Haitian Vodou · Atlas

1. Introduction

Version followed: Haitian Vodou as described in the WHO/PAHO literature review Culture and Mental Health in Haiti (2010, team coordinated and edited by Laurence J. Kirmayer) and in peer-reviewed work on Vodou and mental health (Khoury et al. 2012; Auguste & Rasmussen 2019). The clinician's side follows the DSM-5-TR Cultural Formulation Interview (CFI, APA) and the DSM-5 cultural concepts of distress (their DSM-5-TR status is [uncertain]), which list maladi moun. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader]

What it is. Haitian Vodou is a living religion, not a psychotherapy. Its practitioners serve the lwa, described in the WHO/PAHO review as spirits, ancestors or saints who can protect devotees and can also cause harm if not satisfied. The review states that Vodou "constitutes a health care system" covering healing, prevention and well-being, alongside its religious life (p. 7). This guide describes Vodou only as its practitioners and scholars report it. The psychotherapist does not practise Vodou, and this guide gives no ceremony, song, prayer, sacred object, initiation or divination content. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]

Who holds authority. Within Vodou, the oungan (priest) and manbo (priestess) "possess the knowledge of the tradition" and are respected in their communities (WHO/PAHO 2010, p. 7). The same review distinguishes the bòkò, described as someone who can send curses or spells, from the oungan and manbo. Before 2008, Haiti's oungans were reported to be "largely independent" [uncertain: secondary, unverified]. The Associated Press reported that Max Beauvoir became Vodou's supreme chief in 2008 and led Haiti's main priests' organisation until his death in Port-au-Prince on 12 September 2015 [source: Associated Press 2015]. In June 2026 Le Nouvelliste reported that Augustin Saint-Clou was officially invested as Haiti's National Vodou Ati, with officials of the Konfederasyon nasyonal vodouyizan ayisyen (KNVA) and the Ministry of Cults present [source: Le Nouvelliste 2026]; a 2021 Global Press Journal report had already named him supreme chief. How far any central office speaks for individual temples is [uncertain]; ask the client whom they recognise. In April 2003 President Jean-Bertrand Aristide's government recognised Vodou as a religion, giving Vodou ceremonies such as marriages equal standing with Catholic ones. The US State Department reports that Vodou practitioners may register with Haiti's Bureau of Religious Affairs, though many operate informally, and estimates that about half of Haitians practise Vodou, most alongside other religious practice. [source: https://wildhunt.org/2015/09/max-g-beauvoir-the-voice-and-the-face-of-haitian-vodou.html] [source: https://www.foxnews.com/world/max-beauvoir-leader-of-voodoo-priests-organization-dies-in-haiti.amp] [source: https://lenouvelliste.com/en/article/268846/augustin-saint-clou-officially-installed-as-haitis-national-vodou-ati] [source: https://worldcrunch.com/culture-society/mental-health-vodou] [source: https://pluralism.org/news/voodoo-officially-recognized-religion-government] [source: https://www.refworld.org/node/82549]

Core idea of how change happens (for the therapist). The scholarship describes a "cosmocentric" view in which a person is shaped by relationships with spirits, family and community, rather than an individualistic self (Auguste & Rasmussen 2019). Illness may be understood as natural or as sent or spiritually caused, and many Haitians use several sources of help at once. The psychotherapist's change mechanism is therefore their own culturally responsive work: understanding the client's explanatory model, assessing without pathologising normative religious experience or missing illness, and, when the client wishes, coordinating with the healers the client already trusts. [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]

2. Framework

Vodou is not a staged clinical model, so the framework below is the psychotherapist's own sequence of work with a client for whom Vodou matters. The phases are [synthesis], built from the CFI's structure and the WHO/PAHO review's recommendations. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]

Phase 0. Preparation (before and between sessions). Goal: examine your own beliefs about illness and about Haitian culture, as the WHO/PAHO review asks of helpers (p. 22). Learn the Kreyòl idioms of distress and the historical context, including stigma against Vodou. Arrange a Kreyòl interpreter or cultural broker if needed. Move on when you can name your own assumptions about Vodou and have an interpreter plan.
Phase 1. Engagement and cultural assessment (sessions 1 to 3, often with family). Goal: understand the problem in the client's terms. Use the core CFI (16 questions in four domains), the Informant Version with a family member when the client agrees, and the relevant supplementary modules. APA's published forms give no administration time; a figure of about 15 to 20 minutes for the core CFI is [uncertain]. Move on when you can state the client's explanatory model, help-seeking map and preferences in words the client agrees with.
Phase 2. Differential understanding and risk. Goal: distinguish culturally normative experience, including possession within ceremony, from a disorder needing treatment, and assess suicide and safety risk. Consult a cultural broker or, with consent, the client's religious adviser where the picture is unclear. Move on when the formulation and risk plan are agreed.
Phase 3. Shared plan and collaboration. Goal: agree a concrete plan that fits the client's model. With the client's explicit consent, coordinate with the oungan, manbo, pastor or priest the client already consults, and with any prescriber. Move on when roles, consent limits and communication routes are written down.
Phase 4. Treatment and integration (number of sessions set by the presenting problem). Goal: deliver your usual evidence-based therapy, adapted in language and content, and help the client integrate spiritual and clinical understandings without forcing an "either/or" choice (WHO/PAHO 2010, p. 22). Review the CFI themes periodically; the APA allows the supplementary modules to be repeated during treatment.
Phase 5. Review, safeguarding and ending. Goal: check outcomes against the client's own goals, keep watch for harm from any source, and plan how the client will continue to use family, religious and clinical supports.

3. Guiding principles

Cultural humility. Examine your own beliefs about illness and Haiti before judging the client's. In practice: notice reactions shaped by media images of "voodoo". [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Vodou is a religion and a health system to its practitioners. In practice: speak of it with the respect you would give any faith, using its own terms (Vodou, oungan, manbo, lwa). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Attribute, do not adjudicate. Describe spiritual causes as the client and tradition hold them, neither as fact nor as delusion. In practice: "In your understanding, the lwa..." rather than agreeing or correcting. [synthesis]
Pluralism is normal. Haitians use resources pragmatically and often hold hybrid models, and families willingly combine treatments. In practice: never make the client choose between you and their healer. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Assess content as well as form. The WHO/PAHO review states that assessment "must not look only at the form, but also at the theme or the content" (p. 14). In practice: possession behaviour in its ceremonial context is not, by itself, a symptom. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Avoid both errors. Do not pathologise normative religious practice as psychotic, and do not miss illness hidden behind a spiritual explanation. In practice: look for the wider pattern of symptoms and impairment. [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader]
Be active and concrete. Clients may expect active engagement and a concrete plan, and "neutrality and lack of feedback" may feel like a waste of time (WHO/PAHO 2010, p. 21). In practice: end each session with a clear next step. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Family first. Families are usually consulted first, and personal problems may be seen as a family or religious matter. In practice: invite family involvement when the client wishes it, and check confidentiality limits. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Expect shame and slow disclosure. Mental health problems are often considered taboo and shameful. In practice: do not read guardedness as resistance. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Collaborate with the client's consent and on the client's terms. Spiritual leaders can act as "consultants" or "co-therapists" (WHO/PAHO 2010), and oungans may refer to biomedical care. In practice: contact a healer only with explicit, specific consent. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Name stigma and religious conflict. Vodou practitioners have faced stigma and violence, including killings during the 2010 cholera outbreak, and some clients fear their church will learn they consulted an oungan. In practice: protect such disclosures carefully. [source: https://www.refworld.org/node/82549] [source: https://worldcrunch.com/culture-society/mental-health-vodou]
Stay within your role. Do not perform, prescribe, interpret or recommend Vodou ceremonies, and do not advise on herbal remedies or medicines. In practice: route spiritual questions to the client's own religious authority and medicine questions to the prescriber. [synthesis]
Safeguarding applies to everyone. Harm from any source, whether family, community, religious or clinical, triggers your usual duties. [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work alongside Vodou. None of it is a Vodou practice. Example language is illustrative wording for this guide, not text from any manual.

4.1 Cultural self-examination before and during the work

Purpose / when: before the first session and whenever you notice a strong reaction to spiritual material. The WHO/PAHO review asks helpers to examine their own beliefs about illness and about Haitian culture, and to be prepared to learn from clients (p. 22). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Steps: (1) List your assumptions about Vodou, including any shaped by film, media or your own religious background. (2) Note which are evidence-based and which are stereotypes. (3) Read the client's own terms (see 4.5 and 4.6) before the session. (4) After sessions where possession, curses or spirits came up, write down what you felt and whether it shaped your questions. (5) Take recurring reactions to supervision or consultation with a Haitian colleague. [synthesis]
Example language (illustrative, to yourself or in supervision): "What did I assume when the client said the problem was sent?"
Watch for: the urge to reassure the client that spirits are not real, or the opposite urge to "go along" with spiritual interpretations you do not understand. It is working when your questions become curious rather than corrective. [synthesis]

4.2 Core Cultural Formulation Interview

Purpose / when: at intake, to clarify the problem from the client's and their social network's perspective, including meaning, sources of help and expectations of services. The DSM-5-TR core CFI has 16 questions in four domains: cultural definition of the problem (Q1 to 3); cultural perceptions of cause, context and support (Q4 to 10); cultural factors affecting self-coping and past help seeking (Q11 to 13); and cultural factors affecting current help seeking (Q14 to 16). The APA states that it supports understanding and decision-making and is not meant to be the only basis for a diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Obtain the official form from the APA; clinicians may reproduce it for use with their patients, but modifying or translating it needs APA permission. (2) Explain that you want to understand the problem in the client's own words. (3) Work through the four domains in order, paraphrasing the APA prompts rather than reading them stiffly. (4) Use the client's own words for the problem (for example reflechi twòp or maladi moun) for the rest of the interview. (5) In domain 4, ask directly about the clinician relationship, including language barriers and experiences of racism. (6) Summarise back and check you have it right. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Steps 2, 4 and 6 are [synthesis].
Example language (illustrative): "People describe problems in many ways. How would you describe what is happening, in your own words or in Kreyòl?" / "Who else have you gone to for help with this, for example family, church, an oungan or manbo, a doctor?"
Watch for: brief, guarded answers in early sessions, which the WHO/PAHO review links to shame and stigma (p. 21). It is working when the client corrects or extends your summary. The DSM-5 field trial found that later CFI interviews required less time; a typical duration in minutes is [uncertain]. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]

4.3 CFI Informant Version with family

Purpose / when: families are usually consulted first in Haiti, and problems may be seen as family or religious matters (WHO/PAHO 2010, p. 20). The APA Informant Version (17 questions, labelled DSM-5 2013) is used with a family member or friend; its first question covers the informant's relationship to the patient, then the same four domains follow. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Steps: (1) Ask the client who in the family should be involved and what may and may not be shared. (2) Meet the informant with or without the client, as the client prefers. (3) Use the Informant Version. (4) Compare the family's and the client's models, noting differences in religious affiliation (for example a Protestant relative and a Vodou-serving client). (5) Share back only what the client has agreed. [synthesis, built on the APA form]
Example language (illustrative): "Your mother sees this as something sent. How do you see it? Is it all right if I hear her view too?"
Watch for: family members speaking for the client, especially about possession or curses; conflict between Christian and Vodou relatives; pressure on the client to stop seeing a healer or a clinician. It is working when the family can describe a shared plan. [synthesis]

4.4 CFI supplementary modules

Purpose / when: the APA lists 12 supplementary modules, usable as add-ons to the core CFI or standalone, at first evaluation, later in care or repeatedly. For Vodou-serving clients the most relevant are: Spirituality, Religion and Moral Traditions; Explanatory Model; Coping and Help-Seeking; Cultural Identity; Social Network; Immigrants and Refugees (for diaspora clients); and Caregivers. The core CFI form shows which module expands each subtopic. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) After the core CFI, pick the modules the client's answers point to. (2) Use the Spirituality module to map the client's religious practice, including dual practice (for example Catholic and Vodou) and its role in coping. (3) Use the Immigrants and Refugees module for diaspora clients, covering migration, the 2010 earthquake if relevant, and losses. (4) Repeat modules later if the picture changes. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] Steps 2 and 3 are [synthesis].
Example language (illustrative): "Some people serve the lwa, some go to church, many do both. What role does religion play in how you are coping?"
Watch for: reluctance to disclose Vodou practice to a clinician who seems Christian or secular, and fear that a church will find out. It is working when the client volunteers religious resources without being asked. [source: https://worldcrunch.com/culture-society/mental-health-vodou] [synthesis]

4.5 Eliciting the explanatory model, including Haitian illness categories

Purpose / when: to learn what the client thinks the problem is, what caused it and what should be done. Kleinman, Eisenberg and Good (1978) set out eight explanatory-model questions, paraphrased: what do you call the problem; what caused it; why did it start when it did; what does it do to you and how does it work; how severe is it and will it last; what treatment should you receive; what are the chief problems it has caused; what do you fear most about it. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Haitian categories to listen for (as the sources describe them): natural versus supernatural illness; maladi Bondyè ("God's disease", natural); maladi peyi (common illness of the country); maladi moun fè mal (illness caused by others); maladi lwa; and maladi Satan ("sent" sickness). Natural illness is thought more amenable to biomedical treatment. Hot-cold balance is used to explain natural illness. Supernatural possession or sent spirits was the most often cited cause of severe mental illness in Khoury et al.'s rural study. External attribution may help recovery by allowing people to call on the lwa to intervene (WHO/PAHO 2010, p. 12). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader]
Steps: (1) Ask the eight questions in plain words, in Kreyòl through an interpreter if needed. (2) Ask whether the problem is natural, sent, or both, without suggesting an answer. (3) Ask who in their world agrees and who disagrees. (4) Ask what the client's healer, pastor or doctor has said. (5) Record the model in the client's words. (6) Use the model to frame your treatment rationale (for example, therapy for the "thinking too much" while the client continues spiritual care for what they see as sent). [synthesis, built on the sources above]
Example language (illustrative): "Some people say an illness like this comes from God, some say it was sent by someone, some say both. What do you think?"
Watch for: hybrid models, which are common and not a sign of confusion; fear of naming a person believed to have sent the illness; your own pull to correct the model. It is working when the client can say how your work and their spiritual care fit together. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [synthesis]

4.6 Recognising cultural concepts and idioms of distress

Purpose / when: throughout assessment, so that distress expressed in Haitian terms is neither missed nor misread. DSM-5-TR describes cultural concepts of distress as including "idioms, explanations or perceived causes, and syndromes". [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
What the sources describe:
- Maladi moun ("humanly caused illness") was among the nine DSM-5 (2013) glossary entries: illness believed to be "sent" by others out of envy or hatred, used to explain a range of medical and psychiatric problems, including psychotic and depressive symptoms and school or social problems. DSM-5-TR appears to list maladi dyab instead; that change is [uncertain]. [source: https://revistapsiquiatria.pt/index.php/sppsm/article/download/139/69] [source: https://www.openforum.com.au/from-amok-to-susto/] [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]
- Reflechi twòp ("thinking too much") is troubled rumination overlapping with sadness, severe mental disorder, suicide and social hardship. In the Central Plateau it was linked to higher depression and anxiety scores and about eight times greater odds of suicidal ideation, and it is locally believed to lead to psychosis if untreated (Kaiser et al. 2014). [source: https://hsrc.himmelfarb.gwu.edu/smhs_psych_facpubs/1583]
- Tèt (head) and kè (heart) terms made up most coded idioms of distress in Keys et al. (2012), who identified 44 distress terms. Lay meanings varied widely, and clinicians tended to read them biomedically and miss mental health concerns. [source: https://ideas.repec.org/a/eee/socmed/v75y2012i3p555-564.html]
- Sezisman is paralysis or shock after sudden bad news or witnessing death. Endispozisyon is spells of weakness or fainting linked to emotional distress. Move san is illness "caused by malignant emotions", linked to infant illness and postpartum care. Dépression may mean discouragement, is often expressed somatically, and is "not considered a mental illness" (WHO/PAHO 2010, pp. 14 to 20). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
- Fou (madness) is the term psychiatrists have linked to psychosis, and possession is reported as one cause of it. [source: https://hsrc.himmelfarb.gwu.edu/smhs_psych_facpubs/1583] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Steps: (1) When the client uses a head, heart or blood term, ask what it means for them, since meanings vary. (2) Ask what usually happens to people with this problem and what helps. (3) Screen for depression, anxiety, trauma and suicidal thinking alongside the idiom, especially with reflechi twòp. (4) Record the idiom and its meaning in the formulation, not as a diagnosis in itself. [synthesis, built on the sources above]
Example language (illustrative): "You said your head is heavy and you think too much. Tell me what that is like. When you think too much, do thoughts of not wanting to live ever come?"
Watch for: treating an idiom as a fixed diagnosis; dismissing somatic complaints as "just culture"; missing suicidality behind "thinking too much". It is working when the client recognises their experience in your summary. [synthesis]

4.7 Asking about Vodou and other healers without judgement

Purpose / when: at intake and at review, to map all the help the client uses. Lower-income Haitians in Haiti were reported to consult an oungan first, more affluent Haitians a psychiatrist first, and orthodox Catholics and fundamentalist Protestants generally to avoid oungans and use herbalists and prayer (WHO/PAHO 2010, p. 20). Oungans and pastors in rural Haiti often referred patients to clinics, and folk practitioners wanted to collaborate with biomedical providers (Khoury et al. 2012). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Steps: (1) Normalise using several helpers. (2) Ask who the client sees, how often, what they were told the problem is, and what was recommended in general terms. Do not ask for ceremony details, and do not interpret them. (3) Ask whether any herbal teas, baths or other remedies are being used, only to pass that information to the prescriber. (4) Ask what the client wants from you that the other helpers do not provide. (5) Record the help-seeking map. [synthesis]
Example language (illustrative): "Many Haitian families use a doctor, the church and an oungan or manbo at the same time. I am not here to judge that. Who else is helping you now?"
Watch for: fear that disclosure will be reported to a church or family; shame about consulting either a healer or a psychiatrist; any advice to stop medicines, which should go straight to the prescriber. It is working when the client tells you what the healer said without hesitation. [source: https://worldcrunch.com/culture-society/mental-health-vodou] [synthesis]

4.8 Distinguishing normative possession and spiritual experience from disorder

Purpose / when: when the client or family reports possession, spirit persecution or sent spirits. Within Vodou, possession is understood as a divine experience with ceremonial purposes and cannot be understood apart from that context. Women are more likely than men to be possessed, and possession can be a source of social power for women (WHO/PAHO 2010, pp. 7, 16). [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader] [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Diagnostic anchors: ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder apply only when the state is involuntary and unwanted, is not part of accepted cultural or religious practice, recurs or lasts several days, and causes significant distress or impairment. In 6B63 "the individual's customary sense of personal identity is replaced by an external 'possessing' identity". In DSM-5, identity disruption in dissociative identity disorder "may be described in some cultures as an experience of possession", and the disturbance must not be "a normal part of a broadly accepted cultural or religious practice"; DSM-5-TR keeps this in substance, exact wording [uncertain]. Dissociative trance under other specified dissociative disorder excludes trance that is part of broadly accepted collective practice. A DSM-5-TR note that culturally sanctioned beliefs should not count as psychotic symptoms is [uncertain: not verified]. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]
Steps: (1) Ask where and when the experience occurs: within ceremony and expected, or outside it, unwanted and uncontrolled. (2) Ask whether the client's religious community regards it as normal or as a problem. (3) Look at the wider pattern. The WHO/PAHO review (citing Azaunce 1995) notes that possession linked to schizophrenia usually comes with blunted affect, thought disorder, deteriorating functioning and social withdrawal (p. 14). (4) Note that spiritual beliefs can shape delusional content, such as persecution by a lwa or by a person. (5) With consent, consult a cultural broker, a Haitian clinician or the client's own oungan or manbo about whether the experience is usual. (6) Diagnose only if criteria are met beyond the culturally expected experience. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader] Steps 1, 2, 5 and 6 are [synthesis].
Example language (illustrative): "When this happens in a ceremony, is it what you and your community expect? Has it happened at other times, when you did not want it?"
Watch for: labelling ceremonial possession as psychosis; the opposite error of accepting a spiritual label while sleep, self-care and functioning deteriorate; a family's attribution being imposed on the client. The WHO/PAHO review notes that possession by an evil spirit may be seen as best dealt with by spiritual healers (p. 14), which can coexist with clinical care. It is working when the formulation names both the cultural meaning and any disorder. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [synthesis]

4.9 Suicide and risk assessment within the client's model

Purpose / when: at every assessment and whenever reflechi twòp, hopelessness or a sent illness is reported. Auguste and Rasmussen report that health workers may misread suicidal ideation as anxiety, that some people disclose suicidal thoughts to healers rather than clinicians, and that within maladi moun fè mal a suicide may be seen as blameless. [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader] [source: https://hsrc.himmelfarb.gwu.edu/smhs_psych_facpubs/1583]
Steps: (1) Ask directly about suicidal thoughts, using the client's idiom as a bridge. (2) Ask whether anyone, including a healer or pastor, already knows. (3) Follow your service's standard risk assessment and safety-planning process. (4) Include lethal-means counselling about safe storage and removal. (5) With consent, include trusted family and, if the client wishes, a religious adviser in the safety plan. [synthesis]
Example language (illustrative): "When people feel something has been sent against them, sometimes they think about dying. Has that happened for you?"
Watch for: risk framed as fate or as the sender's doing, which may reduce the client's sense of choice; risk disclosed to others and not to you. It is working when the client can name who to contact in a crisis. [synthesis]

4.10 An active, concrete stance and a culturally consonant rationale

Purpose / when: from the first session. The WHO/PAHO review notes that Haitian clients may expect detailed narratives to be heard, "empathic listening and culturally consonant explanations", active engagement and a concrete plan, and that some may not accept psychotherapy because problems are family or religious matters (pp. 20 to 21). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Steps: (1) Let the client tell the full story before structuring. (2) Explain your approach in terms of the client's model, for example as help for the head and heart that sits alongside spiritual care. (3) Give feedback and a clear plan each session. (4) Deliver your usual evidence-based treatment for the presenting problem, adapted in language and examples. (5) Check at intervals whether the rationale still makes sense to the client. [synthesis, built on the source]
Example language (illustrative): "Your spiritual care is for what you see as sent. What we do here is for the thinking too much and the poor sleep. The two can work together."
Watch for: silence or non-directive reflection being read as indifference; early drop-out after a session without a plan. It is working when the client returns and reports using something from the session. [synthesis]

4.11 Working with interpreters and cultural brokers

Purpose / when: when the client is more at ease in Kreyòl or French, or when cultural meaning is unclear. Keys et al. found that distress terms carry varied lay meanings, and Khoury et al. note that analysis in English rather than Kreyòl was a limitation of their own study. [source: https://ideas.repec.org/a/eee/socmed/v75y2012i3p555-564.html] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Steps: (1) Use a trained interpreter, not a family member, for clinical content. (2) Brief the interpreter on confidentiality and on respectful handling of religious content, and check their own attitude to Vodou, since religious conflict is common. (3) Ask the interpreter to keep the client's idioms and to flag terms with no direct equivalent. (4) Where needed, consult a cultural broker separately, without identifying details unless the client agrees. [synthesis]
Example language (illustrative, to the interpreter): "Please keep the client's own words for the illness, such as tèt or kè terms, and tell me if a word has no easy translation."
Watch for: an interpreter who softens or disapproves of Vodou content; a broker from the client's small community, which may breach privacy. It is working when the client corrects the interpretation freely. [synthesis]

4.12 Collaboration and referral with oungan, manbo and other religious helpers

Purpose / when: when the client wishes their healer or religious leader to be involved. The WHO/PAHO review states that spiritual leaders can act as "consultants" or "co-therapists", may be more trusted than conventional services, and that oungans "are not opposed to biomedical treatments and may refer patients" (pp. 8, 22). Khoury et al. found that folk practitioners wanted to collaborate with biomedical providers. Haiti's Ministry of Public Health and Population reported training Vodou priests to recognise mental illness and refer to specialists. Auguste and Rasmussen cite a project in which Khenti and colleagues trained 40 Vodou priests and priestesses in CBT. A 2015 Thomson Reuters Foundation report describes this as the Toronto Centre for Addiction and Mental Health (CAMH), under Akwatu Khenti, working with 40 religious leaders in Haiti to deliver CBT, within an approach involving Catholic, Protestant and Vodou leaders; a Grand Challenges Canada project record describes training religious and spiritual leaders in culturally adapted CBT for depression. Outcomes of the project are [uncertain]. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf] [source: https://worldcrunch.com/culture-society/mental-health-vodou] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader] [source: https://www.stabroeknews.com/?p=318749] [source: https://drupal-cdn.grandchallenges.org/node/6443]
Evidence from related settings (not Vodou-specific): the COSIMPO cluster randomised trial in Nigeria and Ghana (Gureje et al., The Lancet 2020) found that collaborative shared care between traditional and faith healers and primary care workers gave a greater fall in psychosis symptoms and reduced harmful practices. In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication to prayer-camp care reduced symptoms, but days in chains were not significantly reduced. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] The WHO Traditional Medicine Strategy 2014 to 2023 supports integrating traditional practitioners into health systems where safe. [source: https://www.who.int/activities/implementation-of-the-WHO-traditional-medicine-strategy-2014-2023]
Steps: (1) Ask whether the client wants any contact at all, and with whom. (2) Obtain written, specific consent naming the person, the purpose and what may be shared. (3) Agree roles: the healer leads spiritual care, you lead psychotherapy and risk management, the prescriber leads medicines. (4) Make contact respectfully, as with any professional colleague, and ask how the healer understands the problem and when they would refer for medical care. (5) Agree how urgent concerns will be communicated. (6) Never request, attend or evaluate ceremonies, and never refer a client to a healer the client does not already trust; leave the choice of healer to the client and their community. (7) Review the arrangement with the client regularly. [synthesis]
Example language (illustrative): "Would it help if I spoke with your manbo, so we are not pulling in different directions? You decide what I can share."
Watch for: pressure from either side for the client to choose; confidentiality breaches in a small community; any practice that delays urgent medical care or involves restraint or harm (see 4.17). It is working when the client reports that their helpers agree on the plan. [synthesis]

4.13 Working with family and community

Purpose / when: when family or religious community are central, which the WHO/PAHO review describes as common, and recommends that clinicians "work collaboratively with the family and the community" (p. 22). [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Steps: (1) Map who matters to the client, including religious kin. (2) Hold a family meeting with consent, using the CFI Informant Version if helpful. (3) Explore differing models within the family, especially between Christian and Vodou-serving members. (4) Agree concrete supports. (5) Address shame and hiding of illness, which the review notes alongside sympathy for people seen as victims of forces beyond their control (p. 12). [synthesis, built on the source]
Example language (illustrative): "Each of you sees this a little differently. What can everyone agree would help her this week?"
Watch for: blame directed at a person believed to have sent the illness, which can lead to conflict or violence; family pressure to stop treatment. It is working when the family describes the client's problem with less blame. [synthesis]

4.14 Addressing stigma, religious conflict and collective trauma

Purpose / when: when the client's distress involves anti-Vodou stigma, the 2010 earthquake or later violence. After the earthquake, many evangelical churches and the US televangelist Pat Robertson blamed the disaster on Vodou, and evangelicals threw stones at participants in a Vodou gathering (Desmangles, Religion in the News, 2010). During the 2010 cholera outbreak, mobs killed Vodou practitioners accused of spreading cholera; police confirmed 31 killings. Vodou practitioners who reported more resilience factors were more vulnerable to depression mentale after the earthquake, which Auguste and Rasmussen hypothesise relates to stigma, and they describe anti-Vodou stigma as possibly internalised and rooted in historical trauma. [source: https://www.rwarchives.com/2010/09/vodou-haiti-emerges-stronger-earthquake-conﬂict-evangelicals/] [source: https://www.refworld.org/node/82549] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader]
Steps: (1) Ask about experiences of discrimination for being Vodou-serving, Haitian or both. (2) Assess trauma exposure, including the earthquake, cholera-era violence and migration. (3) Acknowledge stigma as real rather than as the client's distortion. (4) Use your standard trauma-focused treatment where indicated, with the client's spiritual resources as possible supports. (5) Watch for internalised stigma, such as shame about one's own religion. [synthesis]
Example language (illustrative): "Some people were blamed for the earthquake because of their faith. Has anything like that touched you or your family?"
Watch for: your own or the interpreter's religious bias; clients who hide practice entirely. It is working when the client can talk about their faith without apology. [synthesis]

4.15 Integrating spiritual and clinical understandings

Purpose / when: during treatment, when the client has received spiritual care or had meaningful religious experiences. The WHO/PAHO review warns clinicians against forcing an "either/or" choice and asks them to attend to "spiritual understandings of the illness" (p. 22). Auguste and Rasmussen note that Vodou healers expect clients to remain faithful to the tradition until problems resolve, with no set timeframe. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://www.cambridge.org/core/product/B9AB5F3C85F24313479ADAC81443D992/core-reader]
Steps: (1) Ask what the experience meant to the client, without asking for ritual details. (2) Ask what changed afterwards in mood, relationships or hope. (3) Link those changes to therapy goals. (4) If the experience was distressing, process it as you would any distressing experience, respecting its meaning to the client. (5) Respect the client's expectation of continuing spiritual care alongside therapy. [synthesis]
Example language (illustrative): "You said you felt lighter after seeing the oungan. What has been different since, and how can we build on that here?"
Watch for: spiritual explanations used to avoid painful material; your own pull to credit or discredit the spiritual care. It is working when the client describes one coherent story of recovery. [synthesis]

4.16 Liaison over medicines and remedies

Purpose / when: when the client uses herbal teas, baths or other remedies, which the WHO/PAHO review describes for natural illness (p. 11), or takes prescribed medication. A community leader in Khoury et al.'s study described fear of a new condition "as a result of getting the wrong medication". [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Steps: (1) Note any remedies the client mentions, without advising on them. (2) With consent, tell the prescriber. (3) Explore fears about medication and pass them to the prescriber. (4) Never advise starting, stopping or changing any medicine or remedy. [synthesis]
Example language (illustrative): "That sounds important for your doctor to know. May I let them know you are also taking the teas?"
Watch for: stopping medication on a family's or helper's advice; side effects interpreted as a spiritual attack. It is working when the client discusses remedies openly with the prescriber. [synthesis]

4.17 Safeguarding

Purpose / when: whenever any person is at risk of harm, from any source. Harmful practices such as chaining in prayer camps were measured as an outcome in COSIMPO and the Ghanaian trial (not Vodou settings). In Haiti, people accused of sending illness or spreading cholera have been killed. None of the sources cited here documents restraint or abuse by Vodou healers specifically; Khoury et al. report none. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] [source: https://www.refworld.org/node/82549] [source: https://sites.duke.edu/haitilab/files/2014/11/Khoury_etal_2012_CMP_Explanatory-Models-Mental-Health-Vodou-in-Haiti.pdf]
Steps: (1) Ask about restraint, beating, starvation, sexual contact, threats, or delay of urgent medical care in any setting: family, church, temple, hospital. (2) Ask whether the client or family blames a specific person for a sent illness, and assess risk to that person. (3) Follow your jurisdiction's safeguarding and reporting duties for adults and children. (4) Distinguish the religion from an individual's harmful act, so that a report does not become an attack on Vodou. [synthesis]
Example language (illustrative): "In any place you have gone for help, has anyone held you down, hurt you or kept you from a doctor?"
Watch for: tradition used to excuse abuse, and the opposite error of treating religious practice itself as abuse. It is working when risks are named early and plans protect everyone involved. [synthesis]

5. Handling problems

The sources say little about problems in therapy. Responses below are [synthesis] unless a source is cited.

Client will not discuss Vodou or denies it. Stigma and fear of church reprisal are documented. Do not press. Say that many families use several helpers, and return to it later. [source: https://worldcrunch.com/culture-society/mental-health-vodou] [synthesis]
Client sees therapy as pointless because the problem is sent. Agree that spiritual care is the client's choice, then offer help with the effects they want to change, such as sleep, worry or family conflict, framed in their terms. [synthesis]
Client feels you are too passive. The WHO/PAHO review warns that neutrality can seem like a waste of time (p. 21). Give feedback, summaries and a concrete plan. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf]
Stuck between helpers. If the healer and the prescriber give conflicting advice, do not take sides. With consent, arrange a conversation, and route medication questions to the prescriber. [synthesis]
Family conflict over religion. Hold a family meeting, name the shared aim of the client's recovery, and keep religious debate out of the room. [synthesis]
Rupture after a perceived insult to the religion. Name it, apologise specifically, and ask what you misunderstood. A slip such as calling Vodou "voodoo" or "superstition" can end engagement. [synthesis]
Overwhelm or acute distress during sessions. Use your standard grounding and stabilisation, and slow the pace. Do not interpret an acute dissociative episode in session as possession or as illness without assessment. [synthesis]
Uncertainty whether an experience is normative or psychotic. Hold the formulation open, monitor functioning and sleep, consult a cultural broker or the client's religious adviser with consent, and seek psychiatric consultation if deterioration continues. [source: https://inee.org/sites/default/files/resources/WHO_Mental_Health_Haiti_2010_ENG.pdf] [synthesis]
Missed sessions or non-adherence. Check practical barriers, a lack of a clear plan, or advice from family or helpers to stop. Re-agree the goals. [synthesis]
Suicidal risk framed as fate. Address safety directly while respecting the meaning. Include trusted people in the safety plan with consent. [synthesis]
Accusation against a named person. Assess the risk of violence to that person, given documented killings of people accused of spreading illness, and follow safeguarding duties. [source: https://www.refworld.org/node/82549] [synthesis]
Therapist's own discomfort or fascination. Take it to supervision. Do not ask for ritual details to satisfy curiosity, and do not attend ceremonies as part of treatment. [synthesis]
Client asks you to take part in or endorse a ceremony. Decline warmly, explain your role, and direct spiritual questions to their own oungan, manbo or religious leader. [synthesis]

Sources

Vodou, Haiti and mental health

Cultural assessment and diagnosis

APA. DSM-5-TR Cultural Formulation Interview (core)
APA. DSM-5-TR Section III, culture chapter
APA. Cultural Formulation Interview, Informant Version (DSM-5)
APA. Cultural Formulation Interview Supplementary Modules (DSM-5)
Lewis-Fernández R et al. (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview. Br J Psychiatry 210(4):290-297
Same trial, repository record
Szepe and Fritson, DSM-5-TR webinar slides (cultural concepts list)
Teodoro and Afonso (2020), DSM-5 cultural concepts of distress, Revista Portuguesa de Psiquiatria e Saúde Mental
Article on possession, DID and ICD-11 possession trance disorder (PMC9199574)
Lewis (2023), University of Missouri System study guide citing DSM-5-TR
ICD-11 6B62 Trance disorder (third-party mirror of WHO text)
Tanenbaum handout: explanatory models of illness
Dinos et al. (2017), citing Kleinman, Eisenberg and Good (1978)
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.

Collaboration with traditional and faith healers

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