Arabic indigenous and Bedouin medicine

1. Introduction

Version followed: Arabic folk medicine (al-tibb al-sha'bi) and Bedouin healing as clinical surveys from the Negev (Israel) and Benghazi (Libya), social-work and ethnographic studies of Negev Bedouin healers (Al-Krenawi, Graham and colleagues), a Gulf physician's account, and Saudi Arabia's National Center for Complementary and Alternative Medicine (NCCAM) regulation describe them; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). Arabic-language sources were used for the Saudi regulatory material.

What it is. This is not a single codified system with an official textbook or national college. It is a cluster of inherited household and community practices across the Arab world, including among Bedouin communities: therapeutic cautery (kay, also written kaiy), bone-setting, wet cupping (hijama), herbal remedies, and spiritual healing by Qur'anic and Dervish healers. A Saudi newspaper column describes folk medicine as knowledge, skills and practices passed down between generations that differ from one culture to another, and keeps it distinct from "Prophetic medicine" (al-tibb al-nabawi) [source: Al-Nuwaimi 2020, Al Watan]. A Gulf cardiologist describes cautery as one of the oldest Arab therapies, now "fading away" but still practised, mainly by Bedouins and laypeople [source: AlBinali, drhajar.info].

How change is understood within the tradition (attributed). Accounts describe a stepwise pattern of help-seeking: hospital medicine is often tried first, then Qur'anic recitation by a religious healer, with cupping and cautery as a last resort; the proverb "cautery is the last remedy" (الكي آخر العلاج) expresses this [source: Cooper 1999, MJA; Al-Nuwaimi 2020]. Some users believe intense heat destroys disease, or that blistering and discharge carry illness out of the body [source: Farid and El-Mansoury 2015]. Bedouin healers are reported to locate the cause of distress outside the person (God, evil spirits or jinn, sorcery, the evil eye), which reassures patients that the illness is not their fault [source: Abels 1998, summarising Al-Krenawi]. These are the tradition's explanations, described here as its users hold them.

The psychotherapist's role. A psychotherapist does not perform cautery, bone-setting, cupping, herbal treatment or spiritual healing. The therapist's work is culturally responsive assessment, formulation and therapy alongside the client's use of these practices: understanding the client's explanatory model, screening for physical harm and delayed medical care, liaising with medical and (where the client wishes) religious or community helpers, and safeguarding. [synthesis]

2. Framework

2a. The tradition as sources describe it

Practitioner types reported. Bedouin and lay cautery practitioners; folk bone-setters; barbers and others who performed hijama; women healers treating household complaints; religious healers (a matowa, or holy man, who reads from the Qur'an, in a Yemeni account); and Dervish healers in the Negev who specialise in what biomedicine now calls psychiatric disorders [source: AlBinali; Cooper 1999; Al-Krenawi, Graham and Maoz 1996]. The Dervish study examined healers' own concepts of aetiology, symptom classification, diagnosis, stages of treatment and aftercare; the open abstract does not give their content [source: Al-Krenawi, Graham and Maoz 1996] [uncertain: details not verified].
Conditions people bring. Cautery is reported for jaundice, sciatica, chest pain, headache and migraine, epilepsy, "psychosomatic troubles", depression, fractures, diabetic foot and many others; cupping is described as used mainly for problems seen as metaphysical, such as malicious spells or the evil eye [source: Farid and El-Mansoury 2015; Cooper 1999]. No source presents these as treatments with evidence for physical or mental disease.
How common. In a 2016 clinic survey of 250 Muslim Bedouin patients in the Negev, 82% knew of curative cautery, 36% had undergone it, and most of those rated it helpful; men and people over 61 used it more [source: Journal of Immigrant and Minority Health 2016, 18(1):34–41; authors [uncertain]].
Who holds authority. There is no single licensing body for folk cautery or Bedouin spiritual healing. Authority rests with families, tribal and community reputation, and religious standing [synthesis]. In Saudi Arabia, the NCCAM regulation (Ministerial Decision, issued 1435 AH, amended 1441 AH) forbids practising any form of complementary and alternative medicine without an NCCAM licence; listed practices are cupping, acupuncture, bone straightening (taqwim al-'izam), spinal manipulation and natural therapy, with others added by the Center. Licensing requires a recognised qualification or classification by the Saudi Commission for Health Specialties, approved training, examinations and registration; licensed facilities must refer critical, emergency, obstetric and surgical cases to hospitals and report criminal cases [source: NCCAM regulation, text as reproduced by the legal database qanoniah.com; checking against the official NCCAM or government text is advised]. Official Saudi pages confirm the outline: NCCAM was set up within the Ministry of Health by Council of Ministers Resolution No. 236 (1429 AH) as the national body that regulates and monitors complementary and alternative medicine [source: NCCAM, Establishment page]; in 2015 the Ministry of Health announced that NCCAM issues cupping licences, that practitioners must be classified by the Saudi Commission for Health Specialties (as physician, nurse or physiotherapist), complete a cupping course and pass NCCAM's exam, and that clinics need a responsible general practitioner and are inspected, with penalties up to closure [source: Saudi Ministry of Health news, 17 February 2015]. Neither official page mentions cautery. Cautery (kay) and folk medicine are not among the practices the regulation lists. Whether NCCAM licenses kay, prohibits it, or leaves it unaddressed is [uncertain]. How cautery is regulated in Israel, Jordan, Libya and Gulf states other than Saudi Arabia is [uncertain]. Practical meaning: do not tell a client that a cautery practitioner is or is not "licensed"; ask what the client knows and route medical questions to a physician.
Evidence status. No independent systematic review is cited [uncertain: not verified]. A hospital-based Libyan survey (n=50) concluded that kaiy seems to cause more harm than benefit and called for public education and regulation of healers [source: Farid and El-Mansoury 2015]. Positive ratings in the Negev survey are self-report without a comparison group.

2b. The psychotherapist's framework [synthesis]

No source gives a session plan for psychotherapy with clients who use these practices. The phases below are a working structure built from the CFI and the cited studies.

Phase	Goals	Typical format	Move on when
1. Engagement and framing	Safety, trust, confidentiality, gender and language fit	Session 1; interpreter booked if needed	Client can name the problem in their own terms
2. Cultural assessment	Core CFI, explanatory model, help-seeking history including healers, kay, bone-setting, herbs	Sessions 1–3; family informant if client agrees	Shared written formulation in the client's words
3. Physical-safety and medical liaison	Screen burns, wounds, untreated fractures, delayed diagnosis, herb–medicine overlap; route to physician or prescriber	Same sessions, plus referral letters	Medical risks reviewed by a doctor or ruled out
4. Collaborative plan	Agree what therapy offers, what other helpers offer, consent for any contact	1–2 sessions	Client consents to the plan and any liaison
5. Therapy proper	Evidence-based treatment for the diagnosed condition, adapted to the explanatory model	Usual course for that condition	Agreed goals met or reviewed
6. Review and integration	Re-run CFI items as needed, review healer contacts and safety	Every 4–6 sessions and at ending	Ending or step-up of care

The APA notes that the CFI supplementary modules can be used at first evaluation, later in care, or repeatedly [source: APA CFI Supplementary Modules].

3. Guiding principles

The therapist is not the healer. Never perform, imitate or recommend cautery, cupping, bone-setting, herbal treatment or Qur'anic healing; practical meaning: your role is assessment, therapy, liaison and safeguarding. [synthesis]
Start where the client is. Practical meaning: take the client's account of cause first, before offering a psychological one [source: Abels 1998].
Respect explanations without endorsing or dismissing them. Practical meaning: speak of jinn, the evil eye or sorcery as "what you and your family understand", neither confirming nor contradicting [source: Abels 1998] [synthesis].
Avoid premature psychiatric labels, but do not miss illness. Practical meaning: use the CFI and DSM-5-TR cultural criteria before diagnosing, and refer when red flags appear [source: Abels 1998; APA CFI].
Externalise rather than blame. Practical meaning: frame the problem as something acting on the person and family, which fits how Bedouin healers are reported to reassure patients [source: Abels 1998].
Family is a resource and a context. Practical meaning: invite family into understanding the problem with the client's consent, and check whether a technique conflicts with family obligation [source: Abels 1998; Eltaiba 2010].
Expect clients to want direct guidance. Practical meaning: give clear, concrete suggestions where the client expects them [source: Abels 1998; Eltaiba 2010].
Respect gender and religious norms in the room. Practical meaning: ask about preferences on eye contact, handshakes, door position and clinician gender [source: Eltaiba 2010].
Confidentiality is part of treatment. Practical meaning: repeat how information is protected; stigma is high and some clients give false names or check family links [source: Eltaiba 2010].
Distress may arrive as the body. Practical meaning: headaches or chest pain may carry psychological distress, and may also need medical review [source: Eltaiba 2010].
Physical safety first. Practical meaning: ask about burns, wounds and untreated injuries in every assessment where these practices are used [source: Farid and El-Mansoury 2015].
No advice on herbs or medicines. Practical meaning: record what is used and route all questions to the prescriber or pharmacist. [synthesis]
Touch. The psychotherapist does not touch to treat. Any physical examination is done by a medical clinician with explicit consent before and during, the right to stop at any time, never sexual or genital touch. [synthesis]
Consent before any contact with healers or religious figures. Practical meaning: written, specific consent, with limits on what is shared. [synthesis]
Safeguard children. Practical meaning: cautery scars on a child, delayed treatment of a child's illness, or untreated fractures prompt a safeguarding conversation and, where required, a report [source: Al-Nuwaimi 2020; Farid and El-Mansoury 2015] [synthesis].
Humility about your own position. Practical meaning: an outsider rarely fully understands another culture; ask, and let the client correct you [source: Abels 1998].

4. Intervention inventory

All interventions below are the psychotherapist's own work. None is a folk or Bedouin healing practice, and none involves the therapist performing one. Where an item is built from general practice rather than a cited source, it is marked [synthesis].

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with Arab and Bedouin clients, to check your own assumptions about folk medicine, religion, tribe and gender. [source: Abels 1998; Eltaiba 2010]
Steps: (1) Before the first session, note your own reactions to cautery scars, Qur'anic healing or talk of jinn (disgust, fascination, fear of "collusion"). (2) Note what you know only from media. (3) Identify who can advise you (Arab colleagues, supervisors, cultural brokers). (4) In session, treat the client as the expert on their culture. (5) After sessions, review where Western techniques did not fit; Eltaiba describes assertiveness training failing because refusal would breach family duty. [synthesis built on Eltaiba 2010]
Example language (illustrative): "I am not from your community, so please correct me if I get something wrong about how things are done in your family."
Watch for: your own urge to argue the client out of a belief or to over-praise a practice; client deference that hides disagreement. Working if the client corrects you and adds detail. [synthesis]

4.2 Engagement, confidentiality and gender-sensitive framing

Purpose / when: first contact, and whenever stigma or gender norms seem to block disclosure. [source: Eltaiba 2010]
Steps: (1) Explain confidentiality and its limits plainly, and repeat it in later sessions. (2) Ask preferences on clinician gender, handshakes, eye contact, a family member present, and whether the door stays partly open. (3) Set up the room with a clear boundary (desk or table) if helpful. (4) Allow a more conversational, less interview-like pace. (5) Offer a same-gender clinician for topics such as sexuality where feasible. [source: Eltaiba 2010; Abels 1998]
Example language (illustrative): "What we say here stays with our service, unless someone is at risk of serious harm. I will remind you of that from time to time." / "Some people prefer a male or a female clinician for certain topics. Would that matter to you?"
Watch for: a false name, questions about your family links, presentation only of physical complaints; these may signal fear of stigma [source: Eltaiba 2010]. Working if disclosure deepens over sessions.

4.3 Interpreter and cultural broker use

Purpose / when: when the client prefers Arabic or a Bedouin dialect, or when religious and folk terms need explaining. [synthesis]
Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Check the interpreter is not from the client's extended family or tribe, and ask the client's consent to the specific person. (3) Brief the interpreter to translate terms such as jinn, 'ayn (evil eye), sihr (sorcery) and kay literally, and to tell you if a term has no easy equivalent. (4) Debrief after the session. (5) A cultural broker (for example an Arab clinician or community health worker) may explain context, with the client's consent and within confidentiality. [synthesis]
Example language (illustrative): "Before we start, is it all right that [interpreter] helps us today? If you know them or their family, tell me and we will find someone else."
Watch for: the client editing what they say because of the interpreter; terms being softened in translation. [synthesis]

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

Purpose / when: the main structured way to learn the problem from the client's and their network's viewpoint, including sources of help and expectations of services. It has 16 questions across four domains and is meant for any clinician, any client, any setting; it supports clinical decisions and is not the only basis for diagnosis [source: APA DSM-5-TR CFI; APA DSM-5-TR Section III]. Use it at intake. APA permits clinicians to reproduce it for use with their patients; translation or modification needs APA permission [source: APA DSM-5-TR CFI].
Steps (paraphrased, not the items): (1) Cultural definition of the problem: how the client and family describe it, and what troubles them most. (2) Perceived causes, context and supports, including the role of cultural identity (tribe, religion, Bedouin or town identity, migration). (3) Self-coping and past help-seeking, including healers, religious leaders, cautery, bone-setting and herbs, and barriers they met. (4) Current help-seeking preferences and the clinician–patient relationship, including language and experiences of discrimination. (5) Write a short formulation in the client's words. Time required: no figure given in APA forms; field-trial clinicians found later interviews took less time [source: Lewis-Fernández et al. 2017] [uncertain: a 15–20 minute estimate not verified].
Example language (illustrative): "People explain problems like this in many ways. How would you describe what is happening, in your own words?" / "Who else have you gone to for help, for example a sheikh, a healer or a relative who knows remedies?"
Watch for: answers that switch between physical and spiritual explanations; these can coexist. Working if the client offers their own terms rather than borrowing yours. [synthesis]

4.5 CFI Informant Version and family involvement

Purpose / when: when family members hold key knowledge or authority, or when the client is too unwell to give a full account. The Informant Version has 17 questions; the first covers the informant's relationship to the client [source: APA CFI Informant Version]. Bedouin healers are reported to involve all family members in understanding the problem [source: Abels 1998].
Steps: (1) Get the client's consent on who joins and what is discussed. (2) Interview the informant separately or jointly as the client prefers. (3) Compare the family's explanation with the client's. (4) Note who in the family decides about healers or hospital care. (5) Feed differences back carefully. [synthesis on APA structure]
Example language (illustrative): "Your son has agreed that I ask you some questions. How does the family understand what has happened to him?"
Watch for: family pressure overriding the client's wishes; disclosures the client did not consent to share; the Eltaiba case shows family obligation can outweigh individual goals. [source: Eltaiba 2010] [synthesis]

4.6 Supplementary modules: Explanatory Model; Spirituality, Religion and Moral Traditions; Coping and Help-Seeking; Immigrants and Refugees

Purpose / when: deeper assessment when the core CFI shows strong spiritual explanations, complex healer use, or migration. APA lists 12 modules usable as add-ons or alone, at any point in care [source: APA CFI Supplementary Modules].
Steps: (1) Pick the module the core CFI points to. (2) Explanatory Model: explore cause, mechanism, course and feared outcomes. (3) Spirituality, Religion and Moral Traditions: role of faith, religious practices and religious helpers in coping and in the problem. (4) Coping and Help-Seeking: sequence of helpers tried, including kay, cupping, bone-setting and Qur'anic recitation. (5) Immigrants and Refugees: for clients who left the region, including access to familiar healers. (6) Record results in the formulation. [source: APA CFI Supplementary Modules; module contents paraphrased]
Example language (illustrative): "You mentioned prayer and the Qur'an help you. Can you tell me more about how faith fits with what you are going through?"
Watch for: religious guilt or fear of punishment as part of the distress; spiritual coping that is protective. Working if the client feels their faith was taken seriously. [synthesis]

4.7 Kleinman explanatory-model questions

Purpose / when: a short alternative or supplement to the CFI when time is limited [source: Kleinman, Eisenberg and Good 1978, via Tanenbaum handout].
Steps (paraphrased): ask what the client calls the problem; what caused it; 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 the client thinks they should receive; the main problems it has caused; what they fear most about it. [source: Tanenbaum handout]
Example language (illustrative): "What do you think started this, and why then?" / "What do you fear most could happen?"
Watch for: answers such as the evil eye, envy (hasad), jinn or sorcery; record them as the client's model. The feared outcome often points to the therapy target. [synthesis]

4.8 Non-judgemental inquiry about healers and physical treatments

Purpose / when: every assessment, because use is common and often hidden from doctors (one Jordanian patient did not want his psychiatrist to know he had seen a healer for sorcery) [source: Eltaiba 2010; Negev cautery survey 2016].
Steps: (1) Normalise: say many families use both hospital and traditional care. (2) Ask by category: Qur'anic or religious healers, Dervish or other spiritual healers, cautery, cupping, bone-setting, herbal or bought supplements. (3) For each: when, for what, by whom, and what the client felt it did. (4) Ask whether the client plans further treatment. (5) Do not ask for details of rituals, prayers or methods. (6) Record neutrally. [synthesis]
Example language (illustrative): "Many people here use both hospital medicine and traditional treatment, and I will not judge either. Have you had kay, cupping, bone-setting or herbs for this, or seen a sheikh or healer?"
Watch for: shame or quick denial; a pattern of trying cautery after hospital care "failed", which may signal unmet medical need [source: Cooper 1999; Farid and El-Mansoury 2015]. Working if the client volunteers future plans.

4.9 Distinguishing spirit-related explanations from psychiatric disorder

Purpose / when: when the client or family attributes symptoms to jinn, the evil eye or sorcery, or describes possession-like episodes. Avoid both pathologising a shared belief and missing psychosis, mood disorder or a dissociative disorder. [synthesis]
Steps: (1) Establish whether the belief is shared by the client's family and community (CFI, informant). (2) Separate the explanation ("this is the evil eye") from the symptoms (sleep, mood, perception, functioning). (3) Assess symptoms on their own terms. (4) For episodes of altered identity or awareness, apply the cultural criteria: DSM-5-TR dissociative identity disorder allows identity disruption described as possession but excludes states that are a normal part of broadly accepted cultural or religious practice; dissociative trance under other specified dissociative disorder carries a similar exclusion [source: PMC9199574 quoting DSM-5; Lewis 2023 citing DSM-5-TR] [uncertain: exact DSM-5-TR wording not verified]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require that the state is involuntary, unwanted and not part of accepted cultural or religious practice [source: findacode ICD-11 mirror; PMC9199574]. (5) Ask a cultural broker or the client's own religious adviser, with consent, whether the experience is seen as normal in the community. (6) Refer for psychiatric review if there is functional decline, risk, or symptoms the community itself regards as illness. [synthesis]
Example language (illustrative): "Your family feels this may be the evil eye. Whatever the cause, I would like to understand how you are sleeping, eating and feeling day to day, so we can make sure you get every kind of help that could work."
Watch for: command hallucinations, persecutory beliefs beyond what family share, manic signs, self-neglect; possession talk used to explain abuse. The DSM-5-TR note on culturally sanctioned beliefs and psychotic symptoms [uncertain: not verified]. Working if the client accepts a both-and plan. [synthesis]

4.10 Somatic presentation: joint psychological and medical reading

Purpose / when: headaches, chest pain or bodily complaints that may carry psychological distress, and that may also be why the client sought cautery [source: Eltaiba 2010; Cooper 1999].
Steps: (1) Accept the bodily complaint as real. (2) Confirm a medical review has happened or arrange one. (3) Explore links between symptoms, stressors and family events, using the client's language. (4) Offer psychological work as one of several helps, not a replacement for medical care. [synthesis]
Example language (illustrative): "The pain is real, and your doctor should keep checking it. Stress and worry can also make pain worse, so we can work on that side here."
Watch for: new or worsening physical signs; the Benghazi series reports late-stage cancers found after medical care was delayed in favour of kaiy [source: Farid and El-Mansoury 2015]. Working if the client keeps medical appointments.

4.11 Physical-safety screening and medical liaison (cautery, bone-setting, cupping)

Purpose / when: whenever the client reports cautery, bone-setting or cupping, or you see burn scars. The therapist screens and refers; the therapist does not examine or touch. [synthesis]
Documented complications to know: kaiy: disfigurement and keloid scarring, deep infected burns and blisters, abscesses, severe bleeding, septic shock, weight loss, dry gangrene with amputation in diabetic patients, loss of an eye after prolonged treatment for eye pain, and late diagnosis of colon, uterine, lung and breast cancer [source: Farid and El-Mansoury 2015]; scarring is the expected outcome and one recalled patient died weeks after cautery for chest pain [source: AlBinali]; treatments can be "harmful or disfiguring" [source: Cooper 1999]. Clinical reports of complications from Arab folk bone-setting are [uncertain] here; Saudi Ministry of Health fracture-care advice lists general warning signs such as numbness, colour change, swelling, inability to move fingers and odour or discharge [source: Ajel 2021 reporting MOH].
Steps: (1) Ask when and where, any wound still open, fever, pain, discharge, numbness or loss of movement. (2) Ask about diabetes and other conditions where burns heal poorly. (3) If any active sign, arrange same-day medical review. (4) If the client plans further cautery or bone-setting, discuss risks factually and encourage medical review first, without forbidding. (5) In Saudi Arabia, clients can check whether a cupping or bone-straightening practitioner holds an NCCAM licence [source: NCCAM regulation]. (6) Document. [synthesis]
Touch rule: any physical examination is done by a medical clinician, with explicit consent before and during, the right to stop at any time, a chaperone offered, and never sexual or genital touch; intimate areas are described only in clinical terms. [synthesis]
Example language (illustrative): "Thank you for telling me about the kay. Is the place still sore, red or leaking? If so, I would like a doctor to see it today."
Watch for: hidden wounds under clothing, untreated fractures, delayed cancer symptoms (bleeding, weight loss, lumps, cough with blood). Working if medical review happens and the client returns.

4.12 Herbal remedies and supplements: record and route

Purpose / when: whenever the client uses herbs, attar-shop mixtures or bought supplements, especially alongside psychiatric or other medicines. [synthesis]
Background: in a Jordanian survey of 401 community pharmacists, 98.5% of pharmacies sold herbal supplements, 63% of pharmacists were unaware of herb–drug interactions, and the authors raised concern about adulteration of slimming and sexual-enhancement products with undeclared drugs [source: Jalil et al. 2022].
Steps: (1) Ask what is taken, from whom, and for what. (2) Write down names as the client gives them. (3) Never advise starting, stopping or changing any herb or medicine. (4) Pass the list to the prescriber or pharmacist with consent. (5) Report suspected adverse reactions through the medical team. [synthesis]
Example language (illustrative): "I am not able to advise on herbs or medicines, but your doctor needs to know everything you take so they can check it is safe together. May I share this list?"
Watch for: new agitation, sleeplessness, confusion, liver or bleeding signs, or sudden change in a psychiatric medicine's effect; route to the prescriber. [synthesis]

4.13 Externalising, non-blaming formulation

Purpose / when: when shame or self-blame is high; it matches the reported Bedouin healers' practice of telling patients the illness is not their own making [source: Abels 1998].
Steps: (1) Name the problem as something acting on the client and family. (2) Map its effects on each family member. (3) Identify times the client resisted it. (4) Build steps against its influence. (5) Keep spiritual explanations intact; externalising does not require agreeing on cause. [source: Abels 1998, linking to narrative practice] [synthesis on steps]
Example language (illustrative): "This heaviness has taken a lot from you and your family. When has it had less power over you?"
Watch for: externalising that removes responsibility for harm to others. Working if self-blame falls. [synthesis]

4.14 Collaboration with religious and community helpers

Purpose / when: when the client wants their religious healer, imam or a respected elder involved. Al-Krenawi and Graham argue that, among Negev Bedouin, traditional healing and mental-health practice are "potentially complementary" [source: Al-Krenawi and Graham 1996, World Health Forum]. Outside the Arab world, a trial in Nigeria and Ghana found collaborative care between traditional or faith healers and primary-care workers reduced psychosis symptoms and harmful practices [source: COSIMPO, Gureje et al. 2020]; a Ghanaian prayer-camp trial found adding medication reduced symptoms but not days in chains [source: Ofori-Atta et al.]. No Arab-region trial is documented in the sources cited [uncertain].
Steps: (1) Ask whether the client wants any contact. (2) Get specific written consent: who, what may be shared, for what purpose. (3) Contact the helper as a colleague, to agree on shared aims (safety, continuing medical care). (4) Agree on red flags that prompt hospital referral. (5) Review with the client. Do not refer clients to unlicensed physical practitioners, and do not seek or arrange healing rituals. [synthesis]
Example language (illustrative): "You said the sheikh's support matters to you. Would you like me to speak with him, and if so, what would you be comfortable with me sharing?"
Watch for: helpers advising stopping medicine or hospital care; restraint or coercion; breaches of confidentiality in a small community. [synthesis]

4.15 Integrating healing experiences into therapy

Purpose / when: after the client has had cautery, cupping or spiritual healing, to make sense of it within therapy. [synthesis]
Steps: (1) Ask what the experience meant and what changed. (2) Note relief, disappointment or fear. (3) Link helpful meanings (being cared for, family solidarity, faith) to therapy goals. (4) Address any distress from the procedure, including scars, pain or fear. [synthesis]
Example language (illustrative): "What was it like for you, and what did your family feel afterwards?"
Watch for: traumatic responses to painful procedures, especially those done in childhood; body-image distress from visible scars (one adult's chest scars from infant cautery limited what she could wear) [source: Al-Nuwaimi 2020]. Working if the client can hold mixed feelings.

4.16 Safeguarding and reporting

Purpose / when: when a child or a dependent adult has been or may be harmed by cautery, bone-setting, restraint or delay of urgent medical care. [synthesis]
Steps: (1) Ask about children in the household who have had kay or bone-setting, and about any untreated illness. (2) Separate a family's sincere intent from the effect on the child; safeguarding is about harm, not culture. (3) Follow your jurisdiction's child-protection and adult-safeguarding procedures. (4) Explain your duties to the family in plain terms. (5) In Saudi Arabia, licensed CAM facilities must report criminal cases and refer emergencies to hospital [source: NCCAM regulation]; reporting duties elsewhere are [uncertain]. [synthesis]
Example language (illustrative): "I can see your family wants the best for her. Burns on a small child can become infected quickly, so I need a doctor to check her today, and I have to follow our child-safety rules."
Watch for: open or infected burns on a child, untreated limb injury, chest cautery for breathing problems in infants [source: Al-Nuwaimi 2020]; abuse explained away as treatment. Never name minors in records shared outside the care team. [synthesis]

5. Handling problems

Most guidance here is [synthesis]; cited points are marked.

Client hides healer use, then it surfaces. Thank them, do not show disappointment, and re-normalise dual use. Ask what made it hard to say; stigma and fear of the doctor's reaction are reported [source: Eltaiba 2010]. Then complete the safety screen (4.11). [synthesis]
Client plans cautery or bone-setting for a condition under medical care. Do not forbid or ridicule. Give the documented risks factually (infection, scarring, delayed diagnosis) [source: Farid and El-Mansoury 2015], ask the client to talk to their doctor first, and agree on warning signs that mean returning to hospital. If a child is involved, move to safeguarding (4.16). [synthesis]
Client says therapy cannot help because the cause is jinn, sorcery or the evil eye. Do not debate cause. Offer therapy as help with the effects (sleep, fear, family conflict) whatever the cause, and ask whether their religious adviser would support it. [synthesis] Bedouin clients are reported to expect concrete instructions; give clear, practical tasks [source: Abels 1998].
Stuck: Western techniques clash with family obligation. Re-formulate with the family's structure in mind; the Eltaiba case shows assertiveness training failing where refusal breached family duty [source: Eltaiba 2010]. Try problem-solving that keeps family roles, or involve a respected family member with consent. [synthesis]
Family overrides the client's wishes or takes over sessions. Return to consent: who may join, what may be shared. Offer individual time. Name the client's goals alongside the family's. [synthesis]
Non-adherence to psychiatric medication because a healer or relative advised stopping. Do not advise on the medicine. Explore the reasons, then route to the prescriber promptly; if the client consents, a joint conversation with the helper about continuing medical care may help (see 4.14). [synthesis]
Overwhelm or shame when discussing possession or sorcery. Slow down, return to the client's own words, check that the explanation is respected, and ground in the present. Re-state confidentiality. [synthesis]
Rupture over gender or religious norms (handshake, eye contact, female clinician with a male client, or the reverse). Acknowledge it directly, ask what would feel right, and offer a different clinician if wanted [source: Eltaiba 2010] [synthesis on repair].
Rupture because the client feels judged about kay or scars. Apologise for how it landed, restate that you are not judging, and explain why you asked (their safety). [synthesis]
Small-community confidentiality (interpreter, cultural broker or helper knows the family). Check connections before each new person joins and offer alternatives. [synthesis]
Unclear whether possession-like episodes are culturally normative or a disorder. Hold the question open, consult a cultural broker and a psychiatrist, and use the DSM-5-TR and ICD-11 cultural exclusions (4.9). Act on risk regardless of attribution. [synthesis]
Harmful practice discovered (restraint, burns on a child, untreated fracture, withdrawal from cancer care). Prioritise medical safety, follow local reporting duties, explain them to the family, and keep the therapeutic relationship where possible. [synthesis]
The therapist is asked to perform or endorse a remedy. Decline clearly and kindly: your role is therapy, liaison and safety. Do not recommend practitioners, herbs or rituals. In Saudi Arabia, the client may check NCCAM licensing for cupping or bone-straightening practitioners [source: NCCAM regulation]. [synthesis]
Suicide or self-harm risk. Use standard risk assessment and safety planning, regardless of spiritual attribution; involve family and religious supports as protective factors only with consent. [synthesis]

Sources

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