clear cause, misfortune or possession may be attributed to harm by malevolent spirits such as phi pob. The mor tham's authority and Buddhist-framed protection are held to resolve this. The ethnographers add that belief and confidence may themselves have real psychological effects. [source: Phraaphichat Buddhayano et al. 2018] These accounts belong to the traditions and their scholars. This guide neither endorses nor dismisses them.

The psychotherapist's role. A psychotherapist does not practise TTM or spirit healing. TTM is practised by practitioners licensed by the Thai Traditional Medical Council (TTMC). Spirit healing is practised by healers whose authority comes from teachers, precepts and their communities. The therapist's work is culturally responsive assessment and care alongside these systems: understanding the client's explanatory model, telling culturally normative experience apart from disorder, coordinating with prescribers and recognised practitioners when the client wishes, and safeguarding. Change, from the therapist's side, comes through a formulation the client recognises as their own, and through care plans that do not force a choice between systems. [synthesis]

Nuad Thai as a manual therapy is covered in more detail in Domain X. This guide treats it only where it bears on psychotherapy.

2. Framework

2a. How TTM is organised (as official bodies publish it) [source: DTAM BIMSTEC 2023 pp. 108, 111, 116]

Regulator. The Thai Traditional Medical Council (TTMC) implements the Thai Traditional Medical Professions Act B.E. 2556 (2013). It registers and licenses TTM practitioners, runs the licensing examination, sets standard curricula, certifies schools, and enforces the professional Code of Conduct.
Practitioner categories. There are licensed TTM practitioners and licensed applied TTM practitioners. Applied TTM is TTM practised with science-based knowledge, and it may use medical scientific equipment under TTMC rules.
Training. There are two four-year bachelor's degrees: Bachelor of Thai Traditional Medicine (B.TM., offered at 24 universities) and Bachelor of Applied Thai Traditional Medicine (B.ATM., 11 universities). TTMC-certified institutes and licensed TTM facilities also train in one or more branches.
Other regulation. The Department of Health Service Support licenses TTM clinics under the Health Facilities Act B.E. 2541 (1998). It also licenses massage-for-health establishments and providers under the Health Service Establishment Act B.E. 2559 (2016).
Folk healers. The Protection and Promotion of Traditional Thai Medicine Wisdom Act B.E. 2542 (1999) names DTAM as the main implementing body. A Ministry of Public Health Regulation on Certification of Folk Healers, B.E. 2562 (2019), governs certification of folk healers (หมอพื้นบ้าน). [source: Kotsook 2020] The criteria and procedure for certification were not verified. [uncertain: not verified] In one widely reported 2018 case, DTAM certified a folk healer and stated that certification could be withdrawn if he engaged in commercial activity. A senior official said folk doctors treat "for ethical reasons, not for money." [source: The Nation, 7 Feb 2018]
Integration. TTM services are part of the Thai public health service system. [source: DTAM BIMSTEC 2023 p. 108] Some herbal products are on Thailand's National List of Essential Medicines. [source: Tangnitipong et al. 2021]
Diagnosis in TTM (one published account). There are four principles: dhatu (element), aryu (age), ritu (season) and kala (time of day). Life stages are linked to humors (semha, pitta, vata). This account notes that there are "many principles for diagnosis and disease development." [source: Vallisuta] TTM diagnosis is for licensed practitioners. It is described here only so the therapist can understand what a client may report.
Mor tham and mor phi are not licensed under the 2013 Act. Their authority is lineage-, precept- and community-based. [source: Phraaphichat Buddhayano et al. 2018] Whether a given spirit healer also holds folk-healer certification has to be checked case by case. [synthesis]

2b. The psychotherapist's framework alongside (synthesis). No source sets out phases for this work. The structure below is the guide's own [synthesis], built on the CFI's intended uses. [source: APA CFI; CFI Supplementary Modules]

Phase	Goal	Typical length and format	Move on when
1. Engagement and cultural assessment	Understand the problem in the client's terms. Learn which TTM, folk or spirit care is in use.	1–2 sessions. Core CFI plus selected modules. Informant version with family if the client agrees. Interpreter if needed.	The client's own name and cause for the problem are recorded. Current helpers and products are listed.
2. Formulation and differential	Integrate the explanatory model with the clinical picture. Tell culturally normative experience apart from disorder. Screen risk and medical causes.	1–2 sessions, plus medical referral and cultural consultation	There is a shared formulation the client accepts. Medical review is arranged where indicated. Risk is assessed.
3. Collaboration planning	Agree how psychotherapy sits beside TTM or spirit care. Set consent and information-sharing rules.	1 session; contact with prescriber or practitioner if the client consents	There is a written plan covering who does what, what is shared, and safety triggers.
4. Concurrent care and integration	Evidence-based treatment for the presenting problem. Integrate healing experiences. Monitor safety.	Course of treatment as indicated (often weekly)	Goals are met, or the plan is revised.
5. Review and ending	Consolidate. Plan for relapse, including which helper the client will turn to.	1–2 sessions	The client has a relapse plan that names both systems.

The CFI supplementary modules can be used at the first evaluation, later in care, or repeatedly during treatment. Phases 1–2 can therefore be revisited at any point. [source: CFI Supplementary Modules]

3. Guiding principles

The therapist works alongside the system and does not practise it. In practice: never offer TTM diagnosis, herbal advice, massage or spirit-related ritual, and never suggest that you can remove a spirit. [source: scope of TTMC licensing, DTAM BIMSTEC 2023 p. 111; synthesis]
Know who holds authority. In practice: for TTM, check TTMC licence status. For folk healers, ask about DTAM certification. For mor tham, recognise that authority comes from teacher, precepts and community, and do not rank it yourself. [source: DTAM BIMSTEC 2023 p. 111; Kotsook 2020; Phraaphichat Buddhayano et al. 2018]
Attribute and neither endorse nor dismiss. In practice: say "in your understanding, the phi…" or "in Thai medicine, the wind element…", not "the spirit is real" or "that's just a belief." [synthesis]
The CFI is an aid to clinical judgement, not the basis of diagnosis. In practice: use it to shape understanding and decisions, never as a diagnostic instrument by itself. [source: APA CFI]
Avoid both pathologising and missing illness. In practice: possession and trance that are part of broadly accepted cultural or religious practice are excluded from DSM dissociative diagnoses. Spirit attributions can also mask medical illness: in reported phi pob cases, doctors found hypertension and, in one case, an ovarian tumour. [source: PMC9199574; Bangkok Post]
Physical health first where symptoms are new or unexplained. In practice: arrange a medical review before or alongside a spirit attribution or a TTM treatment. No TTM or folk remedy should be relied on for cancer or other serious physical disease. A folk healer's reputation for a cancer "cure" has been publicly questioned. [source: The Nation 2018; synthesis]
Never advise on medicines or herbs. In practice: record all TTM and folk products, including the name and source the client gives, and pass the list to the prescriber or pharmacist. Do not comment on doses, stopping or combining. [source: Tangnitipong et al. 2021 on interactions; synthesis]
Accusation is a safeguarding risk. In practice: treat a phi pob accusation against a client or family as possible exposure to stigma, expulsion or violence, and ask about it directly. [source: Bangkok Post]
Consent and confidentiality across systems. In practice: share nothing with a healer, monk, temple or family member without explicit, specific consent. Village-level gossip can turn into accusation. [synthesis]
Language and dialect. In practice: Isan clients may prefer Isan (Lao) over Central Thai. Use a trained interpreter rather than family where possible, and ask the interpreter about local terms. [synthesis]
Self-examination. In practice: notice your own assumptions about Buddhism, folk belief, "superstition" or Thai massage tourism before they reach the client. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions. TTM diagnosis and treatment, nuad Thai, herbal medicine and mor tham or mor phi healing belong to their own practitioners and are not part of this inventory. Ritual procedures, chants, protective objects and offerings are deliberately not described. [synthesis]

4.1 Cultural humility and self-examination

Purpose: to reduce the risk that the therapist's assumptions (for example "superstition", "exotic massage", or idealising "ancient wisdom") distort assessment. Use before and throughout care. [synthesis]
Steps: (1) Before the first session, write down what you assume about Thai Buddhism, Isan village life, spirits and Thai medicine. (2) Note where those assumptions came from (media, tourism, training). (3) In supervision, review one case moment where your reaction shifted your questions. (4) Ask the client to correct you, and record what they correct.
Example language (illustrative): "I know a little about Thai medicine, but your family's understanding matters more here. Please correct me when I get it wrong."
Watch for: surprise or amusement in your own voice when spirits are mentioned. A client who stops raising spiritual topics after session 1. It is working when the client volunteers explanations you had not asked about.

4.2 Core Cultural Formulation Interview (DSM-5-TR)

Purpose: to clarify the problem from the perspective of the client and their social network: its meaning, possible sources of help, and expectations of services. Use at intake for any client, especially where TTM, folk or spirit care may be involved. [source: APA CFI]
Steps: (1) Use the official APA form. It has 16 questions in four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help seeking; and cultural factors affecting current help seeking, including the clinician–patient relationship. [source: APA CFI] (2) Ask in order, but follow the client's lead. (3) In the help-seeking questions, explicitly name the options: hospital doctor, TTM practitioner or clinic, temple or monk, mor tham or other healer, massage, and self-bought herbal products. [synthesis] (4) Record answers in the client's words, including Thai or Isan terms. (5) Use the answers to shape the formulation, not as a diagnosis. [source: APA CFI] (6) The form may be reproduced for use with your own clients. Modifying or translating it needs APA permission. [source: APA CFI] A validated Thai translation was not verified. [uncertain: not verified]
Example language (illustrative): "People describe problems like this in different ways. How would you or your family describe what is happening?" "Besides doctors, have you or your family looked for help anywhere else, such as a temple, a Thai medicine clinic or a local healer?"
Watch for: answers that change when a family member is present (consider the Informant Version separately). Hesitation about naming a spirit healer, which may signal fear of being judged. Reports of perceived racism or language barriers (domain 4). It is working when you can state the client's own name for the problem, their cause, and their preferred helpers.

4.3 CFI supplementary modules and Informant Version

Purpose: in-depth assessment of selected areas, used as add-ons to the core CFI or as standalone tools, at first evaluation or repeatedly. [source: CFI Supplementary Modules]
Steps: (1) Choose modules by need. Explanatory Model: for TTM concepts (elements, wind) or spirit attribution. Spirituality, Religion, and Moral Traditions: for Buddhist practice, temple ties, merit and karma framings, and the role of monks or mor tham. Coping and Help-Seeking: for parallel use of systems. Cultural Identity: for Isan, Lao, Central Thai or diaspora identity. Immigrants and Refugees: for Thai migrant workers, spouses and students abroad. Social Network: where community standing or accusation is at stake. Caregivers: given to the caregiver. [source: CFI Supplementary Modules; synthesis for selection] (2) Use the Informant Version (17 questions, beginning with the informant's relationship to the client) with a relative, with the client's consent. [source: APA CFI Informant Version] (3) Compare the client's and the family's accounts in the formulation.
Example language (illustrative): "Does religion or spiritual practice help you with this, or make it harder?" "Has anyone in the village said what they think is causing this?"
Watch for: family accounts that blame the client or another person, which may be an early accusation dynamic (see 4.10). It is working when the client and the family's accounts are both recorded and their differences named.

4.4 Eliciting the explanatory model (Kleinman)

Purpose: to map the client's understanding of the illness so that treatment can be negotiated rather than imposed. Use when the client's framing (element imbalance, wind, spirit harm, karma) differs from the clinical one. [source: Kleinman, Eisenberg and Good 1978, via Dinos et al. 2017; Tanenbaum handout]
Steps: cover the eight areas in your own words: (1) what the client calls the problem; (2) what caused it; (3) why it started when it did; (4) what it does and how it works; (5) how severe it is and how long it will last; (6) what treatment the client thinks they should receive; (7) the main problems it has caused; (8) what they fear most. [source: Tanenbaum handout] Then (9) summarise back, and (10) state your own model briefly as "another way of looking at it", with neither model replacing the other. [synthesis]
Example language (illustrative): "You said the trouble started after the wind went wrong in your body. How does that work, as you understand it?" "What worries you most about it?"
Watch for: fear of being labelled phi pob, or fear that a family member is one. This is socially dangerous (see 4.10). A model in which hospital medicine "cannot help with spirit illness", which may lead to medical care being delayed. It is working when the client agrees with your summary and asks how the two approaches fit together.

4.5 Asking about TTM, folk and spirit care without judgement

Purpose: to get an accurate list of all help being used, including herbal products, so that safety and coordination are possible. Use at intake and at each review. [synthesis]
Steps: (1) Normalise: TTM is part of the Thai public health system, and some herbal products are on the national essential medicines list. [source: DTAM BIMSTEC 2023; Tangnitipong et al. 2021] (2) Ask about each kind of help separately: licensed TTM clinic or hospital TTM department, nuad Thai, herbal products (bought, gifted or home-made), temple or monk, mor tham or other healer. (3) For practitioners, ask whether they are licensed or certified, without implying that unlicensed means bad. (4) Record product names and origins as the client gives them. (5) Send the list to the prescriber or pharmacist with consent. Do not comment on safety, dose or stopping. [synthesis]
Example language (illustrative): "Many people use Thai medicine or herbs alongside hospital care. So that your doctor has the full picture, could you tell me everything you are taking or using, even things that seem minor?"
Watch for: products that are home-made or brought from abroad (contamination has been found in some herbal products; see 4.8). The client asking you whether to stop a medicine or an herb: route that question to the prescriber. It is working when the client brings packets or photos to the next session unprompted.

4.6 Spirit attribution, possession and the differential

Purpose: to tell culturally normative spirit experience apart from dissociative, psychotic, mood or medical conditions, so that you neither pathologise belief nor miss illness. Use whenever phi pob, spirit harm, possession or trance is described. [source: PMC9199574; synthesis]
Steps: (1) Record the attribution in the client's and the family's words. (2) Note context. Is the experience part of a broadly accepted collective cultural or religious practice? DSM excludes dissociative trance in that case, and DSM-5 says DID possession-form identity disruption must not be a normal part of such practice. [source: 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]. (3) Where diagnosis is needed, consider ICD-11. 6B62 Trance disorder is involuntary, unwanted trance outside accepted practice, with recurrent episodes or one lasting several days, and distress or impairment. 6B63 Possession trance disorder is where the customary identity is replaced by an external "possessing" identity, involuntarily and unwantedly. [source: findacode ICD-11 mirror; PMC9199574] (4) Screen for psychosis, mood disorder, substance use and trauma using your usual standard instruments. (5) Arrange medical review for new or unexplained physical symptoms. In reported phi pob cases, doctors found hypertension and an ovarian tumour. [source: Bangkok Post] (6) Consult a cultural broker (4.7) about whether the presentation fits local norms. (7) Note that Isan folk medicine itself classes illness "caused by spirits" as mental illness, so a client may expect a mental-health professional to engage with it. [source: Pratumrat et al. 2021] (8) Thai psychiatric literature has described neurotic and psychotic states attributed to phi pob possession (Suwanlert, 1976, a chapter in the Lebra-edited volume Culture-bound syndromes, ethnopsychiatry, and alternate therapies, University Press of Hawaii). [source: Suwanlert 1976 record; Lebra 1976 catalogue records; PubMed record 7225] [uncertain: chapter content not seen] Use this as background that such cases reach psychiatric services, not as diagnostic guidance; the differential rests on steps (2) to (5).
Example language (illustrative): "In your village, when someone is thought to be affected by a phi, what usually happens, and does what is happening to you look like that?" "Alongside whatever the healer does, I'd like a doctor to check your body, because some physical illnesses can feel like this."
Watch for: distress and impairment beyond what the community considers expected. Persistence after community-sanctioned help. Command hallucinations, suicidal thinking and loss of self-care, which should be assessed as you would in any client. It is working when the formulation explains the experience in a way that the client, the cultural broker and the medical review can all accept.

4.7 Interpreters and cultural brokers

Purpose: to get accurate language and local context, especially for Isan or Lao-speaking clients and for spirit-related terms. [synthesis]
Steps: (1) Ask the client which language they prefer: Central Thai, Isan or Lao, or another. (2) Book a trained interpreter, not a family member. (3) Brief the interpreter: translate everything, including spirit terms, and do not soften them. (4) With the client's consent, consult a cultural broker, for example a Thai community worker, a Thai psychiatrist, or a TTM-trained colleague, about local meanings. (5) Do not disclose identifying details to brokers drawn from the client's own community without consent. [synthesis]
Example language (illustrative): "Some words don't translate well. If the interpreter or I miss what you mean, please stop us."
Watch for: an interpreter from the same small community (risk to confidentiality and of accusation). The interpreter's own reactions to spirit topics. It is working when the client's terms are recorded consistently and the client corrects mistranslations.

4.8 Coordinating herbal and medicine safety with the prescriber

Purpose: to make sure that TTM and folk products are known to the prescriber. The therapist does not advise. Use whenever products are reported. [synthesis]
Steps: (1) Pass the list from 4.5 to the prescriber or pharmacist with consent. (2) Tell the client that this is routine. A Thai Department of Medical Sciences study of herbal formulations on the National List of Essential Medicines found heavy metals above limits in about 3.8% of 156 samples, and microbial contamination failures in about 25.9% of 116 samples. [source: Chaiwat et al. 2014] Reviews also note possible reactions when herbs are combined with conventional medicines, and limited clinical safety evidence for many formulas. [source: Tangnitipong et al. 2021] (3) Never suggest starting, stopping, combining or changing any medicine or herb. (4) If the client reports new physical symptoms after a product, advise prompt medical contact. [synthesis]
Example language (illustrative): "I'm not the right person to say whether this is safe with your medicine, but your doctor or pharmacist is. Shall I let them know you're using it?"
Watch for: the client stopping prescribed psychiatric medication in favour of herbs without telling the prescriber. Products marketed as a "cure" for serious disease. It is working when the prescriber confirms they have the list.

4.9 Collaboration and referral with licensed TTM practitioners and community healers

Purpose: to support the client's wish to use TTM or community healing alongside psychotherapy, through legitimate pathways. Use only when the client wants it. [synthesis]
Steps: (1) For TTM, the legitimate pathway is a TTMC-licensed TTM or applied TTM practitioner, or a licensed TTM facility. [source: DTAM BIMSTEC 2023 p. 111] (2) For a folk healer, ask whether they hold certification under the 2019 Ministry of Public Health regulation. [source: Kotsook 2020] (3) For a mor tham or other spirit healer, the pathway is the client's own community and temple. The therapist does not refer to, recruit or evaluate such healers. Do not encourage clients to seek ceremonies outside their community's own pathways. [synthesis] (4) Obtain specific written consent before any contact, stating what may be shared. (5) Agree roles: the healer or practitioner works within their system, and you continue psychotherapy and risk monitoring. (6) Agree safety triggers that bring in medical or crisis care. (7) Outside Thailand, check local law on traditional practitioners before referring. [synthesis]
Example language (illustrative): "If seeing the mor tham helps you feel protected, that can sit alongside our work. Is there anything you'd like me and them to know about each other, or would you rather keep them separate?"
Watch for: pressure from family to choose one system. A practitioner advising the client to stop psychiatric treatment (route this to the prescriber and discuss it with the client). Fees or commercial pressure from someone presented as a certified folk healer, since certification has been tied to non-commercial practice. [source: The Nation 2018] It is working when the client experiences the two kinds of care as complementary and the safety plan holds.

4.10 Safeguarding where phi pob accusations arise

Purpose: to protect a client, or a client's relative, who is accused of being phi pob or of harbouring one, or who is at risk of harm during treatment for supposed possession. [source: Bangkok Post; synthesis]
Steps: (1) Ask directly whether anyone has been accused, shunned, asked to leave, or harmed. Reported consequences include families being pushed out and selling land cheaply, children being teased, and an accused man being whipped. Police in one reported case declined a complaint, calling it a cultural belief. [source: Bangkok Post] Thai community mental health teams have published case reports of crisis intervention where phi pop belief was at the centre of a community crisis, which suggests local mental health services can be a partner [source: Huttapanom et al. 2006, record only] [uncertain: methods and results not seen]. (2) Assess physical safety, housing and income. (3) If the client is the accuser, explore their fear without colluding with the accusation. (4) Follow your jurisdiction's adult and child safeguarding procedures for violence, restraint or threats. Do not name minors in records shared outside the service. (5) Document facts, not the spirit attribution, as the basis for safeguarding. (6) Link the client to legal, housing or community advocacy where available. [synthesis]
Example language (illustrative): "Sometimes when people are said to have a phi pob, others treat them badly. Has anything like that happened to you or your family?"
Watch for: shame, isolation, sudden moves, and children withdrawing from school. The anthropologist Boonyong Ketthet's view that "anyone can be a phi pob if the majority of the community says so" points to how social the risk is. [source: Bangkok Post] It is working when the client is safe and has at least one non-accusing support.

4.11 Integrating healing experiences into therapy

Purpose: to help the client make meaning of a TTM treatment, a temple visit or a mor tham consultation within their own framework, and to connect it with therapy goals. [synthesis]
Steps: (1) Ask what happened, in the client's words, without asking for ritual details. (2) Ask what changed: feelings, relationships, sleep, sense of protection. (3) Link the changes to therapy goals. (4) Respect anything the client says should not be shared. (5) If the experience was distressing, process it as you would any distressing event. [synthesis]
Example language (illustrative): "You don't need to tell me what was done. What's different for you since then?"
Watch for: relief followed by relapse (review the formulation). Experiences of coercion or physical harm during treatment (go to 4.10). It is working when the client can name what helped and how to draw on it again.

4.12 Nuad Thai and other touch-based TTM: what the therapist checks

Purpose: nuad Thai is a manual therapy that combines hand, elbow, knee and foot manipulation, and herbal hot compresses. It is held to rebalance energy along "sen" lines and the four elements. [source: UNESCO] The therapist does not perform it. The therapist's role is to support informed and safe use. [synthesis]
Steps: (1) If a client uses or plans nuad Thai, ask about consent, comfort and any past experience of unwanted touch. (2) Remind the client that they may stop treatment at any time. Licensed massage-for-health providers are regulated under the 2016 Act. [source: DTAM BIMSTEC 2023 p. 111] (3) Clients with trauma histories may wish to plan how they will communicate limits. (4) Any sexual or genital touch is never part of legitimate therapy. Support reporting if it occurs. (5) Direct medical questions, such as fractures, clotting problems or pregnancy, to the client's doctor. For technique, see Domain X. [synthesis]
Example language (illustrative): "It's always your choice to say 'stop' or 'not there'. Would it help to practise how you'd say that?"
Watch for: dissociation or flashbacks after sessions. Reports of boundary violations. It is working when the client describes body treatment as within their control.

4.13 Working with family, temple and community

Purpose: in Isan and many Thai families, illness decisions are collective, and monks and healers may be consulted first for unexplained problems. [source: Phraaphichat Buddhayano et al. 2018] Family work can improve engagement and safety. [synthesis]
Steps: (1) With consent, invite key family members. Use the CFI Informant Version or the Caregivers module. (2) Map who the family consults and in what order. (3) Agree a shared plan that respects religious practice and includes medical and safety elements. (4) Address conflicting attributions, for example a family that blames a neighbour's spirit, with care, and steer away from accusation. [synthesis]
Example language (illustrative): "Everyone here wants her to get better. Let's put together a plan that includes the temple, the doctor and our sessions, and agree what we'll do if things get worse."
Watch for: family members speaking for the client. Plans that leave out the client's own preferences. It is working when the client and the family follow the same plan.

4.14 Risk assessment in spirit-attributed presentations

Purpose: to make sure that spirit framing does not delay assessment of suicide, self-harm, psychosis or medical emergency. [synthesis]
Steps: (1) Carry out your standard suicide and self-harm risk assessment, phrased in the client's terms where helpful. (2) Ask whether the client hears or feels a spirit telling them to harm themselves or others. (3) Build a safety plan that names the community helpers the client trusts and the emergency services. (4) Where risk is high, follow crisis pathways; parallel community care can continue alongside. (5) Do lethal-means counselling as standard: safe storage and removal. [synthesis]
Example language (illustrative): "Sometimes when people feel affected by a spirit, they have thoughts of dying or hurting themselves. Has that happened to you?"
Watch for: the belief that hospital care is useless for spirit illness, leading to refusal. Respond by negotiating parallel care, not by arguing. It is working when the client agrees to the safety plan and the contacts in it.

4.15 Diaspora, migration and structural context

Purpose: Thai and Lao clients abroad may have limited access to licensed TTM, healers or temples, may face racism or language barriers in services, and may feel stigma around "Thai massage" stereotypes. [synthesis]
Steps: (1) Use the Immigrants and Refugees and Cultural Identity modules. (2) Ask about remote contact with family healers or temples. (3) Explore experiences of racism or exploitation, including in massage-sector employment, and safeguard where labour exploitation is suspected. (4) Ask about products sent from home (see 4.8). [source: CFI Supplementary Modules; synthesis]
Example language (illustrative): "Being far from home can make it harder to get the kind of help your family would usually turn to. What do you miss most, and what's still possible from here?"
Watch for: isolation, debt bondage, and visa-related fear of services. It is working when the client has a support network across both settings.

5. Handling problems

The sources do not address psychotherapy problems directly. Everything in this section is the guide's own [synthesis] unless a source is given.

The client sees no point in therapy because "it's a spirit problem". Do not argue the cause. Offer therapy for the distress, sleep, relationships or fear that the problem brings. Ask whether the mor tham or temple would object to the client also seeing you. Ethnographers note that mor tham care is often combined with other treatments, so parallel care is familiar. [source: Phraaphichat Buddhayano et al. 2018; synthesis]
The client is stuck: community healing has not helped and they are losing hope. Revisit the explanatory model (4.4) and ask what the client and the healer think should happen next. Arrange or repeat a medical review. Consider whether a depressive, psychotic or trauma-related disorder is now present (4.6). Offer evidence-based treatment framed as working alongside the healer's care. [synthesis]
Reluctance or resistance to disclosing TTM or healer use. This is often fear of ridicule. Repeat the normalising statement (4.5). Explain why the prescriber needs the list. Accept partial disclosure, and return to it later. [synthesis]
Overwhelm during cultural assessment (for example, fear rising while discussing phi pob). Slow down and ask permission before continuing. Move to grounding or present-focused work. Remember that the CFI modules can be spread across sessions. [source: CFI Supplementary Modules; synthesis]
Non-adherence to psychiatric medication in favour of herbal or TTM treatment. Do not advise on the medicine. Explore the client's reasons with the explanatory model. Inform the prescriber, with consent. Support a joint conversation between the client and the prescriber. [synthesis]
Rupture after an implied dismissal (for example, the therapist's tone at the mention of phi). Name it and apologise. Restate that you are interested in the client's understanding. Use CFI Q16 on the clinician–patient relationship, and invite the client to say whether they feel judged. [source: APA CFI for the domain; synthesis]
Family pressure for an accusation, or the client being accused. Move to the safeguarding steps (4.10). Do not mediate the spirit question itself. Work on safety, housing, social support and stigma. Escalate under local procedures where violence, threats or expulsion occur. [source: Bangkok Post; synthesis]
Harm during spirit-related treatment (restraint, beating, deprivation, sexual abuse, delay of urgent care). Treat it as a safeguarding matter whatever the cultural framing. Report as your jurisdiction requires. Police inaction in one reported case shows that clients may expect no help. Tell them clearly what protection is available. [source: Bangkok Post; synthesis]
A client relying on a folk remedy for cancer or another serious disease. Do not debate the remedy. Encourage medical oncology or other specialist care alongside it. Ask the client's permission to contact their doctor. Note that publicity around a 2018 folk-healer "cure" did not come with confirmed clinical evidence. [source: The Nation 2018; synthesis]
Unclear practitioner credentials. Ask the client to check TTMC registration for TTM practitioners, or DTAM folk-healer certification for folk healers. Outside Thailand, check local regulation. Do not endorse any individual healer. [source: DTAM BIMSTEC 2023 p. 111; Kotsook 2020; synthesis]
Therapist's own discomfort or over-identification (for example, a wish to "try" spirit healing or massage on behalf of the client). Bring it to supervision. Keep roles clear. [synthesis]
Evidence on collaboration. Trials of collaboration between traditional or faith healers and health services exist in West Africa; neither involves Thai healers. The COSIMPO cluster randomised trial in Nigeria and Ghana (Gureje et al., The Lancet 2020) found that collaborative care between traditional or faith healers and primary health care workers reduced psychotic symptoms (PANSS) and harmful practices more than usual care [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]. A Ghana prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)) found that adding psychiatric medication to prayer-camp care reduced symptoms but did not significantly reduce days in chains [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. The WHO Traditional Medicine Strategy 2014–2023 supports safe integration of traditional medicine, including practitioners, into health systems. [source: WHO strategy page]

Sources

Online sources:

Works cited:

Kleinman A., Eisenberg L., Good B. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258 (page range as given by Dinos et al. 2017).
Suwanlert S. Neurotic and psychotic states attributed to Thai "Phii Pob" spirit possession (PubMed record 7225; probably the same work as the 1976 Lebra chapter [uncertain: journal or chapter pages not confirmed])
Lebra W.P. (ed.) (1976). Culture-bound syndromes, ethnopsychiatry and alternative therapies. Mental Health Research in Asia and the Pacific, vol. 4. Honolulu: University Press of Hawaii (University of Groningen record; also Texas A&M library catalogue)
Huttapanom W., Kittiwattanacul K., Punyoyai T., Surinchompu K., Prabchayacrob P. (2006). Effectiveness of community mental health crisis intervention with belief of devil (Phi-pop): 2 reports. Journal of Mental Health of Thailand 14(2):142–149 (NRCT DOI record)
Ministry of Public Health (2019). Regulation on Certification of Folk Healers, B.E. 2562, as cited by Kotsook 2020. [uncertain: text not verified]
Thai Traditional Medical Professions Act B.E. 2556 (2013); Protection and Promotion of Traditional Thai Medicine Wisdom Act B.E. 2542 (1999); Health Facilities Act B.E. 2541 (1998); Health Service Establishment Act B.E. 2559 (2016), as summarised by DTAM 2023 and Kotsook 2020.

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