Filipino folk healers (mananambal, albularyo, hilot, babaylan)

1. Introduction

Version followed: Filipino folk healing as described by Gaabucayan's ethnography of healers in Agusan, Mindanao, by Philippine law (Republic Act 8423, the Traditional and Alternative Medicine Act, TAMA, 1997), by the Philippine Institute of Traditional and Alternative Health Care (PITAHC, FY2024 Annual Report) and by TESDA's Hilot (Wellness Massage) NC II training regulation, with Philippine and diaspora help-seeking research as context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and Kleinman's explanatory-model questions.

What it is. This is not a single therapy but a family of living folk-healing roles found across the Philippines and in Filipino communities abroad. Gaabucayan describes a general practitioner, the mananambal, who may combine several roles: the herbolario (herbalist), the manghihilot (masseur and bonesetter), the mananabang (unlicensed midwife, sometimes male in the area studied), and the mananawal or orasyonan, whom he describes as a specialist in venomous bites who works with prayer, saliva and oil. He also describes the mambabarang, a person said to cause illness through sorcery (barang) who may also heal. [source: Gaabucayan, Asian Ethnology] The term albularyo is used for folk healers in Luzon studies; Cerio interviewed 100 albularyo in Partido District, Camarines Sur. [source: Cerio 2020] The babaylan was a pre-colonial specialist, mostly women, whom Salazar described as "a specialist in the fields of culture, religion, medicine"; babaylan identity is today reclaimed in feminist, decolonial and queer Filipino work. [source: Villariba 2006; Smithsonian APAC, Conaco] In the sources cited here, the terms tawalan, banos (ritual washing) and panagang (protective amulets) were not described, and the healer who treats venomous bites was named mananawal/orasyonan rather than tawalan. [uncertain: not verified]

How change happens, as the tradition holds it. In the Agusan account, illness is divided into natural ailments, treated with herbs, and supernatural ones, attributed for example to offended beings or to sorcery, which call for a healer's ceremonies; Catholic saints and Marian devotion are closely woven into healers' work, and many healers attribute their power to God's grace. [source: Gaabucayan] On Siquijor, people who see an illness as supernatural tend to go to a mananambal, and those who see it as natural tend to go to a medical doctor. [source: Ponteñila and Reynolds, Silliman Journal] These are the tradition's own explanations, reported here without endorsement or dismissal.

The psychotherapist's role. You do not practise any of these roles. Your work is culturally responsive psychotherapy alongside them: understanding the client's explanatory model and help-seeking, telling culturally normative experience apart from disorder, coordinating with the client's healers when the client wishes, keeping the client physically safe (for example after bone-setting or when urgent medical care may be delayed), and safeguarding. [synthesis]

2. Framework

2a. The tradition's own structure (context for the therapist)

Roles. These are mananambal (general), herbolario or albularyo (herbal), manghihilot (massage and bone-setting), mananabang (birth attendant) and mananawal/orasyonan (venomous bites; prayer, saliva and oil). One person may hold several roles. [source: Gaabucayan]
How healers gain authority (community account). Authority comes through dreams in which saints or ancestors call the person, inheritance of prayers, objects or powers from parents or great-grandparents, an innate gift (for the manghihilot, often linked to an unusual birth), and training by a family member. [source: Gaabucayan] For the babaylan, authority came through a sacred call, a dream, a healing experience or inheritance from an elder babaylan, and it rested on community trust and the ability to solve community problems; in some Lumad communities a person must first prove themselves as a warrior. [source: Villariba 2006] Authority therefore sits with families, lineages and the local community, not with any outside credential. [synthesis]
State authority. TAMA (RA 8423) declares a policy of integrating traditional and alternative health care into the national health system. It defines traditional healers as older, respected people with deep knowledge of traditional remedies, and it recognises indigenous communities' ownership of their traditional medicine knowledge, with acknowledgment and benefit-sharing. The Act creates PITAHC under the Department of Health, with duties covering research, training, codes of ethics and standards. The Act itself sets up no licensing or registration scheme for traditional healers. [source: RA 8423 text, StuartXchange]
Hilot certification. PITAHC promotes hilot as "the only traditional medicine in the Philippines" and runs certification or recognition of hilot practitioners and accreditation of hilot facilities. Its National Certification Committee met for hilot twice in 2024, and it holds regional Hilot Congresses. [source: PITAHC FY2024 Annual Report] Separately, TESDA's Hilot (Wellness Massage) NC II is a 120-hour qualification (18 basic, 22 common and 80 core hours). It requires written client consent, identification of contraindications with referral to an appropriate professional, and client screening. It names medical practitioners and albularyo among referral contacts and does not cover bone-setting. [source: TESDA TR Hilot (Wellness) NC II] The two credentials are separate, and a TESDA wellness-massage certificate does not cover bone-setting. [synthesis from these two sources]

2b. The therapist's own process

The stages below are [synthesis] built on the CFI's intended use: it supports understanding and decision-making, is not the only basis for diagnosis, and its supplementary modules can be used at first evaluation, later in care, or repeatedly. [source: APA CFI; APA Supplementary Modules]

Phase	Goal	Typical length and format	Move on when
1. Engagement	Lower shame and stigma barriers and set the frame that traditional help is welcome to discuss	Session 1, individual, with family if the client wants	The client names the problem in their own words
2. Cultural assessment	Core CFI, with Explanatory Model, Spirituality, Coping and Help-Seeking and Cultural Identity modules as needed; map the healers involved	Sessions 1-3; the informant version with family	You can state the client's explanatory model and help-seeking pathway back to them and they agree
3. Formulation and differential	Separate normative experience from disorder; screen physical safety (bone-setting, venomous bites, birth, herbal remedies)	Sessions 2-4; consult a cultural broker or prescriber where needed	Risk is assessed and a working cultural formulation is written
4. Parallel-care plan	Agree how therapy sits alongside the healer, the doctor and church or family supports, with consent	One planning session, then review	The client approves the plan, including any contact with a healer
5. Ongoing work and integration	Treat the agreed problems; make sense of healing experiences; review the explanatory model	Usual course for the presenting problem	Goals are met or the client's preferred mix of care is settled
6. Review and ending	Consolidate, and plan relapse prevention, including when to seek which help	1-2 sessions	The client can say who they would go to, and for what

Session counts are [synthesis]; no source sets them. A first-session time for the core CFI is not given in the APA forms. [uncertain]

3. Guiding principles

Work alongside the tradition. You assess, formulate, treat and coordinate. You never diagnose spiritual causes, perform ceremonies, or recommend prayers, amulets or remedies. [synthesis]
Attribute, do not adjudicate. Write "the client and family understand the illness as caused by sorcery", not "sorcery caused" and not "false belief". [synthesis]
Folk care is usually additive. Quiapo folk-medicine users described folk medicine as a supplement to existing medical treatment, chosen out of satisfaction from past use, family tradition and distrust of the health system. In practice, assume parallel use and ask about it. [source: Rondilla et al. 2021]
Expect late, reluctant arrival. Filipinos in seven countries showed reluctance toward formal help-seeking and used specialist care mainly as a last resort, preferring family and friends. Barriers were stigma, loss of face, shame and conformity, plus cost and access in the Philippines and immigration status, insurance, language and discrimination abroad. In practice, treat the first contact as fragile. [source: Martinez et al. 2020] Folk healers and lay networks may be preferred because of shame, stigma, collectivist values and illness beliefs that differ from the medical model. [source: Tuliao 2014]
Natural and supernatural are both live categories. The client may hold both models at once and choose help accordingly. In practice, ask which kind of problem this is "for them", and whether that has changed. [source: Gaabucayan; Ponteñila and Reynolds]
Name who holds authority. That may be a family lineage, a local healer, the parish, an Indigenous community, or PITAHC for certified hilot. In practice, ask who the client and family trust to decide matters of spiritual cause. [source: Gaabucayan; Villariba; PITAHC]
Indigenous knowledge belongs to its communities. TAMA recognises indigenous ownership of traditional medicine knowledge. In practice, do not document or share a healer's methods beyond what care requires. [source: RA 8423]
Physical safety first. The Agusan author himself argues that fractures need X-ray and surgical care and that snakebite needs antivenom. In practice, screen for these before any psychological framing. [source: Gaabucayan]
Touch. You do not touch clients as part of this work. When clients describe hilot, explore whether consent was asked before and during treatment and whether they could stop it. Any sexual or genital touch is a safeguarding matter, not tradition. [synthesis; TESDA requires written consent]
Medicines and remedies are the prescriber's domain. Never advise starting, stopping or changing any medicine or herbal remedy; route these questions to the prescriber. [synthesis]
Cultural humility includes colonial history. Babaylan were suppressed and recast by Spanish missionaries as devil worshippers, and the word came to be used as the slur "bayot". Some clients carry this history as identity wounding. In practice, do not treat Catholic and pre-colonial frames as opposites you must sort out. [source: Smithsonian APAC, Conaco; Villariba 2006]
Normative is not the same as harmless, and unusual is not the same as ill. Use the DSM-5-TR and ICD-11 cultural exclusions as written (see 4.8). [source: notes on DSM/ICD below]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it reproduces or performs a healer's ceremony, prayer, remedy or technique. All example language is (illustrative).

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout work with Filipino clients and families; especially when you notice reflexive scepticism or fascination about sorcery, spirits or healers.
Steps: (1) Note your own frames: biomedical, Catholic, secular, or diaspora-Filipino. (2) Read the colonial history the client may carry: babaylan were suppressed, recast as devil worshippers, and the word was turned into a slur. [source: Smithsonian APAC, Conaco] (3) Remember that clients may combine Catholic devotion and folk healing without contradiction, as healers themselves do. [source: Gaabucayan] (4) Track whether you are minimising the illness or making it exotic, and take this to supervision.
Example language: "I don't want to assume what this means to you or your family. Can you teach me how you and your family see it?" (illustrative)
Watch for: Clients test you with a small disclosure ("my lola took me to an albularyo") before a larger one; if you show curiosity without judgement, more will follow. A sign it is working is that the client volunteers healer contacts unprompted. [synthesis]

4.2 Opening the door to traditional help-seeking

Purpose / when: In the first session, because parallel use is common, the clinic is often a last resort, and shame and loss of face inhibit disclosure. [source: Martinez et al. 2020; Rondilla et al. 2021]
Steps: (1) Normalise the question by asking it of every client. (2) Ask in sequence about family and friends, the parish or church, folk healers (by the client's own word: albularyo, mananambal, hilot, manghihilot, faith healer), doctors, and remedies bought (for example at Quiapo). (3) Ask what helped and what did not. (4) Ask whether the healer or family has a view on therapy. (5) Record this neutrally.
Example language: "Many families I see try several kinds of help: family, church, a hilot or albularyo, a doctor. Who else has helped with this so far?" (illustrative)
Watch for: Minimising ("just massage"), checking your face, or laughing it off can signal hiya (shame) about disclosing. [synthesis] It is working when the client describes healer visits factually and links them to the problem.

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

Purpose / when: At initial assessment for any client, especially where the client or family hold a supernatural explanation, help-seeking is mixed, or there is a cultural or language gap. The CFI clarifies the problem from the point of view of the person and their social network: its meaning, sources of help, and what they expect from services. APA describes it as for use by any clinician in any setting. [source: APA CFI; APA DSM-5-TR Section III]
Steps: Follow the 16 questions across four domains, in your own words where needed: (1) cultural definition of the problem (Q1-3); (2) cultural perceptions of cause, context and support (Q4-10, including cultural identity); (3) self-coping and past help-seeking, including barriers (Q11-13); (4) current help-seeking preferences and the clinician-patient relationship, for example perceived racism and language (Q14-16). Clinicians may reproduce it for use with their own patients, but translation or modification needs APA permission. Use it alongside, not in place of, diagnostic assessment. [source: APA CFI]
Example language: For domain 3: "When this started, what did you or your family do first? Did you see anyone, such as a healer, a priest or a doctor?" (illustrative)
Watch for: Answers framed in family terms ("we think") are data, not avoidance. In domain 4, ask directly about past discrimination in services. It is working when you can summarise the client's view and they correct or confirm it. [synthesis]

4.4 CFI supplementary modules and Informant Version

Purpose / when: For in-depth assessment when the core CFI shows a strong spiritual, family or migration dimension. Modules can be used at first evaluation, later in care, or repeatedly. [source: APA Supplementary Modules]
Steps: Choose the modules that fit: (a) Explanatory Model, when sorcery, offended beings or a natural/supernatural split is named; (b) Spirituality, Religion, and Moral Traditions, for Catholic, charismatic, Indigenous or babaylan-identified clients; (c) Coping and Help-Seeking, to map healers and remedies; (d) Cultural Identity, for diaspora, Indigenous (Lumad, Igorot and others) and queer Filipino clients; (e) Immigrants and Refugees, for overseas Filipino workers and migrants, given barriers of immigration status, insurance and language [source: Martinez et al. 2020]; (f) Social Network and Caregivers, for family-centred care; (g) the Informant Version (17 questions) with a parent, spouse or elder who holds the family's explanation. [source: APA Supplementary Modules; APA CFI Informant]
Example language: To an elder relative: "You know this family's history. What do you think is happening to her, and what do you think should be done?" (illustrative)
Watch for: The informant's model may differ from the client's. Hold both, and do not use the informant against the client. It is working when disagreements about cause become discussable rather than hidden. [synthesis]

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: Whenever cause, meaning or expected treatment is unclear or contested. [source: Kleinman, Eisenberg and Good 1978, via Tanenbaum handout]
Steps: Ask, in your own words, the eight areas: what the client calls the problem; its cause; why it began when it did; what it does and how it works; how severe it is and how long it will last; what treatment they think they should receive; the main problems it has caused; what they fear most. Then add two Filipino-specific probes [synthesis from Gaabucayan; Ponteñila and Reynolds; Cerio]: (a) is it a natural illness, a supernatural one, or both; (b) who would know, whether a healer, an elder, a priest or a doctor.
Example language: "Some families see an illness like this as natural, something a doctor treats, and some see another cause that a mananambal would deal with. How does your family see it?" (illustrative)
Watch for: Fear of a named person, for example a suspected sorcerer, can drive anxiety, avoidance and family conflict. The Agusan account presents sorcery accusations as one way social conflict is handled where formal sanctions are weak, and it describes a client who became restless after a sorcery warning. [source: Gaabucayan] It is working when the client can say how their model shapes what they want from you.

4.6 Mapping the healer landscape and authority

Purpose / when: After 4.2-4.5, to understand who is treating what and who holds authority.
Steps: (1) For each helper, record the role in the client's words (for example mananambal, herbolario or albularyo, manghihilot, mananabang, mananawal/orasyonan, faith healer, priest) and what it addresses. [source: Gaabucayan] (2) Ask how that person came to the role (family line, calling, training) only if the client offers it, to understand the healer's standing, not to verify it. (3) For hilot, ask whether the practitioner holds PITAHC certification or recognition, or TESDA Hilot (Wellness Massage) NC II, noting that the TESDA qualification covers wellness massage, not bone-setting. [source: PITAHC FY2024; TESDA TR] (4) Note costs and any fear of consequences for non-payment, which the Agusan account reports. [source: Gaabucayan]
Example language: "Who in all this does your family trust most to say what is causing it? And what do they think about you seeing me?" (illustrative)
Watch for: Asking about credentials can sound like a challenge, so frame it around safety, not legitimacy. It is working when you have a shared map of who does what. [synthesis]

4.7 Working with sorcery, spirit and offended-being attributions

Purpose / when: When the client attributes symptoms to barang (sorcery), offended beings or other supernatural causes. [source: Gaabucayan; Ponteñila and Reynolds]
Steps: (1) Reflect the belief as the client holds it, without confirming or disputing it. (2) Ask about the social story: who, when, what conflict. (3) Assess fear, sleep, avoidance and safety, including risk to or from the suspected person. (4) Ask what their healer or family says will resolve it, and what they need from you meanwhile, such as sleep, anxiety, grief or conflict. (5) Agree targets that make sense inside their model, for example "being able to sleep and work while this is being dealt with". [synthesis]
Example language: "While your family and the mananambal deal with the cause in their way, could we work on the fear that is keeping you awake?" (illustrative)
Watch for: Accusations against a neighbour or relative, especially a child or older person, can escalate to harm; see 4.15. It is working when distress falls and the client stays engaged with both kinds of help. [synthesis]

4.8 Distinguishing normative experience from disorder

Purpose / when: When the presentation includes trance, possession-like states, hearing or seeing spirits, a sense of being called to heal, or behaviour the family attributes to supernatural causes.
Steps: (1) Ask whether the experience is part of a broadly accepted collective cultural or religious practice for this client's community, and whether it is wanted or unwanted. (2) Apply the DSM-5 wording: in dissociative identity disorder, identity disruption "may be described in some cultures as an experience of possession", and the disturbance must not be "a normal part of a broadly accepted cultural or religious practice"; dissociative trance is excluded when it is part of such practice. [source: PMC9199574, quoting DSM-5] DSM-5-TR keeps these points in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; its exact wording is [uncertain]. (3) Apply ICD-11: 6B62 Trance disorder and 6B63 Possession trance disorder both require the state to be involuntary and unwanted and outside accepted cultural or religious practice, with significant distress or impairment. [source: findacode mirror of ICD-11; PMC9199574] (4) The DSM-5-TR glossary of cultural concepts of distress, as listed in a secondary source, contains no Filipino-specific concept, so do not force a Filipino idiom into one of those categories. [source: UNMC DSM-5-TR slides] (5) Screen for psychosis, mood disorder, substance use and medical causes in the usual way. (6) Consult a cultural broker, such as a community member, Filipino clinician or the family's trusted elder, with consent, about whether this is ordinary in their community. [synthesis]
Example language: "In your community, would people see what happened to you as something that sometimes happens and is understood, or as something unusual and worrying?" (illustrative)
Watch for: Two errors: pathologising a sanctioned experience, and missing psychosis or medical illness because it was framed spiritually. If the family themselves say "this is not the usual thing", give that weight. It is working when your formulation is acceptable to the client and still clinically safe. [synthesis]

4.9 Collaboration and referral with the client's healers

Purpose / when: Only when the client wishes, for example to coordinate care or to avoid conflicting advice.
Steps: (1) Ask whether the client wants any contact, and with whom. (2) Obtain written, specific consent stating what may be shared, for what purpose and for how long; the default is minimal sharing. (3) Clarify roles: the healer addresses what the tradition addresses, and you address the agreed psychological goals; the client decides. (4) Where the client asks you to find a healer, do not recommend one. Point to the client's own family and community pathways; for hilot, the client can check PITAHC certification or recognition. [source: PITAHC FY2024; synthesis] (5) Respect that traditional medicine knowledge is the community's own. Record only what care needs. [source: RA 8423 s.2, s.4(i)] (6) Collaboration between traditional or faith healers and health workers has been trialled elsewhere. 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]. It has not been tested with Filipino healers [uncertain: not verified].
Example language: "If it would help, I'm willing to speak with the albularyo or your parish priest about how we can avoid giving you mixed messages. Only what you agree to, though." (illustrative)
Watch for: The client may feel caught between authorities. Watch whether contact increases the client's sense of control, and stop if it does not. [synthesis]

4.10 Physical-safety screening: bone-setting, hilot, birth and bites

Purpose / when: Whenever a client has used, or plans to use, a manghihilot for injury, a mananabang for birth, or a healer for a venomous bite or fracture.
Steps: (1) Ask what was treated and when. (2) Screen for persisting pain, deformity, reduced function, wound problems and delay in seeing a doctor. In a West Java hospital series of 86 fracture patients previously treated by traditional bonesetters, about half had malunion and 29% arrived 1-3 months after injury. This is Indonesian data, given here as regional context. [source: Warman et al., Althea Medical Journal] (3) The Agusan author holds that fractures need X-ray and surgical care, snakebite needs antivenom and midwives need better training. Snakebite and complicated birth are emergencies for medical services. [source: Gaabucayan] (4) Refer for medical review and do not evaluate the healer's technique. (5) For hilot massage, TESDA's standard lists contraindications such as infection, skin lesions and trauma, burns, allergies, hypertension, implants or pacemakers and intoxication, to be identified and referred. Ask whether the client was screened and asked for consent. [source: TESDA TR]
Example language: "I'm glad the hilot helped with the pain. Has a doctor also checked the arm since then, maybe with an X-ray? Sometimes that's worth doing alongside." (illustrative)
Watch for: Shame about having "gone to a bonesetter first". Frame the medical review as an addition, not a correction. It is working when the client attends the medical review without dropping the healer relationship. [synthesis]

4.11 Touch and consent in hilot: what to explore

Purpose / when: When a client describes massage, bone-setting or birth-related touch that felt intrusive, painful, coerced or sexual, or when you are asked whether hilot is "safe".
Steps: (1) You do not touch clients and do not demonstrate techniques. (2) Explore whether consent was asked before and during treatment, whether the client could stop it, and whether privacy was respected. TESDA's standard requires written consent and attention to privacy and appropriate wardrobe. [source: TESDA TR] (3) Any sexual or genital touch is not part of legitimate practice; treat it as possible abuse and follow 4.15. Use clinical, non-explicit terms in notes. [synthesis] (4) Process body memories or trauma responses triggered by touch with standard trauma-informed methods. [synthesis]
Example language: "Did you feel you could say stop at any point? What happened when you wanted to?" (illustrative)
Watch for: Deference to elders and healers may have made refusal feel impossible. Distinguish the client's own boundary from cultural norms, without blaming the tradition as a whole. [synthesis]

4.12 Herbal remedies and medicines

Purpose / when: When the client takes herbal tonics, baths or applications from a herbolario or albularyo, or products such as those sold at Quiapo, alongside prescribed medicine. [source: Gaabucayan; Rondilla et al. 2021]
Steps: (1) Ask what is taken and record it; ask the client to bring the names, or the products themselves, to the prescriber or pharmacist. (2) Never advise starting, stopping or changing any medicine or remedy. Route every question to the prescriber. (3) The Agusan author criticised unsanitary preparation of some remedies, so note any related symptoms for medical review. [source: Gaabucayan] (4) Do not record or discuss preparations or amounts. [synthesis]
Example language: "I can't advise on herbs or medicines, but your doctor or pharmacist should know about everything you're taking. Could we write the list together for your next appointment?" (illustrative)
Watch for: Stopping prescribed psychiatric medicine in favour of folk treatment. Explore this without judgement and liaise with the prescriber, with consent. [synthesis]

4.13 Family and collectivist work

Purpose / when: When family and friends are the main source of help, decisions are made collectively, or shame about "the family's name" limits help-seeking. [source: Martinez et al. 2020; Tuliao 2014]
Steps: (1) Ask whom the client wants involved. (2) Use the Informant Version or Social Network module with family (4.4). (3) Build on the facilitators identified by Martinez et al.: the client's perception of distress, social support, financial capacity, and any past positive experience with formal help. [source: Martinez et al. 2020] (4) Address confidentiality with family explicitly, especially for young adults and overseas workers who send money home. [synthesis]
Example language: "Your family clearly cares about you. How would you like them to be involved here, and what would you prefer to keep between us?" (illustrative)
Watch for: Hidden coercion, for example a family insisting on a healer, or on stopping one. It is working when the client's own preference is visible in the plan. [synthesis]

4.14 Babaylan identity, decolonial and queer Filipino work

Purpose / when: When the client draws on babaylan as identity, healing ancestry or activism, including feminist and queer Filipino reclaiming. Sources describe babaylan values used in gender, justice and peace work, and a queer Filipino reclaiming in response to intergenerational trauma. [source: Villariba 2006; Smithsonian APAC, Conaco]
Steps: (1) Use the Cultural Identity and Spirituality modules. (2) Explore what babaylan means to this client, such as ancestry, gender identity, vocation, or a calling to heal, and how it relates to their Catholic upbringing and family. (3) Do not confer, confirm or question the title. Who is recognised as babaylan today is decided within communities and lineages; in the account cited, recognition rests on a sacred call, dream, healing experience or inheritance and on community trust. [source: Villariba 2006] (4) Do not take part in or direct the client to babaylan rites outside their own community pathways. [synthesis]
Example language: "When you say you feel connected to the babaylan, what does that give you, and is there anyone in your community you go to about it?" (illustrative)
Watch for: Identity repair and grief about colonial loss are legitimate therapeutic aims. A "calling" accompanied by functional decline, sleeplessness or grandiosity needs the assessment in 4.8. [synthesis]

4.15 Safeguarding

Purpose / when: When a practice or accusation harms someone: restraint, beating, starvation, sexual contact, sorcery accusations against a person (especially a child or older adult), or delay of urgent medical care such as for fractures, venomous bites or complicated birth. [synthesis; medical points from Gaabucayan]
Steps: (1) Assess immediate risk. (2) Follow your jurisdiction's child and adult protection procedures. (3) Separate the tradition from the harm: report the harmful act, not the culture. (4) Document factually and in clinical, non-explicit terms. (5) Keep the client's cultural frame in the safety plan where possible. [synthesis]
Example language: "I respect that your family is seeking help in the way they trust. My job is also to make sure no one gets hurt, so I need to understand what happens during these visits." (illustrative)
Watch for: Fear of a sorcerer's retaliation, or of consequences for not paying a healer, may silence disclosure. [source: Gaabucayan, on fear of retaliation for non-payment]

4.16 Interpreters and cultural brokers

Purpose / when: When the client prefers Tagalog/Filipino, Cebuano/Bisaya, Ilocano or another Philippine language, or when the family's explanation is easier to give in that language. [synthesis]
Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Brief the interpreter on healer terms and on neutrality. (3) Check that healer and illness terms are rendered as the client says them, not translated into psychiatric labels. (4) Check for a shared community, since some communities are small. [synthesis]
Example language: To the interpreter: "Please keep the client's own words for healers and illnesses, and tell me if a word has no simple English match." (illustrative)
Watch for: Interpreter embarrassment or editorialising about folk beliefs. [synthesis]

4.17 Integrating healing experiences and ongoing review

Purpose / when: After a client sees a healer, attends a rite in their own community, or receives hilot, and in later sessions as the explanatory model shifts.
Steps: (1) Ask what happened, as much as the client wishes to share, without asking for ritual detail. (2) Ask what changed, in symptoms, relationships, fear and meaning. (3) Link gains to the therapy goals. (4) Revisit the explanatory model and help-seeking map; the modules can be repeated. [source: APA Supplementary Modules] (5) Update the cultural formulation.
Example language: "You don't need to tell me what was done. I'm interested in how you have been since." (illustrative)
Watch for: Relief followed by renewed fear ("it was not fully removed"), or the healer advising against therapy or medication. Explore this openly. It is working when the client can use both kinds of help without secrecy. [synthesis]

5. Handling problems

The sources cited here do not address therapy process problems directly. Except where cited, everything in this section is [synthesis].

Late arrival, early dropout. The clinic is often a last resort, and stigma and loss of face are the main barriers. [source: Martinez et al. 2020] Response: make the first session useful in itself, with one concrete gain and a clear summary of the client's model. Offer flexible contact, and include family if the client wishes. Name the cost of therapy plainly, since cost is a barrier in the Philippines. [source: Martinez et al. 2020; Tuliao 2014]
"You'll think I'm superstitious." Response: "I'm not here to judge what caused it. I want to understand how you see it so my help fits." Then move to the Explanatory Model module.
Client stuck between two models. For example, the family says sorcery and the doctor says depression. Response: map both models side by side, ask which parts of each the client accepts, and agree goals that both can accommodate, such as sleep, safety and functioning.
Healer or family advises stopping therapy or medication. Response: do not compete. Ask what worries them about therapy, offer contact with consent (4.9), and route medication questions to the prescriber. If risk is high, for example psychosis or suicidality, say clearly that you are concerned, and follow standard risk procedures.
Persistent fear of sorcery or retaliation. Response: treat the fear and its effects (sleep, avoidance, hypervigilance) within the client's model. Assess risk to and from the person believed responsible, and keep conflict-resolution aims modest. [synthesis; context from Gaabucayan]
Overwhelm or dissociation in session when discussing spirits or sorcery. Response: slow down, ground the client with ordinary present-moment orientation, ask permission before returning to the topic, and reassess per 4.8.
Possible psychosis framed as possession or a calling. Response: complete a standard psychiatric assessment, apply the cultural exclusions in 4.8, consult a cultural broker and a psychiatrist, and tell the client and family your reasoning in terms that respect their model.
Physical complications after bone-setting, or a delayed bite or birth emergency. Response: arrange urgent medical referral (4.10). Do not argue about the healer's competence, and address any shame about having gone first to a healer.
Disclosure of sexual touch or coercion by a healer. Response: believe, assess safety, follow safeguarding procedures (4.15), and avoid framing the whole tradition as abusive. [synthesis]
Ruptures about colonial or religious history. For example, the client hears the clinician's questions as missionary or colonial judgement. Response: name the history, acknowledge the possibility of a repeat, and invite correction. Repair is the intervention.
Request that you act as a healer ("can you remove it?", "can you pray over me?"). Response: say clearly what you do and do not do, and support the client in finding help through their own family, parish or community. Never improvise a ritual.
Requests for a referral to a babaylan or ceremony. Response: do not refer to individuals or events outside the client's own community pathways. Explore the client's own connections, and remember that recognition is a community matter. [source: Villariba 2006 on authority; synthesis]
Non-adherence to between-session tasks. Response: check whether a task conflicts with the client's model or the family's wishes, adapt it (for example, a family-based task instead of a solitary one), and ask what the healer has advised.
Diaspora-specific strain. Immigration status, insurance, language and discrimination can block care. [source: Martinez et al. 2020] Response: use the Immigrants and Refugees module, work practically on access, and ask about discrimination in past services (CFI Q16).

Sources

Web sources:

Cited by author, year and title:

Kleinman, A., Eisenberg, L. and Good, B. (1978). "Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research". Annals of Internal Medicine 88:251-258.
Gureje, O. et al. (2020). COSIMPO c luster randomised trial of c ollaborative care between traditional and faith healers and primary health care workers for psychosis in Nigeria and Ghana, The Lancet (abstract, PubMed 32861306); journal per Centre for Global Mental Health.

Not verified: the meanings of tawalan, banos and panagang; Filipino folk-illness terms such as usog, pasma and kulam (a book titled "Usug, kulam, pasma: traditional concepts of health and illness in the Philippines" exists in Philippine library catalogues); whether DSM-5-TR keeps the exact DSM-5 possession and trance wording (it keeps the substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]); and any UNESCO listing. All are [uncertain: not verified].

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