Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 083
Guide XI-083

Obeah and myal

Jamaica and the Caribbean
A 36 · L 53 · M 1117 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: obeah and myal as Caribbean historians describe them (Diana Paton's work on obeah law and the Obeah Histories project; Monica Schuler's encyclopedia entry on myal), alongside Jamaica's Revival and balmyard healing as historical and press sources describe it. Clinical procedures follow the DSM-5-TR Cultural Formulation Interview (CFI) with its supplementary modules and Kleinman's explanatory-model questions.

What it is. Obeah and myal are not one therapy. They are Afro-Caribbean spiritual and healing traditions, and they have no single text, founder or governing body. What follows describes them for the psychotherapist who works with clients for whom they matter. It does not teach them. [synthesis]

  • Obeah. Paton describes obeah as a set of spiritual healing practices. These are often labelled "African" and tied to Africa as a symbol, but in practice they drew on African, European, Amerindian and Indian traditions, and on Spiritualism and Theosophy. [source: https://www.stabroeknews.com/?p=231945] In everyday Jamaican use the word means harmful spiritual practices that many people fear. In law it was defined far more widely: Jamaica's 1898 Act covered anyone using, or pretending to use, occult means or supernatural power for gain or to frighten people. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws] When undercover police posed as clients, the requests they recorded were about ill health, love, work and business, not about harming enemies. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]
  • Myal. Schuler describes myal as an African-Jamaican tradition led by spirit mediums. They drew on ancestral power to heal, to relieve misfortune that people blamed on others' "jealousy, greed, and enmity", and to counter the danger believed to come from harmful obeah specialists. Planter Edward Long described a myal society in the 1760s. After emancipation, myal fed into Native Baptist practice and then into the Revival movement of 1860. In the twentieth century, myal practices survived in St Elizabeth and Manchester parishes, and among Maroon and Central African descendants in Portland and St Thomas. [source: https://encyclopedia.com/history/encyclopedias-almanacs-transcripts-and-maps/myal] Jamaican law from 1854 treated obeah and "myalism" as the same thing. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]
  • Balmyards, bush baths and herbal treatment. Balmyards are healing centres linked to Revival worship. Historical cases describe balmyard healers who knew herbs and who used Christian words and symbols. [source: https://obeahhistories.org/rose-ann-and-george-forbes-jamaica-19101916/] [source: https://jamaica-gleaner.com/article/news/20251019/sean-major-campbell-healing-balmyard] Herbal bathing has been studied among Maroon peoples in Suriname. [source: https://scholarlypublications.universiteitleiden.nl/access/item%3A2974571/download] Home use of herbal medicine in Jamaica, and its use alongside pharmaceutical medicines, has also been studied. [source: https://tramil.net/bibcite/reference/51] The purposes and meanings of Jamaican bush baths specifically are [uncertain: not verified]. This guide gives no preparations, plants or procedures.

Legal status, as sources state. Obeah was first criminalised in Jamaica in 1760, after Tacky's Rebellion, and most Caribbean colonies had outlawed it by 1838. [source: https://www.stabroeknews.com/?p=231945] Laws were repealed in Anguilla (1980), Barbados (1998), Trinidad and Tobago (2000) and St Lucia (2004). Jamaica's 1898 Obeah Act remains in force, although Paton found no conviction after 1964 and no arrest after 1977. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws] A 2013 amendment removed flogging as a penalty. [source: https://www.stabroeknews.com/?p=231945] In 2013 obeah was still an offence in Guyana under the Summary Jurisdiction (Offences) Act [source: https://www.stabroeknews.com/?p=231945], and the government later announced that it intended to remove it from the criminal code [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]. Whether that has happened is [uncertain: not verified]. Obeah is "still illegal in many places today" [source: https://obeahhistories.org/law/], but the status in other territories (for example those once under the 1904 Leeward Islands Obeah Act) is [uncertain: not verified]. Paton argues that the laws were used almost entirely against poor, mostly Black people. Those prosecuted included balm healers, Revivalists, Garveyites and early Rastafari, many of whom were themselves hostile to obeah. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]

How change happens, for the psychotherapist. Within the tradition, healing is understood in its own spiritual terms: a medium's or healer's work against misfortune or harm that others are believed to have caused. These are the tradition's beliefs, which this guide neither affirms nor dismisses. [source: https://encyclopedia.com/history/encyclopedias-almanacs-transcripts-and-maps/myal] The psychotherapist's contribution works differently. Clients improve when the clinician understands the problem in the client's own terms (the CFI and the client's explanatory model). That understanding guards against two errors: treating a shared belief as a symptom, and missing a disorder because it is framed in spiritual language. It also lets treatment run alongside the help the client already uses, with the client's consent. Ellis argues that failing to understand obeah-illness from a culturally informed position leads to less-than-optimal care. [source: https://research-portal.najah.edu/migrant/26576/] [synthesis]

2. Framework

None of the sources sets out a staged protocol for psychotherapy with clients who draw on obeah, myal or balmyard healing. The sequence below is [synthesis], built on how the APA says the CFI should be used.

Who holds authority. No regulator, licensing body or council governs obeah, myal or balmyard healing. Authority has rested with individual healers, mediums and Revival leaders whom their own clients and congregations recognise. Oral tradition, for example, traces one historical balmyard healer's authority to a calling in a vision. [source: https://jamaica-gleaner.com/article/news/20251019/sean-major-campbell-healing-balmyard] [synthesis] Historically the state appears as the prosecutor, under obeah, vagrancy and medical-licensing laws. [source: https://obeahhistories.org/law/] No statements published by practitioners or Revival bodies for outside clinicians have been identified [uncertain: not verified]. So the client is the main guide to which healer, church or elder they regard as legitimate.

Phase A: Engagement and cultural assessment (sessions 1-3, individual; family or informant if the client wishes).

  • Goals: safety and risk screen; the core CFI (16 questions across four domains: cultural definition of the problem; perceptions of cause, context and support; self-coping and past help seeking; current help seeking). [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Ask without judgement about healers, balmyards, churches, bush baths and herbs.
  • Format: APA says the CFI can be used "by any clinician providing services to any individual in any care setting." [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] How long the core CFI takes is [uncertain]. In the DSM-5 field trial, later administrations took less time. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]
  • Move on when: you can state the client's own name for the problem, their view of its cause, what help they have used, and what they hope you will do. Any acute risk must also be managed.

Phase B: In-depth modules and differential (sessions 2-5, as needed).

  • Goals: add the supplementary modules that fit. These are usually Explanatory Model; Spirituality, Religion and Moral Traditions; Coping and Help-Seeking; Cultural Identity; Patient-Clinician Relationship; Immigrants and Refugees (for diaspora clients); and the Informant Version with family. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] Distinguish culturally shared belief and experience from disorder.
  • Move on when: you have a written cultural formulation the client recognises as accurate, and a working diagnosis (or none) that does not rest on the spiritual content alone. The CFI is not meant to be the sole basis for a diagnosis. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

Phase C: Shared plan and parallel care (ongoing, usually weekly).

  • Goals: agree a plan that names what the client will keep doing within their tradition, what therapy offers, and, if the client wishes, whether and how you will communicate with a pastor, healer or elder. Route all herbal and medicine questions to the prescriber.
  • Move on when: the plan is in use, the client reports that they can speak openly about spiritual help, and risk and medical issues are being managed.

Phase D: Review, integration and ending.

  • Goals: revisit the explanatory model (APA allows the modules to be repeated during treatment) [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf], integrate what the client has drawn from both kinds of help, and plan for relapse within the client's own frame.
  • End when: the treatment goals are met and the client has a relapse plan that names both clinical and community supports.

3. Guiding principles

  • You work alongside the tradition, not inside it. Never offer obeah, myal, balmyard or bush-bath healing, interpret signs, or endorse or recommend a particular practitioner's spiritual work. [synthesis]
  • Describe spiritual causes as the client holds them. Use phrases such as "you understand this as…", and neither confirm nor dismiss the belief. [synthesis]
  • Know the history of criminalisation and stigma. The laws targeted African-linked religion and poor, mostly Black people, and the word "obeah" still carries fear and shame. Expect clients to hold back disclosures at first. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]
  • Do not merge distinct traditions. The law treated healers, Revivalists and Rastafari as obeah practitioners, even though many opposed obeah. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws] Myal stood historically against harmful obeah. [source: https://encyclopedia.com/history/encyclopedias-almanacs-transcripts-and-maps/myal] Practically, never call a client's church, balmyard or healer "obeah" unless the client uses that word.
  • Do not label beliefs as "superstition." That framing stigmatises and can reduce help seeking. [source: https://openknowledge.nau.edu/id/eprint/5773/] Practically, treat cultural concepts as information, not as a sign of poor insight.
  • Treat obeah as a core belief that can shape how distress presents. Learn the idioms clients use. [source: https://research-portal.najah.edu/migrant/26576/] Practically, ask what the client calls the problem before you name it.
  • Avoid both errors. Do not pathologise shared belief, and do not miss illness. Practically, base a diagnosis on form, course, impairment and divergence from the client's own community norms, never on content alone. [synthesis]
  • Consent and confidentiality govern all contact with healers or clergy. Where obeah is still a criminal offence, a careless record could expose the client or a healer. Practically, record only what the care needs. [synthesis]
  • Herbs and medicines are the prescriber's domain. Ask about bush teas, baths and herbal remedies so the prescriber is informed. Never advise starting, stopping or changing any remedy or medicine. [synthesis]
  • Safeguarding comes before deference. Cultural respect never overrides the duty to act on exploitation, abuse, harm to children or delay of urgent medical care. [synthesis]
  • Cultural humility is ongoing. Practically, ask the client to correct you, and review your own assumptions about African-Caribbean religion. [synthesis]

4. Intervention inventory

These are the psychotherapist's own interventions. None of them is an obeah, myal, balmyard or bush-bath practice. Where a step is not taken from a cited source, it is marked [synthesis]. All example language is illustrative.

4.1 Cultural humility and self-examination

  • Purpose / when: before and throughout work with Afro-Caribbean clients. It helps you notice inherited views of African-derived religion as "superstition" or as dangerous. [source: https://openknowledge.nau.edu/id/eprint/5773/] [synthesis]
  • Steps: (1) Before the first session, note your own reactions to the words obeah, Revival, balmyard and "bush medicine." (2) Read the history of how the law suppressed these traditions (see Section 1). (3) In supervision, review one case for places where you treated spiritual content as a symptom by default. (4) Plan to ask the client to correct your understanding. [synthesis]
  • Example language (illustrative): "I'm not from your tradition, so I may get things wrong. Please tell me when I do."
  • Watch for: a pull to argue with the belief or to reassure the client out of it; the opposite pull to avoid the topic altogether. It is working when the client brings up spiritual material without being prompted and corrects you comfortably.

4.2 Core Cultural Formulation Interview

  • Purpose / when: at the first assessment, for any client, and especially when the client frames the problem in spiritual or interpersonal-harm terms. It clarifies what the problem means, possible sources of help and what the client expects from services. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • Steps: (1) Use the free APA form. Clinicians may reproduce it for use with their patients. Modifying or translating it needs APA permission. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] (2) Work through the four domains in order: the client's definition of the problem; perceived causes, stressors, supports and the role of cultural identity; self-coping, past help seeking and barriers; current preferences and the client-clinician relationship. (3) Write the client's own words down verbatim. (4) Note each point where a supplementary module would expand the topic. The core form flags these points. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • Example language (illustrative): "Sometimes people describe their problem in their own words, which may be different from how doctors describe it. How would you describe what's been happening?"
  • Watch for: answers that stay guarded or generic, which may signal fear of being judged or reported (see 5.1). It is working when the client names their own cause and their own sources of help. The CFI informs diagnosis but should not be its sole basis. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

4.3 Explanatory-model inquiry (Kleinman; CFI Explanatory Model module)

  • Purpose / when: when the client attributes the problem, wholly or in part, to spiritual harm, to another person's envy or ill will, or to a spiritual calling. It is also useful when the client's model and yours seem to differ.
  • Steps: (1) Cover Kleinman's eight areas in your own words: what the client calls the problem; its cause; why it began when it did; what it does and how it works; how severe it is and how long it will last; what treatment the client thinks they should get; the main problems it has caused; what they fear most about it. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] (2) If the client wants more depth, use the APA Explanatory Model module. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] (3) Sum up the client's model in their terms, and check that you have it right. (4) Tell them how you see the problem and how you might help, framed as something that can sit alongside their model, not replace it. [synthesis]
  • Example language (illustrative): "You've said you believe someone may be behind this. What do you think they did, and why now? What do you fear most could happen?"
  • Watch for: the client's model shifting under questioning, which can mean they are distressed or are looking for your approval; making the client choose between their model and yours. It is working when you can name the client's most feared outcome and agree on a shared goal (for example, sleep, safety or getting back to work).

4.4 Spirituality, Religion and Moral Traditions module

  • Purpose / when: when church, Revival, balmyard, Rastafari, Hindu, Muslim or other affiliations, or a mix of them, shape the client's understanding of the problem and their coping. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • Steps: (1) Ask which communities the client belongs to now and belonged to in the past. (2) Ask what each community teaches about the cause of this kind of suffering and what to do about it. (3) Ask whether any of these affiliations is a source of conflict or shame, for example a church that condemns balmyard healing. (4) Note who the client regards as having spiritual authority. [synthesis]
  • Example language (illustrative): "Does your church have a view on what you're going through? Do people around you agree on what should be done?"
  • Watch for: conflict between the client's church and family, or between generations, over "obeah" accusations. Sources describe clergy who are themselves wary of practitioners exploiting fear. [source: https://jamaica-gleaner.com/article/news/20251019/sean-major-campbell-healing-balmyard] It is working when you know whose spiritual guidance the client trusts.

4.5 Asking about healers, balmyards, bush baths and herbal remedies

  • Purpose / when: at assessment, and again whenever symptoms change. You need to know about parallel help so care can be coordinated and safety checked. Home use of herbal medicine in Jamaica, including alongside pharmaceuticals, has been the subject of research [source: https://tramil.net/bibcite/reference/51]. Prevalence figures are [uncertain: not verified].
  • Steps: (1) Make it normal: say that many clients use more than one kind of help. (2) Ask what help they have tried (prayer, church, a healer or balm yard, baths, bush teas or other remedies) and what effect each had. This draws on the CFI Coping and Help-Seeking module. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] (3) Ask whether the prescriber knows about any remedies taken by mouth. (4) Ask about money paid, promises made and any instructions to avoid doctors or medicines. (5) Do not ask about, or record, the content of rituals. [synthesis]
  • Example language (illustrative): "A lot of people try more than one kind of help: church, a healer, bush tea, a bath. There's no wrong answer. What have you tried, and did any of it help?"
  • Watch for: denials that sound reflexive. They may reflect the old criminal status and stigma (Section 1). Also watch for any instruction to stop prescribed medicine, which you pass to the prescriber with the client's consent. It is working when disclosures include specifics and the client raises new help-seeking unprompted.

4.6 Informant Version and family sessions

  • Purpose / when: when family members hold a strong spiritual explanation (for example, that someone has "set" something on the client; illustrative phrasing, not a documented idiom), when they disagree about what help to seek, or when the client cannot give a history. The Informant Version is for a relative or friend of the person seeking care. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
  • Steps: (1) Get the client's consent for each person and each topic. (2) Use the Informant Version with the relative separately, then meet jointly if helpful. (3) Map where explanations agree and where they differ. (4) Agree on practical tasks everyone can support, such as safety, sleep, attending appointments and medication taken as prescribed. [synthesis]
  • Example language (illustrative): "Everyone here wants your sister to be well, even if you see the cause differently. What could each of you do this week that you'd all agree helps?"
  • Watch for: blame aimed at a named relative or neighbour as the source of harm, which can escalate into conflict or threats (see 4.14, 4.16); family pressure overriding the client's own wishes. It is working when family members support the plan even though their explanations still differ.

4.7 Cultural Identity and Immigrants and Refugees modules (diaspora clients)

  • Purpose / when: for clients living in the UK, North America or elsewhere, and for second-generation clients. Ellis addresses obeah-illness among Jamaican immigrants specifically. [source: https://research-portal.najah.edu/migrant/26576/]
  • Steps: (1) Ask about country of origin, generation, migration history and links to home. (2) Ask whether healers or churches are reachable from where they live, or only "back home." (3) Ask how racism and immigration stressors bear on the problem. [source: https://psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] (4) Ask whether family abroad are advising or arranging spiritual help. [synthesis]
  • Example language (illustrative): "Does your family back home have their own ideas about what's going on? Are they helping arrange anything from there?"
  • Watch for: sending large sums abroad for spiritual help (see 4.16); the client feeling cut off from trusted help where they now live. It is working when the plan includes supports the client can actually reach.

4.8 Addressing the clinician relationship, racism and history (CFI Patient-Clinician Relationship)

  • Purpose / when: early, and whenever trust seems low. The CFI covers the clinician-patient relationship, including perceived racism and language barriers. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] The obeah laws were used mainly against poor Black people and to suppress African-linked religion. [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]
  • Steps: (1) Ask directly whether differences between you and the client could get in the way. (2) Acknowledge that services have dismissed or punished these beliefs in the past. (3) Explain what you will and will not record, and why. (4) Revisit this whenever you sense a rupture. [synthesis]
  • Example language (illustrative): "People from Caribbean backgrounds have sometimes been dismissed, or worse, when they talked about spiritual matters. I want to understand, not judge. Is there anything that would make it hard to be open with me?"
  • Watch for: guarded politeness; missed appointments after spiritual topics come up. It is working when the client says what they are afraid you will think.

4.9 Using cultural concepts of distress and idioms

  • Purpose / when: when the client presents distress as obeah-illness or as spiritually caused harm. Ellis describes culture-bound syndromes linked to obeah that clinicians may meet in Jamaican patients, and urges clinicians to learn the idioms, beliefs and practices involved. [source: https://research-portal.najah.edu/migrant/26576/] DSM-5-TR defines cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] No DSM-5-TR glossary entry for obeah has been confirmed, and the current glossary list is [uncertain]. The DSM-5 glossary included maladi moun, a Haitian concept of "humanly caused illness" [source: https://revistapsiquiatria.pt/index.php/sppsm/article/download/139/69], which is related in idea but belongs to another tradition. Do not use it as a label for Jamaican clients. [synthesis]
  • Steps: (1) Record the client's term exactly. (2) Ask whether it is an explanation (a cause), an idiom (a way of saying "I am suffering"), or a named condition in their community. (3) Ask how common it is among people they know and how it is usually dealt with. (4) Assess symptoms, impairment and risk on their own terms as well. (5) In the formulation, record the concept as the client's explanation next to any diagnosis, never instead of one. [synthesis]
  • Example language (illustrative): "When you say this is obeah, is that what you believe caused it, or is it also how people where you're from describe this kind of suffering?"
  • Watch for: reading every use of the idiom as delusion, or as mere metaphor. It is working when your formulation holds the client's idiom and the clinical picture side by side.

4.10 Distinguishing culturally shared experience from disorder

  • Purpose / when: when the client reports being targeted by spiritual harm, sensing spirits, possession-like experiences, or a spiritual calling. Also when others say the client is "under obeah."
  • Steps: (1) Find out whether the belief is shared by the client's family, church or community, using informants and cultural brokers (4.11). (2) Assess form, not just content: fixity beyond what peers hold; elaboration; other psychotic features (thought disorder, hallucinations outside culturally expected contexts); mood and sleep change; and loss of function. [synthesis] (3) For possession or trance: DSM-5-TR dissociative identity disorder notes that identity disruption may be described as possession in some cultures, and excludes disturbances that are part of a broadly accepted cultural or religious practice. Dissociative trance under other specified dissociative disorder is excluded on the same grounds. [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] (exact DSM-5-TR wording [uncertain]) ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] (4) Weigh distress, impairment, involuntariness and whether the client's own community sees the experience as an illness. (5) If psychosis, mania, severe depression or risk is present, treat it as such, and keep honouring the client's explanation as their own. [synthesis]
  • Example language (illustrative): "Would people in your church see what you're going through as something spiritual that will pass, or would they also be worried about you?"
  • Watch for: fear of being targeted that spreads to more and more people, sleeplessness, or threats or plans against a suspected person. All of these need risk assessment. It is working when the diagnosis (or the decision not to diagnose) is backed by more than spiritual content, and the client still feels respected.

4.11 Cultural brokers and interpreters

  • Purpose / when: when you cannot judge how normative a belief or experience is, or when the client is more fluent in Jamaican Patwa or another Creole language than in English. [synthesis]
  • Steps: (1) With the client's consent, ask a culturally knowledgeable colleague or a community member the client chooses. (2) Brief them on confidentiality, and ask only about what is normative, not about ritual details. (3) Use a trained interpreter, not family, where language is a barrier. The CFI flags language barriers in the clinician-patient relationship. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] (4) Record the broker's view as an opinion, attributed to them. [synthesis]
  • Example language (illustrative): "Would it help if I spoke with someone you trust from your community to make sure I understand properly? I'll only share what you agree to."
  • Watch for: brokers whose own views on obeah, Revival or Rastafari are partisan. It is working when the broker's input changes or confirms your formulation in a specific way.

4.12 Herbal remedy and medicine liaison with the prescriber

  • Purpose / when: whenever the client takes bush teas or other herbal remedies, or a healer or family member advises on medicines. [synthesis]
  • Steps: (1) Ask what is taken by mouth or applied, how often, and since when. Write down the names the client uses. Do not identify plants or assess their safety yourself. (2) With consent, pass this to the GP, psychiatrist or pharmacist. (3) If the client is told to stop prescribed medicine, do not advise either way. Explain that the prescriber needs to know, and help arrange contact. (4) Watch for physical symptoms and route them to medical care. [synthesis]
  • Example language (illustrative): "I'm not the right person to judge herbs or medicines. Your doctor or pharmacist is. Could we tell them what you're taking so they can check it fits with your prescription?"
  • Watch for: reluctance to tell the prescriber, and new physical symptoms. It is working when the prescriber has a complete list.

4.13 Collaboration and referral with healers, clergy or elders the client trusts (only when the client wishes)

  • Purpose / when: when the client wants their spiritual helper involved, or when coordination would reduce risk. No formal collaboration programme for obeah, myal or balmyard practitioners has been identified [uncertain: not verified]. The trial evidence for collaboration comes from West Africa. The COSIMPO trial (Gureje et al., The Lancet, 2020) tested collaborative shared care between traditional and faith healers and primary health workers for psychosis in Nigeria and Ghana. Symptoms fell more with collaboration, and harmful practices fell more too (57% to 9%, against 42% to 10% in controls). [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication reduced symptoms, but days in chains were not significantly reduced. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] Applying these findings to Caribbean healers is [synthesis].
  • Steps: (1) Ask the client whether they want contact, with whom, and what may be shared. Get written consent. (2) Agree the aim of the contact, such as shared safety concerns, support for attending appointments, or not discouraging medical care. (3) Make contact respectfully, without endorsing or evaluating the healer's spiritual work. (4) Share only what the client has agreed to. (5) Bear in mind that where obeah is still an offence, a healer may be wary of contact with services. Keep records minimal and neutral. (6) Never refer a client to a specific spiritual practitioner on your own initiative. [synthesis]
  • Example language (illustrative): "You've said your pastor is helping you. Would you like me to speak with them, so we're not working against each other? What would you want me to say, and what should stay private?"
  • Watch for: pressure from a helper to stop treatment, high fees, or practices that confine or hurt the client (4.16). It is working when the client feels the two kinds of help support each other.

4.14 Working with fear of spiritual harm and interpersonal suspicion

  • Purpose / when: when the client believes that envy or ill will is behind their misfortune, an attribution that sources record within the tradition [source: https://encyclopedia.com/history/encyclopedias-almanacs-transcripts-and-maps/myal], and the fear, conflict or isolation is causing distress. [synthesis]
  • Steps: (1) Validate the distress and the real stressors behind it (conflict, losses, rivalry over work or relationships). Do not debate whether spiritual harm is real. (2) Work on the stressors and relationships the client can act on: problem-solving, assertive communication and support networks. (3) Use the client's own protective resources (prayer, church, trusted elders) as coping, without prescribing rituals. (4) Screen for threats against a suspected person. [synthesis]
  • Example language (illustrative): "Whatever is behind this, the fear is wearing you down. Let's look at what we can change in your days and your relationships, and at what already helps you feel protected."
  • Watch for: accusations naming a person, plans for revenge, or social withdrawal. It is working when fear and avoidance ease, even if the explanation stays the same.

4.15 Integrating healing experiences

  • Purpose / when: after the client has visited a healer, balmyard or church, or taken part in other spiritual help, and wants to make sense of it in therapy. [synthesis]
  • Steps: (1) Ask what the experience meant to the client and what changed afterwards, without asking for details of the ritual. (2) Strengthen whatever helped, such as feeling cared for or rejoining the community. (3) Explore anything distressing, such as fear, shame or cost, and check for harm. (4) Link the experience to treatment goals. [synthesis]
  • Example language (illustrative): "You don't need to tell me what happened there. What I'd like to know is how you've felt since, and whether it helped."
  • Watch for: new fears or obligations that arose from the experience, or a sense of failure if it did not "work." It is working when the client can draw on both kinds of help without conflict.

4.16 Safeguarding

  • Purpose / when: whenever there are signs of exploitation (large payments, fear used for profit), abuse, confinement, harm to children, accusations that put someone at risk, or delay of urgent medical care. Sources record clergy concern about practitioners exploiting people's fear. [source: https://jamaica-gleaner.com/article/news/20251019/sean-major-campbell-healing-balmyard] [synthesis]
  • Steps: (1) Ask directly about payment, threats, restriction, physical treatment and children's involvement. (2) Follow local safeguarding, adult-protection and child-protection procedures and your duty-to-warn law. (3) Arrange urgent medical care where it is being delayed. (4) Separate the specific harm from the tradition. Act on the harm without condemning the client's faith. (5) Document the facts, not the beliefs. [synthesis]
  • Example language (illustrative): "I respect your faith. I'm also responsible for your safety. Has anyone asked you for money, told you to stop seeing a doctor, or done anything that hurt you?"
  • Watch for: stigma creating false alarms (traditional practice misread as abuse) and the reverse (abuse hidden as tradition). It is working when the risk is managed and the client stays in care.

4.17 Writing the cultural formulation and keeping records

  • Purpose / when: after Phase B, and whenever it is updated. [synthesis]
  • Steps: (1) Summarise the client's cultural identity, their explanatory model and idioms, stressors and supports, help seeking (including parallel help), and relationship factors. (2) State the diagnosis, or none, and the evidence for it apart from spiritual content. (3) Record the client's consent decisions about contact with healers or clergy. (4) Where practising obeah is still a criminal offence, do not record identifying details of healers or practices beyond what care needs. (5) Read the summary back to the client. [synthesis]
  • Example language (illustrative): "Here's how I've written up my understanding. Does it match how you see things? Is there anything you'd rather I left out?"
  • Watch for: language such as "superstitious" or "lacks insight" used about cultural belief. It is working when the client agrees the summary is accurate.

5. Handling problems

None of the sources gives problem-handling guidance specific to this setting. Everything below is [synthesis] unless a source is cited.

  • 5.1 The client denies any use of healers, or gives guarded answers. Possible reasons: fear of legal consequences or of being judged, given the history of criminalisation and stigma [source: https://www.historyworkshop.org.uk/the-racist-history-of-jamaicas-obeah-laws]. Response: say that many people use several kinds of help; explain what you record; come back to the question later and do not press. Illustrative: "You don't have to tell me now. The door's open if it ever matters."
  • 5.2 "This is spiritual, so therapy can't help." Do not compete. Agree that the client has their own ways of addressing the spiritual side, and offer help with sleep, fear, relationships and functioning alongside them. Illustrative: "You may be right that the cause is spiritual. Meanwhile, could we work on getting you sleeping again?"
  • 5.3 The client asks, "Do you believe in obeah?" Answer briefly and honestly, without endorsing or dismissing, then turn back to the client's experience. Illustrative: "I'm not in a position to judge that. What matters here is what you're going through and what helps."
  • 5.4 Rupture after a spiritual belief was treated as a symptom. Name the rupture and own your part. Explain the reasoning behind any diagnosis in terms of sleep, mood and functioning, not the belief itself, and re-check the client's explanatory model (4.3). This uses the CFI patient-clinician relationship domain. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • 5.5 You cannot tell whether a belief is shared or psychotic. Pause before diagnosing. Use the Informant Version and a cultural broker (4.6, 4.11), and assess form, course and function (4.10). Keep monitoring risk throughout. If the presentation is severe, treat the risk first.
  • 5.6 Fear is escalating, or a named person is being accused. Assess risk to the client and to others. Consider duty-to-warn and safeguarding duties. Involve family with consent, and treat any underlying mood or psychotic disorder.
  • 5.7 A healer or family member tells the client to stop medicine or leave treatment. Do not argue against the healer. Make sure the prescriber knows, explore what the client wants, and with consent offer contact with the helper (4.13). Never advise on medicines or remedies yourself (4.12).
  • 5.8 Large payments or exploitation. Name the pattern gently and explore it. Follow adult safeguarding procedures if the client lacks capacity or is being coerced (4.16). Sources record concern about people exploiting fear. [source: https://jamaica-gleaner.com/article/news/20251019/sean-major-campbell-healing-balmyard]
  • 5.9 Conflict between church and family over "obeah." Use the Spirituality module (4.4) to map who holds which view, then hold a family session focused on shared practical goals (4.6). Do not take sides on doctrine.
  • 5.10 The client asks you to recommend a healer, or to prescribe bush baths or herbs. Decline either role. Explain that the choice of spiritual helper belongs to the client and their community, and that remedies are for the prescriber or pharmacist to assess (4.12).
  • 5.11 A diaspora client is cut off from trusted helpers. Explore which local church, community or cultural organisations the client might trust. Support the client's own search, and do not make a referral yourself (4.7).
  • 5.12 Your own discomfort, or the urge to "correct" the belief. Take it to supervision and repeat the self-examination in 4.1.
  • 5.13 Overwhelm when spiritual fear comes up in session. Slow the pace. Use grounding the client finds acceptable, which may include their own prayer. Return to stabilisation before going further into the explanatory model.
  • 5.14 Non-attendance. Check for logistical and relationship barriers (CFI barriers question) and for spiritual advice against attending. Offer flexible contact. [source: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

Sources

Web sources

Books and articles cited

  • Handler JS, Bilby KM (2013). Enacting Power: The Criminalization of Obeah in the Anglophone Caribbean, 1760-2011. University of the West Indies Press. (Named on the Obeah Histories legislation page; contents [uncertain: not verified].)
  • Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.

Still uncertain: the meanings of bush baths in Jamaica specifically; Guyana's current legal position and the status of obeah laws in other territories; prevalence of herbal use alongside medicines in Jamaica; whether any obeah-related concept appears in the DSM-5-TR glossary; how long the core CFI takes.

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