Burmese nat kadaw mediums

1. Introduction

Version followed: the worship of the Thirty-Seven Lords (nat) of Central Burma as described in anthropological fieldwork by Bénédicte Brac de la Perrière (CNRS; 2009, 2017) and Lorenzo Chiarofonte (2025), with recent press reports on the Taungbyone festival. These are outsiders' scholarly accounts. No publication by a mediums' own body addressed to clinicians is documented in the sources cited here [uncertain: not verified]. The therapist's own procedures follow the DSM-5-TR Cultural Formulation Interview (CFI) and related APA, WHO and Kleinman material.

What it is. A nat kadaw is a spirit medium of the nat, the guardian spirits of Myanmar. The term has often been translated as "spirit's spouse", and press reports render it as "spirit consorts". Mediums act as the nats' representatives among people. They embody the spirits in sequence at privately sponsored ceremonies (nat kana pwe), dance on behalf of devotees, and intercede with the spirits for them; fortune-telling is also part of the role. The official pantheon of the Thirty-Seven Lords is described as integrated within Burmese Theravada Buddhism. [source: Chiarofonte 2025, pp. 31, 34–35; DVB 2026] Nat belief predates the 11th-century adoption of Theravada as the principal faith under King Anawrahta, and it persists alongside Buddhism, including among strict Buddhists. [source: Burma/Myanmar Studies conference paper, Chiang Mai 2015] Brac de la Perrière and Jackson (2022) argue that spirit possession in mainland Buddhist Southeast Asia is growing rather than declining, across social classes. [source: NUS Press / NIAS Press book page]

Who becomes a medium, and who holds authority. In mediums' own accounts, the spirit starts the relationship: a person cannot simply choose to become a nat kadaw. Mediums first submit to the spirit. After years of apprenticeship they gain authority over the spirits without becoming their masters, and they stay partly aware during possession, which ordinary devotees are less able to do. Mediums whom Chiarofonte met described a family bond with their spirit (sibling or parent) rather than a marriage. [source: Chiarofonte 2025, pp. 33–35] Brac de la Perrière's 2009 article frames the same shift in its title: from "nats' wives" to "children of nats", and from spirit possession to transmission among the ritual specialists of the Thirty-Seven Lords. Only the article's title-level framing is used here; its detailed argument is [uncertain: secondary, unverified]. Her 2017 article compares initiation rituals across three paths of Burmese religion (Buddhist monasticism, Buddhist esotericism and spirit worship) and reads them as differently valued forms of practice within one Buddhist religious field [source: Brac de la Perrière 2017, abstract]. Cultural authority therefore lies with established mediums and the lineages of ritual specialists who train and recognise new ones (at a festival, pupils are expected to dance in the same period as their master [source: Chiarofonte 2021, p. 131]), set within the wider Buddhist religious field. No state licensing or regulatory body is reported. Chiarofonte cites Ho (2009) for the view that a government ban on the supernatural under Ne Win pushed the role underground and towards stigmatised groups. [source: Chiarofonte 2025, p. 34, n. 5]

Gender and sexuality. The role was historically female. In urban centres most mediums today are meinmasha (trans women). They face stigma and the pejorative label achauk, which is often explained as the karmic result of a past-life fault. Mediumship can bring them some respectability. Cross-gender mediums are said to be better suited to embody both male and female spirits. Women and cross-gender people are believed to have "weaker souls", which makes them more open to spirit power. Some musicians "believe in nats, but do not trust the meinmasha nat kadaw", and mediums are often seen as not keeping the Five Precepts. [source: Chiarofonte 2025, pp. 34–35] Press coverage calls Taungbyone an unofficial Pride celebration in a country where homosexuality is criminalised. [source: DVB 2026]

Taungbyone. This is the largest nat festival of the year. It is held in Madaya Township, north of Mandalay, in the monsoon season, and the press dates it to August. It centres on two brother spirits who, in the festival's story, were executed by a king after failing to donate bricks to his pagoda. It was sharply scaled back in 2024 and 2025 because of nearby fighting. The DVB report speaks of 111 nats honoured there, while scholarship uses the official pantheon of 37; the two counts refer to different groupings [uncertain]. [source: DVB 2026; Frontier Myanmar 2016]

How change happens, in the therapist's frame. The psychotherapist does not practise mediumship or any ritual. For a client who is a medium, a devotee, or a family member, change comes through therapy that understands distress within the client's own explanatory model: nats, karma and Buddhist moral thought, gender identity, and the war since the 2021 coup. The therapist separates culturally normative possession from disorder, and supports collaboration with the community's own specialists where the client wants it. [synthesis; source: APA CFI; Kleinman et al. 1978]

2. Framework

The tradition has its own pathway to mediumship: the spirit's choice, submission, apprenticeship and ritual recognition. That pathway belongs to its specialists and is not described here. The framework below is the psychotherapist's own course of work. Phases and session numbers are [synthesis]; no source sets them.

Phase 1: Engagement and safety (sessions 1–2). Goals: build trust, agree on language and on an interpreter if needed, and screen for risk (suicidality, violence, medical urgency, conflict-related trauma, safety for an LGBTQ client). Move on when the client can describe the problem in their own terms and immediate risk is managed.
Phase 2: Cultural assessment (sessions 1–3, often alongside Phase 1). Goals: the core CFI (16 questions across 4 domains), then supplementary modules as needed: Spirituality, Religion, and Moral Traditions; Explanatory Model; Cultural Identity; Coping and Help-Seeking; Immigrants and Refugees; Social Network. An informant version (17 questions) can be used with family. [source: APA CFI; APA Supplementary Modules; APA Informant Version] A typical time of 15–20 minutes for the core CFI is [uncertain]. Move on when you can state the client's explanatory model, who they consult (mediums, monks, traditional medicine, doctors), and what they expect from you.
Phase 3: Formulation and differential (sessions 2–4). Goals: decide whether possession or spirit experiences are normative within nat worship or meet criteria for a disorder, and write a cultural formulation. Move on when the formulation is shared with the client and agreed with them, with input from a cultural broker if the picture is unclear.
Phase 4: Collaborative treatment (variable; often 8–20 sessions). Goals: evidence-based treatment for the identified problems (for example trauma, depression, minority stress or family conflict), adapted to the explanatory model. Where the client wishes, coordinate with the medium, monk or other figure the client chooses. Review progress at regular intervals.
Phase 5: Integration and ending. Goals: help the client make meaning of ceremonial or festival experiences and of their spiritual calling or relationship, relapse planning, and ending. Revisit the CFI modules if the client's life changes (migration, a new spirit relationship, coming out, bereavement). The modules can be repeated during treatment. [source: APA Supplementary Modules]

Format: individual sessions, family sessions with consent, and joint meetings with community figures only at the client's request. Use a trained interpreter with Burmese (or the relevant ethnic language) where needed. [synthesis]

3. Guiding principles

You work alongside the tradition, not inside it. Never perform, imitate, arrange or direct ceremonies, possession, dance or fortune-telling, and do not ask for ritual details. [synthesis]
Authority rests with the tradition's own specialists. Recognition as a medium comes through the spirit's choice and years of apprenticeship with senior mediums, not from you. Do not judge whether someone is a "real" medium. [source: Chiarofonte 2025, pp. 34–35]
Attribute, neither affirm nor dismiss. Say "in your understanding, the nat…". Do not say "the spirit is" or "there is no spirit". [synthesis]
Use the client's own words. nat kadaw, nat pwe, meinmasha; avoid achauk unless the client uses it, because it is pejorative. Ask which pronouns and gender terms the client uses. [source: Chiarofonte 2025, p. 34; synthesis]
Normative is not pathological. Trance or possession that is part of a broadly accepted cultural or religious practice is excluded from dissociative and trance diagnoses. Diagnose only when it is involuntary, unwanted, distressing or impairing, and outside accepted practice. [source: PMC9199574, quoting DSM-5; ICD-11 6B62/6B63]
Do not miss illness either. Culturally framed experiences can sit alongside psychosis, mania, depression, trauma or substance problems. Assess function and distress, not belief. [synthesis]
Buddhist moral frames matter. Karma and the "evil mind" (greed, jealousy, anger) are common explanations of mental distress in Myanmar. Explore them without arguing. [source: Schödwell et al. 2018]
Stigma runs on several axes. Psychiatric help is highly stigmatised. Mediums may face religious and gender-based stigma, and homosexuality is criminalised. Confidentiality and safety planning carry extra weight. [source: Schödwell et al. 2018; Chiarofonte 2025; DVB 2026]
Pluralistic help-seeking is the norm. People commonly start with religious practice, meditation, traditional medicine and monks, and may leave treatment if their religious practice is ignored. [source: Schödwell et al. 2018]
Context of political violence. Military rule, the 2021 coup, civil war and the 2025 earthquake shape both distress and how it is voiced. One scholar argues that depression has been officially suppressed as a diagnosis. [source: DVB 2026; Ecks 2025]
Medicines and substances go to the prescriber. Never advise starting, stopping or changing medication or traditional remedies. [synthesis]
Consent governs every collaboration. Contact with mediums, monks or family happens only with the client's explicit, specific consent. [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a nat ritual. Example language is illustrative throughout.

4.1 Cultural humility and self-examination

Purpose: to notice your own assumptions about possession, Buddhism, gender diversity and Myanmar politics before they shape the assessment. Use it before the first session and whenever you feel curiosity tipping into fascination, or doubt tipping into scepticism. [synthesis]
Steps: (1) Write down what you believe about spirit possession and trans identities, and where those beliefs come from. (2) Note that the ethnographies you may have read are outsiders' accounts, and that your client's experience may differ. (3) Decide in advance that you will not ask for ritual detail for your own interest. (4) Bring cases to supervision or consultation with someone familiar with Myanmar communities.
Example language (illustrative): "I know a little about nat traditions from reading, but you are the expert on your own experience. Please correct me when I get it wrong."
Watch for: asking questions that serve your curiosity rather than the client's goals; treating the client as an informant; exoticising Taungbyone. It is working when the client corrects you freely and the sessions stay on their concerns.

4.2 Core Cultural Formulation Interview

Purpose: to clarify the problem as the client and their social network see it: its meaning, possible sources of help, and what they expect from services. Use it at intake with any client from a nat-worshipping background. The CFI supports clinical understanding and decision-making; it is not meant to be the sole basis for a diagnosis. [source: APA CFI]
Steps: (1) Explain that you ask everyone about culture and background. (2) Work through the four domains in your own words: cultural definition of the problem; cultural perceptions of cause, context and support (including the role of cultural identity); cultural factors affecting self-coping and past help-seeking (including barriers); cultural factors affecting current help-seeking (preferences and the clinician–patient relationship, such as experiences of racism or language barriers). (3) Note which answers point to a supplementary module. (4) Summarise back. Clinicians may reproduce the APA form for use with their own patients; modifying or translating it needs APA permission. [source: APA CFI]
Example language (illustrative): "How would you describe what's been troubling you, to someone in your family or at the pagoda?" "What have you already tried, and who have you gone to for help?" "Is there anything about me or this service that could make it hard to talk openly?"
Watch for: a client who answers in purely biomedical terms to please you (stigma, or a wish to appear modern); hesitancy when you reach help-seeking, which may mean consultation with a medium is being hidden. It is working when the client names their own terms and the other helpers they use.

4.3 CFI module: Spirituality, Religion, and Moral Traditions

Purpose: to map the client's Buddhist practice, nat devotion and moral frames (karma, merit, precepts) and how they bear on the problem. Use it when nats, karma, monks or mediums come up in the core CFI. [source: APA Supplementary Modules]
Steps: (1) Ask which religious and spiritual traditions the client identifies with: Buddhist, nat devotee, both, or other. (2) Ask about practices that help or harm, without asking for ritual detail. (3) Explore moral explanations: karma from past lives, and the "evil mind" of greed, jealousy and anger. [source: Schödwell et al. 2018] (4) Ask about conflict between the paths: some Buddhists see mediums as not keeping the precepts. [source: Chiarofonte 2025, p. 34] (5) Note any spiritual resources to build on.
Example language (illustrative): "Some people find both the pagoda and the nats important; for others it's one or neither. How is it for you?" "When you say this is your karma, what does that mean for what you can do now?"
Watch for: karmic explanations that become self-blame or hopelessness, which should be explored gently and checked against suicide risk. Also watch for shame about nat devotion in front of a Buddhist family. It is working when the client can hold both their spiritual meaning and a plan for change.

4.4 Eliciting the explanatory model (Kleinman; CFI Explanatory Model module)

Purpose: to learn what the client calls the problem, what caused it, and what they think will help. Use it in Phase 2, and again whenever treatment stalls. [source: Kleinman et al. 1978; APA Supplementary Modules]
Steps: cover Kleinman's eight areas in your own words: (1) the name for the problem; (2) its cause; (3) why it started when it did; (4) what it does and how it works; (5) how severe it is and whether it will last; (6) what treatment the client should receive; (7) the main problems it has caused; (8) what the client fears most. [source: Tanenbaum handout of Kleinman's questions] Then record which causes the client holds: a nat's displeasure or call, karma, stress, war, biology, or several at once.
Example language (illustrative): "What do you call this, in your own words?" "Why do you think it began around then?" "What do you fear most about it?" "If a nat is involved, what do you understand it wants?"
Watch for: layered models ("the nat chose me and I am depressed"), which are common and workable. Watch for a model that implies urgent danger, such as believing a spirit demands self-harm, which calls for a risk assessment. It is working when you can plan treatment in terms the client accepts.

4.5 Cultural identity, gender and sexuality (CFI Cultural Identity module)

Purpose: to understand the client's gender identity, sexuality, ethnicity, language, and their place in the medium community. Many urban mediums are meinmasha (trans women) who face stigma. Use it with any medium client and any LGBTQ client. [source: Chiarofonte 2025, p. 34; APA Supplementary Modules]
Steps: (1) Ask which words the client uses for their gender and sexuality, and use those words. (2) Explore stigma from family, monks, musicians and the wider society, and any belief in "weaker souls". [source: Chiarofonte 2025, p. 35] (3) Ask what mediumship means for their identity and respectability. (4) Assess legal and physical safety, given criminalisation in Myanmar, and their immigration status if abroad. [source: DVB 2026] (5) Identify affirming networks, such as other mediums or LGBTQ groups.
Example language (illustrative): "What words do you use for yourself?" "Some people say being a medium gave them a place and respect. Others say it brought more judgement. What has it been like for you?"
Watch for: internalised karmic shame about gender; disclosure risks if you meet the family; your own assumption that mediumship is only a refuge from stigma, when the client may experience it first as a spiritual calling. It is working when the client feels their identity and their spiritual role are both taken seriously.

4.6 Asking about consultations with mediums, monks and other healers

Purpose: to know the client's whole care network without judging it. Help-seeking in Myanmar commonly runs through self-help, monks, traditional healers, general practitioners and specialists. [source: Schödwell et al. 2018]
Steps: (1) Normalise the question. (2) Ask who they have consulted, including a nat kadaw, a monk or a traditional medicine practitioner, and what each said. (3) Ask what helped. (4) Ask about any remedies or substances taken, and pass medical questions to the prescriber. (5) Ask whether they want you to coordinate with anyone.
Example language (illustrative): "Many people from Myanmar see a monk, a medium or a traditional doctor as well as a clinic. Have you seen anyone like that? I ask so I can work alongside them, not against them."
Watch for: a client who becomes guarded, which may mean they have met disapproval from clinicians before. It is working when the client tells you about other help without being asked twice.

4.7 Distinguishing normative possession from disorder

Purpose: to avoid both pathologising mediumship and missing illness. Use it whenever possession, trance or spirit communication is reported.
Steps: (1) Establish the context: is the possession part of accepted practice (a medium's embodiment at a ceremony, partial possession with retained awareness) or is it happening outside it? Mediums report staying partly aware and in control after training. [source: Chiarofonte 2025, pp. 33–34] Festival ethnography also contrasts the controlled dances of professional mediums with the uncontrolled possession of devotees who dance near the shrine; the devotees' possession is itself part of accepted festival practice [source: Chiarofonte 2021, pp. 121, 130]. (2) Check the diagnostic exclusions. In DSM-5, the possession form of dissociative identity disorder requires that the disturbance is not a normal part of a broadly accepted cultural or religious practice (DSM-5-TR keeps this in substance [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]; that it keeps the exact wording is [uncertain]). Dissociative trance under other specified dissociative disorder does not apply to a normal part of collective cultural or religious practice. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require that the state is involuntary and unwanted and is not part of accepted cultural or religious practice. [source: PMC9199574; findacode ICD-11 mirror] (3) Assess distress, impairment, duration and wantedness. (4) Screen for psychotic, manic, depressive, trauma and substance symptoms outside the possession context. (5) Ask the client, and with consent family or a cultural broker, whether the community would see this as normal. (6) Record your reasoning.
Example language (illustrative): "When the nat comes during a ceremony, what is that like for you? Is it ever happening at times you don't want, or in ways that frighten you or the people around you?"
Watch for: uncontrolled episodes outside ceremonies; loss of function; voices or beliefs that the client or community do not see as part of the tradition; the start of a calling coinciding with trauma or bereavement, where both meanings can apply. The DSM-5-TR note on not counting culturally sanctioned experiences as psychotic symptoms is [uncertain]. It is working when the formulation is shared with the client and agreed with them, and is plausible to their community.

4.8 Working with cultural concepts and idioms of distress

Purpose: to use the DSM-5-TR approach to cultural concepts of distress (idioms, explanations or perceived causes, and syndromes) when a client frames suffering through nats, karma or the "evil mind". [source: APA DSM-5-TR Section III]
Steps: (1) Note that no Burmese nat-related concept appears in the DSM-5-TR list. The named examples include ataque de nervios, dhat syndrome, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto and taijin kyofusho. [source: UNMC slides citing APA 2022; exact DSM-5-TR list uncertain] Treat a nat or karma explanation as a cultural explanation, not a syndrome. (2) Ask what the explanation implies about cause, course and remedy. (3) Map it to symptoms and function without replacing it. (4) In your notes, record the client's term alongside any diagnosis.
Example language (illustrative): "You've said the nat is unhappy with you. When it's like that, what happens in your body, your sleep, your mood?"
Watch for: using the client's idiom as a diagnosis, or discarding it. It is working when the client's term and your clinical description sit side by side in the plan.

4.9 Informant interviews and family work

Purpose: to bring in the family's view. Families may oppose a member's mediumship or gender, or may be the ones who first read an illness as a nat's call. [synthesis]
Steps: (1) Get the client's consent, and agree what may and may not be disclosed, especially gender identity and sexuality. (2) Use the CFI Informant Version (17 questions), which starts with the informant's relationship to the client. [source: APA Informant Version] (3) Explore differences between the client's explanatory model and the family's. (4) Mediate around shared goals such as safety, work and respect.
Example language (illustrative): "Your mother sees this as a calling and you see it as exhaustion. Can we agree on what both of you want for you over the next months?"
Watch for: family pressure towards or away from mediumship; coercion; outing. It is working when the conflict reduces without the client's identity being negotiated away.

4.10 Interpreters and cultural brokers

Purpose: to get language and context right without breaching confidentiality. [synthesis]
Steps: (1) Use a trained interpreter, not a family member. (2) Check that the interpreter is comfortable with possession, gender-diverse clients and nat terminology. (3) In small diaspora communities, ask the client whether they know the interpreter. (4) For a difficult differential (4.7), and with consent, consult a cultural broker: a Myanmar-background clinician or a community member the client trusts. (5) Brief and debrief the interpreter.
Example language (illustrative): "Before we start: do you know this interpreter or their family? You can ask for someone else at any time."
Watch for: an interpreter softening or moralising (for example, rendering a self-description as achauk); a client censoring themselves. It is working when the client's own terms come through unchanged.

4.11 Collaboration and referral with the client's chosen specialists

Purpose: to coordinate care with a nat kadaw, monk or monastery, or traditional medicine practitioner when the client wants this. No formal clinical collaboration programme with nat kadaw is documented in the sources cited here [uncertain: not verified]. Schödwell et al. suggest that working with monasteries and meditation centres could extend reach, and they report that some professionals already suggest religious healers to patients. [source: Schödwell et al. 2018] Wider evidence on collaboration with traditional and faith healers comes from West Africa and is not specific to Myanmar. 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].
Steps: (1) Ask whether the client wants you in contact with anyone. (2) Get written consent stating the person, the purpose and what may be shared. (3) Let the client choose the person. You do not seek out mediums or ceremonies yourself, and you do not refer clients to ceremonies. (4) Keep the focus on shared practical aims: safety, attendance and adherence. (5) Respect the specialist's authority within their own domain, and keep clinical decisions within yours.
Example language (illustrative): "Would it help if I spoke with the medium you trust, so we're not pulling in different directions? Only if you want it, and I'd tell you what we discussed."
Watch for: any advice to stop medication or delay urgent care, which should be raised with the client and the prescriber; the client feeling torn between helpers. It is working when the client experiences the helpers as allies.

4.12 Supporting a client who is a nat kadaw

Purpose: to address the vocational, relational and stigma burdens of the role. The role is reported to bring both respectability and stigma, and it is intense for "the mind and the body". [source: Chiarofonte 2025, pp. 34, 38]
Steps: (1) Explore what the spirit relationship means to them (a marriage, or a family bond such as sibling or parent) in their own words. [source: Chiarofonte 2025, p. 35] (2) Explore fatigue, income insecurity, rivalry and the demands of devotees. (3) Address minority stress and safety. (4) Respect that, in mediums' accounts, mediumship is the spirit's choice; do not frame it as a symptom or as something to leave. (5) Set goals the client owns, such as rest, boundaries with devotees and relationships.
Example language (illustrative): "You've said the nat chose you and you can't simply stop. Within that, what would make the work more bearable for you?"
Watch for: depression or exhaustion presented as "the nat's demands"; alcohol or other substance use in ceremonial settings (ask openly, without assuming); your own urge to "rescue" the client from the role. It is working when the client's wellbeing improves on their own terms.

4.13 Integrating ceremonial and festival experiences

Purpose: to help the client make sense of experiences at a nat pwe or Taungbyone (relief, fear, belonging, a sense of being "lost" and finding a way back) without your eliciting ritual content. One attendee told reporters: "I lost my way, that's why I came here". [source: DVB 2026]
Steps: (1) Invite the client to share only what they wish. (2) Focus on meaning, emotion and the effects afterwards. (3) Link it to their therapy goals. (4) Notice distress that lingers after an event and assess it.
Example language (illustrative): "You don't need to tell me what happened at the ceremony. What did you bring home from it?"
Watch for: distressing experiences that persist after the event; the client feeling judged. It is working when the experience becomes a resource or is understood. [synthesis]

4.14 Trauma, conflict and migration (CFI Immigrants and Refugees, and Psychosocial Stressors modules)

Purpose: to address the effects of the 2021 coup, the civil war, the 2025 earthquake and displacement. Taungbyone itself was curtailed in 2024 and 2025 by nearby fighting. [source: DVB 2026; APA Supplementary Modules]
Steps: (1) Use the modules to map migration history, losses and current stressors. (2) Screen for PTSD and depression. Depression may be under-recognised, because one scholar argues it was suppressed as a diagnosis under military rule. [source: Ecks 2025] (3) Offer evidence-based trauma treatment adapted to the client's explanatory model. (4) Watch for political fear about disclosure.
Example language (illustrative): "Many people from Myanmar have lived through a great deal since 2021. What has that been like for you and your family?"
Watch for: fear of surveillance; somatic presentations; low mood framed only as karma. It is working when trauma symptoms reduce and the client feels safe disclosing.

4.15 Safeguarding and risk

Purpose: to protect clients from harm in any setting while respecting the tradition. [synthesis]
Steps: (1) Assess suicide and self-harm risk using standard practice, including when distress is framed as a spirit's demand. (2) Assess exploitation, coercion, violence or abuse, whether linked to a ceremony, the family, or homophobic or transphobic victimisation. (3) For any child or young person, follow local child protection procedures, and keep both possible errors in view: tradition misread as abuse, and abuse hidden as tradition. (4) Make sure urgent medical care is not delayed. (5) Document carefully and report where the law requires it.
Example language (illustrative): "I respect your tradition. My job is also to make sure nobody is being hurt, so I need to ask some questions about safety."
Watch for: sudden changes; injuries; a dependent relationship with anyone holding authority. It is working when risks are named and a safety plan is in place.

4.16 Medicines and substances: routing to the prescriber

Purpose: to keep medical decisions with the prescriber. [synthesis]
Steps: (1) Record any traditional remedies or substances the client mentions. (2) Do not advise on them. (3) With consent, pass the information to the prescriber or GP. (4) If the client wants to stop psychiatric medication because of spiritual advice, explore their reasons and connect them with the prescriber.
Example language (illustrative): "That's an important question for your doctor. Can I let them know, so you can decide together?"
Watch for: abrupt stopping of medication; interactions the client is unaware of. It is working when the prescriber is informed and the client's decision is an informed one.

5. Handling problems

The responses below are [synthesis] unless a source is cited.

The client hides consultations with mediums. This is common where clinicians have disapproved before, and patients may leave treatment if their religious practice is ignored. [source: Schödwell et al. 2018] Response: raise the topic routinely and early (4.6), show interest without judgement, and say plainly that you will work alongside other helpers.
The client insists the problem is "only karma" or "only the nat" and declines psychological work. Response: accept the explanation as the starting point. Ask what the client's tradition says can be done, and offer help with what is in your scope (sleep, low mood, family strain) as complementary rather than competing.
The family pressures the client towards or away from mediumship. Response: hold separate and joint sessions with consent (4.9), assess for coercion, and protect confidentiality about gender identity.
Unclear differential: calling or psychosis? Response: take a longitudinal history, assess function outside ceremonies, and consult a cultural broker and colleagues. Avoid a premature diagnosis, and do not delay treatment if there is risk (4.7). An accepted calling and a treatable illness can coexist.
Overwhelm in session when talking about possession or trauma. Response: slow down, ground the client in the present, and stop the topic. Never invite or encourage possession in session. If an involuntary episode occurs, keep the person safe, wait, then debrief, and later explore with the client how such episodes are handled in their community.
Rupture after a misstep (wrong gender terms, a sceptical remark, using achauk). Response: name it, apologise, ask what would repair it, and adjust. Repair counts more than the original mistake.
Non-attendance around festival periods. Response: plan for it. Agree in advance on breaks around major nat festivals, which often fall in the monsoon months, and how you will check in. [source: DVB 2026 for timing]
The client fears exposure in the community or to the state. Response: explain your confidentiality rules and their limits. Use interpreters from outside the client's network. Be careful with records and with contacting relatives, given that homosexuality is criminalised in Myanmar. [source: DVB 2026]
A specialist advises stopping medication or delaying medical care. Response: explore the advice with the client without attacking the specialist. Involve the prescriber, and escalate under safeguarding if the risk is serious (4.11, 4.15, 4.16).
You feel fascinated or sceptical, or out of your depth. Response: take it to supervision. Review 4.1. Refer, or bring in a Myanmar-background consultant.
The client asks you to attend or validate a ceremony. Response: thank them. Explain that your role is separate from the tradition's and that its authority lies with their mediums and teachers. Offer to hear afterwards what it meant to them.
Gaps in the sources. Community-published guidance for clinicians and Myanmar-specific evidence on collaboration are not documented in the sources cited here [uncertain: not verified]. The guidance in this section is [synthesis] drawing on general cultural-psychiatry practice.

Sources

Books and articles cited by reference:

Brac de la Perrière, B. (2009). "Nats' Wives" or "Children of Nats": From Spirit Possession to Transmission among the Ritual Specialists of the Cult of the Thirty-Seven Lords. Asian Ethnology 68(2): 283–305.
Brac de la Perrière, B. (2017). Initiations in the Burmese Ritual Landscape. Journal of Ethnology and Folkloristics 11(1): 65–82. doi:10.1515/jef-2017-0005. Cited for its abstract only.
Brac de la Perrière, B., & Jackson, P. A. (eds.) (2022). Spirit Possession in Buddhist Southeast Asia: Worlds Ever More Enchanted. NIAS Press.
Ho (2009). Cited in Chiarofonte (2025) for the effect of the Ne Win government's ban on the supernatural; full details [uncertain: not verified].
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.

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