Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 045
Guide XI-045

Hippocratic–Galenic humoral medicine

Hippocrates, Galenancient Greece
A 35 · L 56 · M 916 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Hippocratic–Galenic humoral medicine as medical historians describe it (Royal College of Physicians Museum, 2025; Telles-Correia and Gama Marques, 2015; Laios et al., 2012), with its living successors described as their own official bodies publish them: Unani as presented by India's AYUSH services and regulated under the National Commission for Indian System of Medicine Act 2020, and Persian (Iranian traditional) medicine as presented by a university faculty of traditional medicine in Iran. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) as published by the American Psychiatric Association.

What it is. Hippocratic–Galenic medicine was a complete medical system, not a psychotherapy. It held that health depends on the balance of four humours (blood, phlegm, yellow bile and black bile), which correspond to four elements, four qualities (hot, cold, dry, wet), the seasons, the stages of life and four temperaments (sanguine, phlegmatic, choleric, melancholic). Treatment aimed to restore balance by opposing or removing the excess humour, chiefly through bloodletting and purging, together with regimen. [source: RCP Museum, Forde 2025] It shaped medical practice in Europe from ancient Greece to the start of the industrial era; humours were discredited as real substances during the 1800s, and by the 1900s medicine had abandoned Galenic therapeutics. [source: RCP Museum, Forde 2025]

What remains today. The system survives in three forms. (1) Unani, which its Indian government sources trace to Hippocrates and describe as developed in Arab and Persian lands and brought to the Indian subcontinent about a thousand years ago; it is a recognised Indian system of medicine with regulated education and registration. [source: AYUSH Delhi, Unani page; NCISM Act 2020] (2) Persian (Iranian traditional) medicine, taught in Iranian university faculties that describe temperament (mizāj) as a foundation of humoral medicine (tebb-e akhlāt). [source: Tabriz University of Medical Sciences, Faculty of Traditional Medicine] (3) Folk hot–cold systems, for example in Latin America, where people use biomedicine first for treatment but still explain illness and organise prevention in humoral terms. [source: Foster 1984] Whether Latin American hot–cold beliefs derive historically from Hippocratic–Galenic medicine is debated in the anthropological literature [uncertain: not verified].

Mental health within the system (attributed). In this tradition melancholy (melancholia) was attributed to an excess of black bile; Hippocratic writers described its core features as fear and sadness, and Galen added the melancholic temperament and described patients with fixed, strange ideas but otherwise intact minds, who still showed "fear and despondency". [source: Telles-Correia and Gama Marques 2015] The Aristotelian Problemata 30.1 linked overheated black bile to mirthfulness and overcooled black bile to moroseness, and Rufus of Ephesus held that some people have a melancholic humour by nature. [source: Laios et al. 2012] Medieval Persian physicians described melancholia, mania, paranoia (ghotrab) and lovesickness (ishgh) in humoral terms. [source: Vakili and Gorji 2006] Unani sources state that imbalance in the six essentials, including "psychic movement and repose", underlies mental as well as physical illness. [source: AYUSH Delhi, Unani page]

How change happens, and the therapist's place. Within the system, change comes from restoring humoral balance and the body's own healing power (tabiyat in Unani) through regimen, diet, evacuation and medicines, given by a trained practitioner. [source: AYUSH Delhi, Unani page and Modes of Treatment] The psychotherapist does not practise humoral medicine and does not diagnose temperaments or prescribe regimens. In psychotherapy, change comes from understanding the client's explanatory model, assessing and treating any mental disorder on its own terms, keeping the client physically safe, and coordinating with legitimate practitioners when the client wishes. [synthesis]

2. Framework

This entry is a medical system and a historical tradition, not a staged therapy, so there is no published session protocol for it. The framework below has two parts: the structure of the system as its sources describe it, and the psychotherapist's own phases of work alongside it.

2a. Structure of the system (as described, not for the therapist to apply)

  • Theory. Elements, qualities, humours and temperaments form a single scheme. In the RCP account: blood is hot and wet (spring, childhood, sanguine temperament); yellow bile is hot and dry (summer, youth, choleric temperament); black bile is cold and dry (autumn, maturity, melancholic temperament, linked to sadness, reflection and, in excess, mental illness); phlegm is cold and wet (winter, old age, phlegmatic temperament). [source: RCP Museum, Forde 2025] Unani names the humours dam (blood), balgham (phlegm), safra (yellow bile) and sauda (black bile), and holds that a balance of elements (arkan), humours (akhlat) and temperament (mizaj) keeps body and mind healthy. [source: AYUSH Delhi, Unani page] A Persian source describes nine types of temperament arising from the mixture of the four elements, citing the medieval Zakhīre-ye Khwārazmshāhī. [source: Tabriz Faculty of Traditional Medicine, mizāj page]
  • The six essentials (the "non-naturals"). Unani lists six factors that must be kept in balance: environmental air (hawa); food and drink (makool wa mashroob); bodily movement and rest (harkat wa sukoon badni); psychic movement and rest (harkat wa sukoon nafsani); sleep and wakefulness (naum wa yaqza); retention and evacuation (ehtabaas wa istafraagh). [source: AYUSH Delhi, Unani page] The equivalent European list is usually called the six non-naturals [uncertain: not verified from a primary text].
  • Diagnosis. Unani names pulse (nabz), urine (baul) and stool (baraz) as its three main diagnostic tools. [source: AYUSH Delhi, Unani page]
  • Treatment. Historically: treatment by opposites, especially bloodletting and purging. [source: RCP Museum, Forde 2025] Unani today names four modes: regimenal therapy (ilaj bil-tadbir: thirteen procedures including purging, vomiting, sweating, diuresis, venesection, enema, Turkish bath, massage, exercise, douches, cauterisation, cupping/hijama and leech application); diet therapy (ilaj bil-ghiza); pharmacotherapy with drugs of plant, animal and mineral origin, often in compound formulations (ilaj bil-dawa); and surgery (ilaj bil-yad). [source: AYUSH Delhi, Modes of Treatment] Medieval Persian treatment of melancholia combined regimen (climate, moderate exercise, avoiding excess and idleness), pastimes and company (reading, music, chess, social gatherings), travel, baths and massage, sleep, diet, verbal advice and moral instruction, bloodletting and many plant, mineral and animal remedies. [source: Vakili and Gorji 2006] These are described here so the therapist can recognise them; none is an instruction.
  • Who holds authority. Historical Galenic medicine has no living licensing body; its authority today is scholarly (historians of medicine and medical museums). [source: RCP Museum, Forde 2025] In India, Unani is one of the systems defined as "Indian System of Medicine" under the NCISM Act 2020 (Act No. 14 of 2020); a Board of Unani, Siddha and Sowa-Rigpa sets education standards and recognises qualifications; a National Register is kept; and only persons enrolled in a State or National Register may practise as qualified practitioners, with penalties for breach (s. 34). The Act repealed the Indian Medicine Central Council Act 1970. [source: NCISM Act 2020] Registration and regulation of Unani and Persian-medicine practitioners in other countries (for example the UK, US, Iran, Pakistan) [uncertain: not verified].
  • Evidence status. Humours were discredited as real bodily substances in the 1800s. [source: RCP Museum, Forde 2025] One review of medieval Persian psychiatry notes that some traditional remedies have since been studied but most remain unexamined. [source: Vakili and Gorji 2006] Independent systematic reviews of Unani or Persian-medicine treatments for mental disorders [uncertain: not verified].

2b. The psychotherapist's phases of work alongside it

No source sets session counts for this work; the phases and criteria below are [synthesis], built on the CFI's published structure.

  1. Engagement and cultural assessment (sessions 1–2). Goal: understand the problem in the client's terms, including any humoral language (temperament, "too much heat", sauda, melancholy by nature), and map help-seeking. Use the core CFI (16 questions in four domains) and, where useful, its supplementary modules. [source: APA DSM-5-TR CFI] Time for the core CFI is not stated in APA's forms; the field trial found that later interviews took less time [uncertain: no figure in minutes]. [source: Lewis-Fernández et al. 2017] Move on when you can state the client's explanatory model back to them and they agree, and you know which practitioners and remedies are involved.
  2. Safety and medical review (in parallel, from session 1). Goal: identify risks from remedies, regimens or procedures (heavy metals, interactions, cupping infections, purging or fasting), and route physical questions to the prescriber or GP. Move on when any medical concern has a named person following it up.
  3. Formulation and shared plan (sessions 2–4). Goal: a formulation that holds both the client's humoral account and your clinical assessment, and a plan the client endorses, including whether and how to coordinate with an Unani or Persian-medicine practitioner. Move on when the client agrees the plan and has given consent for any contact.
  4. Treatment (number of sessions set by the evidence-based therapy you are using for the presenting disorder). Goal: deliver standard treatment, using the client's idioms as bridges where they fit.
  5. Review and integration (every 4–6 sessions and at ending). Goal: check that the cultural frame still fits, revisit help-seeking and safety, and support the client to integrate both systems in a way they choose.

3. Guiding principles

Principles 1–3 rest on the CFI's published aims; the rest are [synthesis] unless tagged.

  • Describe, do not practise. You may understand humoral medicine; you do not assess temperament, read pulses or recommend regimens. Practical meaning: when a client asks "what is my temperament?", redirect to their own view and their practitioner.
  • The client's perspective defines the problem first. The CFI exists to clarify the problem as the person and their social network see it, its meaning, sources of help and expectations. [source: APA DSM-5-TR CFI] Practical meaning: ask what they call it before you name it.
  • Cultural information informs, it does not decide, diagnosis. The CFI supports clinical understanding and is not meant to be the only basis for diagnosis. [source: APA DSM-5-TR CFI] Practical meaning: a humoral explanation neither rules out nor confirms depression.
  • Attribute, neither endorse nor dismiss. Humoral concepts are held by living systems and communities; speak of them as "in Unani" or "as you understand it". Practical meaning: no "that's an old myth", and no "yes, you have too much black bile".
  • Historical and living are different things. Galenic medicine in Europe is history; Unani and Persian medicine are current, regulated systems in some countries. [source: RCP Museum; NCISM Act 2020] Practical meaning: do not treat a client's hakim as a relic of medieval practice.
  • Authority sits with the regulator and the practitioner, not with you. In India, registration on a State or National Register is required to practise as a qualified practitioner. [source: NCISM Act 2020] Practical meaning: if coordination is wanted, ask who the practitioner is and, where relevant, whether they are registered.
  • Physical safety comes first and goes to the right person. Remedies and procedures can cause harm (heavy metals; infection after wet cupping). [source: CDPH; Wang et al. 2023] Practical meaning: you screen and route; you never advise starting, stopping or changing any medicine or remedy.
  • Standard risk assessment always applies. A temperament account ("I am melancholic by nature") does not lower the need to assess suicide risk. Practical meaning: assess risk in every client with low mood, whatever the frame.
  • Use idioms as bridges, not as treatment claims. The six essentials (sleep, activity, food, emotional states, environment, elimination) overlap with behavioural targets. Practical meaning: you may build on a client's wish for balance in sleep or activity, while saying clearly that your method is psychological.
  • Consent and confidentiality govern any collaboration. Practical meaning: written consent before contacting any practitioner, stating what will and will not be shared.
  • Watch your own bias. Clinicians trained in biomedicine may hear humoral talk as ignorance; clinicians who romanticise tradition may miss harm. Practical meaning: note your reaction in supervision.
  • Touch and procedures are outside your role. Practical meaning: you do not perform or demonstrate massage, cupping or any procedure, and you do not refer for one.

4. Intervention inventory

These are the psychotherapist's own interventions. Humoral diagnosis, regimen, diet therapy, evacuation, cupping, venesection and remedies belong to trained and, where regulated, registered practitioners; they are not in this inventory. All example language is illustrative. [source for CFI content: APA DSM-5-TR CFI, Informant Version and Supplementary Modules; for explanatory-model questions: Kleinman, Eisenberg and Good 1978 as paraphrased in the Tanenbaum handout]

4.1 Cultural humility and self-examination

  • Purpose / when: before and throughout work with any client who uses humoral, Unani, Persian-medicine or hot–cold language, so your reaction does not shape the assessment. [synthesis]
  • Steps: (1) Note what you already believe about humoral medicine: "debunked history", "exotic tradition", or something you grew up with. (2) Separate the European history (abandoned by medicine by the 1900s) from living systems that are regulated today, such as Unani in India. [source: RCP Museum; NCISM Act 2020] (3) List what you do not know (the client's tradition, language, practitioner, remedies). (4) Bring strong reactions, either contempt or idealisation, to supervision. (5) Re-check after each session whether you used the client's words or replaced them with yours.
  • Example language (illustrative): "I know something about the history of humoral medicine, but very little about how you and your family use it. I'd like to learn it from you."
  • Watch for: correcting the client's physiology; jokes or a tone of amusement; the opposite error of accepting every remedy as safe because it is "traditional". It is working when the client uses their own terms freely and corrects you.

4.2 Core Cultural Formulation Interview, attending to humoral idioms

  • Purpose / when: at assessment, and whenever cultural factors seem to affect diagnosis, engagement or treatment. APA states it is designed for any clinician with any person in any setting. [source: APA DSM-5-TR Section III]
  • Steps: (1) Introduce it as a way to understand the problem from the client's perspective. (2) Work through the four domains in order: cultural definition of the problem (Q1–3); cultural perceptions of cause, context and support (Q4–10: causes, stressors and supports, role of cultural identity); cultural factors affecting self-coping and past help-seeking (Q11–13); cultural factors affecting current help-seeking (Q14–16, including the clinician–patient relationship). [source: APA DSM-5-TR CFI] (3) Write down the client's exact words for the problem and its cause (for example "heat", "dryness", sauda, safra, "my melancholic nature", "imbalance"). (4) Under help-seeking, ask specifically about hakims, Unani or Persian-medicine practitioners, diet changes, cupping, baths, purges and remedies. (5) Use the CFI to inform, not settle, the diagnosis. [source: APA DSM-5-TR CFI] (6) Use the official APA form; it may be reproduced by clinicians for use with their patients, but modification and translation need APA permission. [source: APA DSM-5-TR CFI]
  • Example language (illustrative): "People often understand problems like this in different ways. How would you describe what is happening to you?" / "When you say your temperament has become too dry, what does that mean for you day to day?"
  • Watch for: rushing past the client's term to a diagnostic label; asking leading questions about "old beliefs". It is working when the client explains their model at length and you can summarise it to their satisfaction. The APA does not give a duration [uncertain: time in minutes not verified].

4.3 Explanatory-model inquiry (Explanatory Model module and Kleinman's questions)

  • Purpose / when: when the client's account of cause and cure differs from yours, or treatment expectations are unclear. The CFI Explanatory Model supplementary module expands this area. [source: APA CFI Supplementary Modules]
  • Steps: cover, in your own words, Kleinman's eight areas: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and whether it will be short or long; what treatment they think they should receive; the chief problems it has caused; what they fear most about it. [source: Kleinman, Eisenberg and Good 1978, paraphrased in Tanenbaum handout] For humoral models, also ask how the problem relates to temperament, season, age, diet, sleep, emotional states and evacuation, since these are the factors the system itself names. [source: AYUSH Delhi, Unani page; RCP Museum] Record the model in the notes in the client's language.
  • Example language (illustrative): "What do you think set this off, and why now?" / "In your understanding, what would bring things back into balance?" / "What worries you most about it?"
  • Watch for: the client expecting a single cure (a purge, a diet) that conflicts with safety; fear that the problem is permanent because it is their "nature" (see 4.12). It is working when you can name points of agreement (for example that sleep, activity and grief matter) and points of difference.

4.4 Cultural identity and spirituality modules

  • Purpose / when: when humoral practice is tied to religious, family or community identity, or the client is an immigrant or refugee. Relevant supplementary modules: Cultural Identity; Spirituality, Religion and Moral Traditions; Immigrants and Refugees; Older Adults; Coping and Help-Seeking. [source: APA CFI Supplementary Modules]
  • Steps: (1) Choose the module(s) that fit; they can be used as add-ons or standalone, at first evaluation or later, and repeatedly. [source: APA CFI Supplementary Modules] (2) Ask what these practices mean in the client's family and faith. (3) Ask who in their community they trust on health questions. (4) For migrants, ask what was available at home and what is available now.
  • Example language (illustrative): "Is this way of looking after your health something your family or your faith community shares?" / "Who back home would you have gone to with this?"
  • Watch for: assuming that a client from a Muslim, South Asian, Iranian or Latin American background holds humoral views at all; collapsing religious and medical meanings that the client keeps separate. Whether wet cupping is understood by particular communities as a religious practice should be learned from the client, not assumed [synthesis]. It is working when the client tells you which parts of their practice matter most to them.

4.5 Practitioner and remedy inventory

  • Purpose / when: at assessment and each review, because remedies and procedures can interact with treatment or cause harm. CDPH advises clinicians to ask all patients whether they use herbal products or other remedies, and notes these often come from practitioners, shops or the internet and are frequently compounded rather than branded. [source: CDPH]
  • Steps: (1) Ask, without judgement, who they consult (hakim, Unani physician, Persian-medicine practitioner, family elder, online seller). (2) Ask what they take or have done: remedies (name and source only; you do not assess them), diet changes, fasting, purges or enemas, sweating or baths, cupping, leeches, cauterisation, massage. (3) Ask whether their prescriber knows. (4) With consent, pass the list to the prescriber or GP. (5) Never comment on whether to continue, stop or change any medicine or remedy.
  • Example language (illustrative): "Many people use more than one kind of medicine. Is anyone else helping you with this, and is there anything you take or have done for it?" / "Would it be all right for me to let your doctor know, so they have the full picture?"
  • Watch for: the client hiding remedies because they expect disapproval; a client who has stopped prescribed medication for a remedy (route to prescriber the same week). It is working when the inventory is complete and the prescriber has it.

4.6 Physical-safety screen and medical routing

  • Purpose / when: whenever the inventory shows remedies or procedures, or physical symptoms appear. You do not diagnose; you notice and refer.
  • Steps: (1) Heavy metals: CDPH warns that many Ayurvedic remedies are contaminated with lead, arsenic and mercury; symptoms include anaemia, abdominal pain, nausea, poor appetite and fatigue, and at very high levels encephalopathy and seizures; children and pregnancy are at special risk; a venous blood lead test is the recommended test. [source: CDPH] That warning concerns Ayurvedic products; comparable testing of Unani or Persian-medicine products [uncertain: not verified]. If a client reports these symptoms and uses imported or compounded remedies, ask them to see their GP and, with consent, tell the GP why. (2) Wet cupping: a 2023 case report and literature review describes scarring, burns, headache, itching, dizziness and anaemia as relatively frequent but usually mild, and rare serious infections (for example epidural abscess after back cupping), usually starting within a week with local pain, swelling or skin lesions; most case reports involved unqualified practitioners. [source: Wang et al. 2023] Urge same-day medical review for fever, spreading redness, severe back pain or new weakness after cupping. [synthesis] (3) Evacuation and diet regimens: repeated purging, vomiting, enemas, sweating or restrictive diets can also be eating-disorder behaviour or cause dehydration; screen for an eating disorder and refer for medical review if present. [synthesis] (4) Herb–drug interactions: route any combination of remedies and psychiatric medication to the prescriber; specific interaction data for Unani remedies [uncertain: not verified]. (5) Document what you advised and to whom you referred.
  • Example language (illustrative): "Some imported remedies have been found to contain metals like lead. I'm not saying yours do, but tiredness and stomach pain are worth checking. Would you see your GP about a simple blood test?"
  • Watch for: you drifting into advice on remedies (stop, and route); the client minimising symptoms. It is working when every physical concern has a named clinician following it.

4.7 Differential assessment: melancholy as idiom, depressive and bipolar disorders

  • Purpose / when: when a client describes melancholy, black bile or a melancholic temperament. Historically, melancholia was fear and sadness attributed to black bile; today the word mostly survives in psychiatry as depression with melancholic features in DSM-IV and DSM-5. [source: Telles-Correia and Gama Marques 2015] The Aristotelian account tied black bile both to moroseness and to mirthfulness, which modern readers have linked to mania, though the authors caution against a bipolar reading. [source: Laios et al. 2012]
  • Steps: (1) Ask what the client means by the term; it may be a temperament, a mood, a diagnosis given by a practitioner, or a literary idea. (2) Carry out a standard assessment for depressive disorder, including melancholic features, and for bipolar disorder (past elevated mood, reduced need for sleep). (3) Carry out standard suicide risk assessment with every client who describes melancholy or low mood. (4) Ask about fixed or unusual beliefs in the ordinary way; humoral explanations of illness are a shared cultural model and are not in themselves delusional [synthesis; the DSM-5-TR culture note on culturally shared beliefs is uncertain: not verified]. (5) Write both the client's account and your diagnosis in the formulation.
  • Example language (illustrative): "You said your practitioner told you black bile is high. What does that feel like for you? Has there been a time when you felt the opposite, unusually full of energy?" / "Sometimes when people feel this low they think about not wanting to live. Has that happened to you?"
  • Watch for: accepting "melancholic nature" as a reason not to assess risk; treating humoral beliefs as symptoms. It is working when you can say what the client means and whether a disorder is present, independently.

4.8 Informant interview and work with the family

  • Purpose / when: when family members hold or direct the humoral account, arrange practitioner visits or manage diet and remedies. The CFI Informant Version (17 questions, beginning with the informant's relationship to the patient) covers the same four domains. [source: APA CFI Informant Version] The Caregivers module is given to the caregiver. [source: APA CFI Supplementary Modules]
  • Steps: (1) Obtain the client's consent. (2) Use the Informant Version with a relative or friend. (3) Compare the two accounts and note differences. (4) Agree with the client which differences to discuss in a joint session. (5) In joint sessions, keep the client's own preferences central.
  • Example language (illustrative): "You've both been worried about her. Could you tell me how the family understands what's going on, and what you've tried?"
  • Watch for: family members speaking for the client; pressure to follow or abandon a regimen; elders' authority silencing a younger client. It is working when the client's own wishes are stated and heard in the family.

4.9 Interpreters and cultural brokers

  • Purpose / when: when the client's health vocabulary is in Urdu, Hindi, Persian, Arabic, Spanish or another language, or when terms such as sauda, safra, mizaj, balgham or hot–cold categories carry meanings you cannot check. [synthesis]
  • Steps: (1) Use a professional interpreter, not a family member, for assessment. (2) Brief the interpreter beforehand that you want the client's health terms kept, not translated into English medical words. (3) Ask the interpreter afterwards about any term that seemed to have a specific meaning. (4) Where available and with consent, consult a cultural broker (for example a community health worker from the client's community) on how a term is commonly used. (5) Keep confidentiality rules explicit with both.
  • Example language (illustrative): to the interpreter: "If she uses a word like sauda or 'heat', please keep that word and tell me it was used, rather than translating it as 'depression'."
  • Watch for: interpreters adding their own views of traditional medicine; small communities where the interpreter knows the family or the practitioner. It is working when the client's own words appear in your notes.

4.10 Cultural formulation that holds both models

  • Purpose / when: after assessment, to plan treatment the client can accept. DSM-5-TR Section III contains an Outline for Cultural Formulation alongside the CFI. [source: APA DSM-5-TR Section III]
  • Steps: (1) Summarise the client's explanatory model in their words. (2) Summarise your clinical assessment and any diagnosis. (3) Name overlaps (for example both see poor sleep, grief or overwork as important). (4) Name differences openly (for example they see an excess of black bile; you see a depressive episode). (5) Propose a plan that works in the overlap and makes the differences discussable. (6) Check agreement and write it down.
  • Example language (illustrative): "In your understanding the problem is an imbalance, with too much of the cold and dry. In mine, it looks like depression. We both think sleep, worry and the loss of your father matter. Could we start there?"
  • Watch for: a formulation that quietly drops the client's model; a client agreeing politely while planning to follow only the practitioner. It is working when the client restates the plan in their own words.

4.11 Bridging through the six essentials into behavioural work [synthesis]

  • Purpose / when: when the client values balance in daily life. The Unani six essentials name air and environment, food and drink, bodily movement and rest, psychic movement and rest, sleep and wakefulness, and retention and evacuation. [source: AYUSH Delhi, Unani page] Several of these are also targets in standard behavioural treatments of depression and insomnia. This bridge is your own psychological work; it is not Unani treatment, and you do not set diets, evacuations or regimens.
  • Steps: (1) Ask which of these areas the client already sees as out of balance. (2) Choose areas that overlap with your evidence-based treatment, mainly activity and rest, sleep and wakefulness, and emotional states. (3) Use the standard method of your chosen therapy (for example activity monitoring and scheduling, sleep-pattern work, emotion work) in the client's language of balance. (4) Leave food, drink and evacuation to the client's physician and practitioner; if eating or purging is a concern, see 4.6.
  • Example language (illustrative): "You've said movement and rest are out of balance. In my work we look closely at what you do each day and how it affects your mood. Would you be willing to track that this week?"
  • Watch for: the client hearing you as endorsing the humoral theory, or as offering an Unani treatment (say clearly that your method is psychological); any regimen that becomes rigid or restrictive. It is working when the client engages with the task and mood or sleep measures change.

4.12 Working with temperament as identity [synthesis]

  • Purpose / when: when a client sees their low mood or anger as fixed by temperament ("I am melancholic by nature", "choleric"). Rufus of Ephesus held that some people have a melancholic humour by nature, and Galen tied the melancholic temperament to black bile, so this self-view has a long history. [source: Laios et al. 2012; Telles-Correia and Gama Marques 2015]
  • Steps: (1) Explore what the temperament means to the client, including any strengths it carries (reflection, depth, seriousness). (2) Separate the enduring trait they value from the current episode of suffering. (3) Explore whether the label leads to hopelessness or avoiding help. (4) Agree goals that address the episode without asking them to give up the identity.
  • Example language (illustrative): "Being a reflective, serious person may be part of who you are. Feeling this hopeless every morning sounds different. Can we work on that part?"
  • Watch for: fatalism that blocks treatment; risk hidden behind "it's just my nature" (assess). It is working when the client can hold both their temperament and the possibility of change.

4.13 Collaboration and referral with registered practitioners

  • Purpose / when: when the client wants their Unani or Persian-medicine practitioner involved, or wants help finding one. Trials elsewhere show that structured collaboration with traditional and faith healers can help: in Nigeria and Ghana, collaborative shared care between healers and primary-care workers for psychosis reduced symptoms more than usual care and reduced harmful practices. [source: COSIMPO, Gureje et al. 2020] Those trials concerned different healers and a different setting, so their transfer to humoral medicine is [synthesis].
  • Steps: (1) Ask what the client wants from collaboration (information-sharing, a joint plan, nothing). (2) Ask who the practitioner is; in India, qualified practice requires enrolment on a State or National Register under the NCISM Act 2020. [source: NCISM Act 2020] Registration elsewhere [uncertain: not verified]; ask the client and do not refer to anyone you cannot identify. (3) Obtain written consent stating what will be shared and with whom. (4) Make contact by letter or phone, explaining your role as a psychotherapist and asking about the practitioner's view. (5) Include the prescriber where medicines or remedies are involved. (6) Agree what each person will do, especially about medicines (the prescriber decides). (7) Review at set intervals.
  • Example language (illustrative): to the client: "Would it help if I wrote to your hakim so we're not pulling in different directions?" To a practitioner: "I am seeing your patient for psychological therapy for low mood. With their consent, I'd value your view of what you are offering, so that we can coordinate."
  • Watch for: practitioners advising the client to stop psychiatric medication (route to prescriber); referral to unregistered or unknown practitioners; breaches of confidentiality in small communities. It is working when the client experiences their helpers as coordinated.

4.14 Safeguarding

  • Purpose / when: when a remedy or procedure harms or could harm a client or a child. CDPH reports infant lead poisonings from an Ayurvedic tonic given to babies, and that lead crosses the placenta. [source: CDPH] Serious infections after wet cupping were mostly reported with unqualified or untrained practitioners. [source: Wang et al. 2023]
  • Steps: (1) Ask about remedies given to children or during pregnancy. (2) If a child may be exposed to a contaminated remedy or injured by a procedure, discuss with the family and their doctor, and follow your local child-safeguarding procedure. (3) If an adult at risk is being pressured into procedures or regimens, follow adult-safeguarding procedures. (4) Respect that most use of traditional medicine is not abuse; act on harm and risk, not on tradition as such. [synthesis] (5) Record your reasoning.
  • Example language (illustrative): "I'd like to check something with you, because it concerns your baby's safety. Some imported tonics for infants have been found to contain lead. Could we ask your doctor to look at the one you mentioned?"
  • Watch for: delay in urgent medical care; procedures on children by unqualified people; a family's fear of being judged, which can end engagement. It is working when the risk is assessed by the right professional and the family stays engaged.

4.15 Historical psychoeducation on melancholy [synthesis]

  • Purpose / when: when a client finds meaning in the history of melancholy (literary, philosophical or family tradition) or when a client from a European tradition uses "melancholic" as self-description.
  • Steps: (1) Ask what the word means to them. (2) If it helps, explain briefly that melancholy was once explained by black bile and that the word now survives in psychiatry as a feature of some depressions. [source: Telles-Correia and Gama Marques 2015] (3) Use the history to reduce shame (people have described this suffering for over two thousand years) rather than to correct the client. (4) Return to their current experience and goals.
  • Example language (illustrative): "People have written about this kind of heavy sadness and fear since ancient Greece. You are not the first to feel it, and there are ways to help."
  • Watch for: lecturing; implying the client's living tradition is "just history". It is working when the client feels less alone and more hopeful.

4.16 Addressing barriers, racism and the therapeutic relationship

  • Purpose / when: at assessment and whenever engagement falters. The CFI covers barriers to help-seeking (Q13) and the clinician–patient relationship (Q16, for example perceived racism and language barriers); a Patient–Clinician Relationship module expands it. [source: APA DSM-5-TR CFI; APA CFI Supplementary Modules]
  • Steps: (1) Ask directly whether the client expects to be judged for using traditional medicine. (2) Ask about past experiences of dismissal or racism in health services. (3) Acknowledge them without defensiveness. (4) Agree how the client can tell you if they feel judged.
  • Example language (illustrative): "Some people have been made to feel foolish by doctors for using traditional medicine. Has that happened to you? I'd want to know if anything I say feels like that."
  • Watch for: silence about remedies after a dismissive comment from you or another clinician. It is working when the client raises disagreements openly.

5. Handling problems

The sources above do not address psychotherapy problems directly; all responses below are [synthesis] unless tagged.

  • The client asks you to confirm their humoral diagnosis or name their temperament. Decline kindly and stay curious: "That's something your practitioner is trained to judge. What I can do is understand what it means for you and help with the low mood." Do not argue the theory.
  • The client asks whether they should try cupping, a purge, a diet or a remedy. Do not advise for or against. Say it is outside your role, suggest they discuss it with their physician and practitioner, and give the safety information in 4.6 if the question involves known risks (for example signs of infection after wet cupping). [source for risks: Wang et al. 2023]
  • The client has stopped or wants to stop prescribed psychiatric medication in favour of Unani or Persian-medicine treatment. Do not endorse or oppose. Ask them to speak with the prescriber before acting, offer to help arrange that, and with consent inform the prescriber. Assess risk if they have already stopped.
  • Stuck: the client agrees in session but follows only the practitioner. Name it gently, ask what makes the practitioner's advice more trustworthy, and look for one shared goal. Offer coordination (4.13). Consider whether the plan asked them to give up something central to their identity.
  • Resistance because the client expects judgement. Return to 4.16. Acknowledge past dismissal by health services, ask what would help them feel respected, and show your interest by using their terms accurately.
  • Overwhelm: the client feels torn between two systems or between family and clinic. Slow down, map who is advising what, and help the client decide what they want, not what either system or the family wants. Use a joint family session only with consent.
  • Non-adherence to between-session tasks. Check whether the task clashed with their sense of balance (for example activity scheduling during a period they see as needing rest). Re-design it with them using the six-essentials language (4.11).
  • Rupture after you dismissed or seemed to mock the tradition. Acknowledge it plainly, apologise, and ask how it affected them. "I think I sounded dismissive about your hakim's advice. I'm sorry. Your way of understanding this matters to the work." Then repair through accurate use of their model.
  • The opposite error: you endorsed a remedy or regimen. Correct it at the next session: clarify that you are not qualified to judge remedies and that their physician should be consulted.
  • Physical warning signs (anaemia-type fatigue, abdominal pain, neurological symptoms in someone using imported remedies; fever, spreading redness or severe back pain after cupping). Route to GP or emergency care the same day as appropriate. [source: CDPH; Wang et al. 2023]
  • Purging, fasting or restrictive diets that look like an eating disorder. Assess for an eating disorder without assuming the regimen is the cause or that it is benign; arrange medical review; discuss with the client how their practitioner's advice fits with recovery.
  • Suicide risk framed as temperament or fate. Assess risk fully using current standard practice. Do not let the "melancholic nature" frame reduce the response. Involve family supports the client trusts.
  • Possible mania framed as a humoral shift (for example a client describing unusual cheerfulness as heat). Assess for bipolar disorder in the ordinary way; the historical link between black bile and both moroseness and mirth is not a diagnosis. [source: Laios et al. 2012]
  • The practitioner is unknown, unregistered or abroad. Do not refer to anyone you cannot identify. Where Indian regulation applies, registration on a State or National Register is required to practise as a qualified practitioner. [source: NCISM Act 2020] Elsewhere [uncertain: not verified]; discuss concerns with the client and their physician.
  • Child safety concerns. Follow 4.14 and local safeguarding procedures; never name the child in shared notes beyond what the procedure requires.
  • Your own uncertainty about the system. Use the client as the primary informant, a cultural broker as secondary, and supervision for your reactions. Do not fill gaps from general reading and present it as the client's tradition.

Sources

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