Aymara qulliri and yatiri

1. Introduction

Version followed: the healing roles as described in published ethnography (Fernández Juárez 1997; Burman 2011; Carreño-Calderón 2021) and in the state frameworks of Bolivia (Law 459 of 2013), Chile (Programa Especial de Salud y Pueblos Indígenas, PESPI) and Peru (Supreme Decree 016-2016-SA). The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What this is. This is not a psychotherapy. It is a living Aymara healing tradition of the Andean highlands of Bolivia, Peru and Chile, with its own practitioners and sources of authority. A psychotherapist does not practise it. This guide covers what communities, state bodies and scholars publish about it, who holds authority, and the psychotherapist's own culturally responsive work alongside it.

Qulliri (also spelled quilliri) is described as a healer or herbalist with fewer religious functions than the yatiri. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] A tertiary encyclopedia summary describes qulliri as the general term for an Aymara healer, needing no special initiation, and the yatiri as a special subclass of qulliri. [source: https://en.wikipedia.org/wiki/Yatiri] [uncertain: the encyclopedia summary rests on Huanca's 1987 University of Florida thesis, not verified]
Yatiri means "the one who knows". Ethnography describes a ceremonial specialist who diagnoses and heals, especially illness understood as affecting the soul, and who also advises on work, travel and business. Locally such specialists are often called "maestros". [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] One Chilean study calls the yatiri's role "the closest to that of the classical shaman" (an outsider's comparison). [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf]
The calling. In published ethnography, being struck by lightning is held to confer the calling and power. Other signs reported include twin birth, recovery from an illness thought incurable, dreams, disability and extreme poverty. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] The encyclopedia summary adds that the person struck cannot refuse the call. [source: https://en.wikipedia.org/wiki/Yatiri] [uncertain: not verified in a primary source]
Coca. Coca leaf reading is part of yatiri diagnosis, and respectful terms for yatiri refer to coca. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] [source: https://en.wikipedia.org/wiki/Yatiri] This guide gives no reading method.
Ch'amakani is described as a higher-ranked specialist who "works in darkness" and communicates with spirits. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] The encyclopedia summary describes the ch'amakani as the elder yatiri who trains an apprentice. [source: https://en.wikipedia.org/wiki/Yatiri] [uncertain: tertiary source] The two accounts differ. Whether training is always given by a ch'amakani is [uncertain].
Other Aymara and Andean figures in the same sources: usuyiri (midwife, women's reproductive health) [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf]; kallawaya healers, who families may also consult [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92].

How change happens, as the tradition is described. Health is understood as balance and harmony, with spirit and body treated as one. [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92] Health depends on relations with nature, community and ancestors, and the yatiri works to repair those relations. [source: https://en.wikipedia.org/wiki/Yatiri] [uncertain: tertiary source] In northern Chile, Aymara participants tie health to land, water and collective memory, and say the core problem is that "living well has been lost". [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] One ethnography links colonialism with illness, and decolonisation with healing. [source: https://www.lunduniversity.lu.se/lup/publication/710a2d74-c3e8-42a5-aa8a-5a77c1c24a17] These are the tradition's and scholars' accounts. They are reported here, not stated as fact or dismissed.

The psychotherapist's change model. In this guide, the therapist's work helps when the client's own explanatory model, help-seeking and relationships with recognised healers are understood and respected. Diagnosis then avoids both pathologising normative experience and missing illness, and care is coordinated when the client wishes. [synthesis, built on the CFI's stated purpose: source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

2. Framework

Who holds authority

Within communities. Ethnography places recognition in the calling, training over time under an experienced teacher with permission from sacred places, and the community's judgement. The same source separates fully trained yatiris from amateurs and charlatans who compete for paying clients in the city. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] Yatiri wait to be asked for help, never initiate healing, and keep their ordinary community and farming duties. [source: https://en.wikipedia.org/wiki/Yatiri] [uncertain: tertiary source]
Bolivia. Law 459, the Traditional Ancestral Bolivian Medicine Law (19 December 2013), regulates practice and its link to the National Health System. It recognises four categories: traditional doctors, spiritual guides ("guías espirituales", recognised spiritual authorities who guard sacred sites), traditional midwives and naturists. The text does not use the words yatiri or qulliri. Practitioners outside Indigenous territories must register in the Registro Único de la Medicina Tradicional Ancestral Boliviana (RUMETRAB). Those inside recognised territories may register through their own organisations. Practice without registration counts as illegal practice (Art. 33). Policy sits with the Ministry of Health's Viceministry of Traditional Medicine and Interculturality. A national council (CONAMETRAB), departmental councils and a Permanent National Commission of Spiritual Guides advise. Practitioners must refer patients with complications or serious risk to the nearest health facility (Art. 9.10). Users have the right to choose their practitioner and to make their own health decisions (Art. 35). The implementing regulation is DS 2436 (1 July 2015). [source: https://www.lexivox.org/norms/BO-L-N459.html]
Chile. PESPI (Ministry of Health) funds care by Indigenous healers, naming qulliri and yatiri among others, through referral protocols with biomedical care. Where a facility has no healer, the health service signs agreements with Indigenous organisations. Intercultural facilitators help users navigate services and refer to Indigenous medicine. Joint mental health work by healers and psychologists has been used in some areas. The legal basis cited includes Law 20.584, Art. 7, and ILO Convention 169. [source: https://www.dipres.gob.cl/597/articles-212527_doc_pdf1.pdf] An ethnography dates PESPI in Arica to 1997, and the budget document dates the programme from 2000. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] [uncertain: dates differ]
Peru. Supreme Decree 016-2016-SA (2 April 2016) approved the Sectoral Intercultural Health Policy. One axis promotes traditional medicine and its link with conventional medicine, and asks for traditional medicine practitioners, defined as community members recognised for ancestral health knowledge, to take part in health services. Another axis builds health staff's intercultural skills. [source: https://busquedas.elperuano.pe/normaslegales/aprueban-la-politica-sectorial-de-salud-intercultural-decreto-supremo-n-016-2016-sa-1363166-6/] Aymara-specific arrangements in Peru are [uncertain: not verified].
Coca leaf. Bolivia re-acceded to the 1961 UN Single Convention from 10 February 2013 with a reservation allowing coca leaf chewing as "a traditional practice among its people". The Convention still treats coca leaf as a narcotic drug and controls cultivation. [source: https://unodc.org/unodc/en/frontpage/2013/January/bolivia-to-re-accede-to-un-drug-convention-while-making-exception-on-coca-leaf-chewing.html] Status in Peru, Chile and countries of migration is [uncertain: not verified].

Phases of the psychotherapist's work [synthesis: the sources give no phase model for clinicians; the sequence below organises the CFI-based work]

Phase	Goal	Typical format	Move on when
0. Preparation	Examine own assumptions about Andean healing, coca and Indigenous peoples; learn local referral routes (RUMETRAB, PESPI, intercultural facilitators)	Before contact; supervision	Therapist can name own biases and knows local programmes
1. Cultural assessment	Core CFI, relevant modules, explanatory model, help-seeking including yatiri or qulliri	1–2 sessions; CFI time [uncertain]	Client's own name, cause and expected help for the problem are recorded in their words
2. Differential formulation	Separate culturally normative experience from disorder; risk screen	Within assessment; consult cultural brokers	Formulation states what is normative, what is disorder, what is unclear
3. Shared plan	Agree what therapy offers, what the healer offers, what medicine offers; consent for any contact	1 session, family if client wishes	Client has chosen, and consent is documented
4. Ongoing therapy alongside	Evidence-based treatment adapted to the client's model; integration of healing experiences	Usual course for the condition	Goals met or plan revised
5. Review and safeguarding	Revisit the CFI, check harms, delayed medical care, coercion	At reviews and on any red flag	Ongoing

3. Guiding principles

Alongside, not inside. The therapist does not read coca, diagnose soul loss or perform any part of the healing. Practical meaning: refer questions about the tradition to the client or to people the client's community recognises. [synthesis]
Authority lies with communities and their institutions. Practical meaning: ask the client who recognises a given healer; do not judge authenticity yourself. Ethnography reports both trained specialists and unqualified competitors. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357]
Attribute, do not adjudicate. Practical meaning: write "the client understands this as loss of ajayu", not "the client lost ajayu" or "the client believes, falsely, …". [synthesis]
The client defines the problem first. The CFI clarifies the problem from the perspective of the person and their network. Practical meaning: record the client's term before your diagnostic term. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Assess beliefs before applying a standard model. Researchers studying Aymara and non-Aymara patients with schizophrenia recommend this, especially with ethnic minorities. Practical meaning: never assume an Aymara client holds "traditional" beliefs. In that study, Aymara caregivers scored higher on psychosocial explanations, not on magical-religious ones. [source: https://ideas.repec.org/a/sae/socpsy/v61y2015i1p82-91.html]
Plural help-seeking is normal. Aymara users in northern Chile seek care from public services and from traditional and newer healers in Peru and Bolivia. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] Some yatiris see biomedicine as effective for the body but not for illness of the soul. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] Practical meaning: frame therapy as one part of the client's care, not a rival.
Health is collective and territorial. Practical meaning: ask about land, water, mining, displacement and community conflict as part of the problem, not as background. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf]
Avoid a narrow culturalist lens. Aymara participants have pushed back on state plans to bring yatiri into consulting rooms for "traditional" illnesses, saying the main problems are pollution, mining and landlessness. Practical meaning: do not reduce an Aymara client's distress to folk illness. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf]
Neither pathologise nor miss illness. Possession and trance that are a normal part of accepted cultural or religious practice are excluded from DID and trance diagnoses. Practical meaning: assess function, distress and wishedness, not content alone. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
Consent governs every contact with a healer. Practical meaning: no contact, letter or referral without explicit, documented consent, and the client may withdraw it. Bolivian law gives users free choice of practitioner and autonomy in health decisions. [source: https://www.lexivox.org/norms/BO-L-N459.html]
Do not encourage ceremonies outside community pathways. Practical meaning: do not recommend a healer, market stall or tourist offering; let the client and their community decide. [synthesis]
Never advise on medicines or substances. Practical meaning: questions about stopping medication, coca or herbs go to the prescriber or doctor. [synthesis]
Safety outranks deference. Practical meaning: restraint, violence, sexual contact, harm to a child or delay of urgent medical care trigger safeguarding regardless of the cultural frame. Bolivian law itself requires traditional practitioners to refer serious risk to health facilities. [source: https://www.lexivox.org/norms/BO-L-N459.html] [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is yatiri or qulliri practice. Sources are cited per item. Where steps are the therapist's own organisation of a published tool, they are marked [synthesis].

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with Aymara clients, or any client who mentions a yatiri, qulliri or coca. Reduces the risk of exoticising ("shaman", "witch market" framings) or dismissing the tradition. [synthesis]
Steps: (1) Write down what you associate with yatiri, coca and Andean Indigenous peoples, and where those ideas came from (tourism, media, drug policy). (2) Check whether you hold "traditional versus modern" assumptions; the Aymara caregivers in Caqueo-Urízar et al. scored higher on psychosocial causes, not magical-religious ones. [source: https://ideas.repec.org/a/sae/socpsy/v61y2015i1p82-91.html] (3) Learn the local routes: RUMETRAB and departmental councils in Bolivia, PESPI facilitators in Chile, intercultural health services in Peru (section 2). (4) Bring cases to supervision with someone who knows Andean communities, where possible. [synthesis]
Example language (illustrative): "I know only a little about Aymara healing, so I'll rely on you to tell me what matters about it for you."
Watch for: curiosity that serves your interest rather than the client's need; asking for details of ceremonies or coca reading that the client has not offered. Working when the client corrects you freely and brings up the healer without prompting. [synthesis]

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

Purpose / when: at initial assessment with any client, and especially when the client mentions a yatiri, qulliri or Aymara illness terms. The CFI has 16 questions that clarify the problem from the perspective of the person and their social network: what it means, possible sources of help, and what they expect from services. It is "designed to be used by any clinician providing services to any individual in any care setting". It supports clinical understanding and is not the only basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: (1) Introduce it as questions about how the client and the people around them see the problem. (2) Cover the four domains in order: cultural definition of the problem (Q1–3); cultural perceptions of cause, context and support (Q4–10: causes, stressors and supports, role of cultural identity); cultural factors affecting self-coping and past help seeking (Q11–13: self-coping, past help seeking, barriers); cultural factors affecting current help seeking (Q14–16: preferences and the clinician-patient relationship, including perceived racism and language barriers). [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] (3) In the help-seeking questions, ask about yatiri, qulliri, kallawaya, church and pharmacy as ordinary options. (4) Use the client's words in the record. (5) Use the official APA form; clinicians may reproduce it for use with their patients, but modifying or translating it needs APA permission. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Time needed: the DSM-5 field trial found later interviews took less time, but the abstract gives no minutes. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] [uncertain: a 15–20 minute figure is not verified]
Example language (illustrative): "What do you call this problem, in Aymara or Spanish or however you'd say it at home?" / "Who else have you gone to for help with it: a doctor, a yatiri, a qulliri, the church, anyone else?"
Watch for: clipped answers that may signal fear of judgement or of being reported (see 4.15 on coca). Working when the client names their own term and their own sources of help.

4.3 CFI supplementary modules

Purpose / when: to go deeper after the core CFI, or as standalone tools at any point in care. There are 12: Explanatory Model; Level of Functioning; Social Network; Psychosocial Stressors; Spirituality, Religion, and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient-Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; Caregivers. The core 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: choose modules by what the core CFI raised [synthesis]: Explanatory Model when the client names soul loss, fright or a harmful being; Spirituality, Religion, and Moral Traditions when Catholic, Evangelical and Andean practice intersect; Cultural Identity for language, Aymara identity, urban versus rural life; Coping and Help-Seeking for healer consultations; Immigrants and Refugees for migrants to La Paz or El Alto, northern Chile, Argentina or Brazil; Social Network and Caregivers when family is central; Older Adults and School-Age Children as fits. Give modules over several sessions if needed. Do not reproduce module items in handouts beyond APA's permissions.
Example language (illustrative): "You mentioned the church and also going to a yatiri. Can we spend some time on how faith and these traditions fit together for you?"
Watch for: module fatigue; switch to open conversation if the client tires. Working when the formulation gains details the core CFI did not yield.

4.4 CFI Informant Version with family

Purpose / when: when a family member arranged the yatiri consultation, holds the explanatory model, or the client cannot answer fully. It has 17 questions; the first covers the informant's relationship with the patient. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Steps: (1) Get the client's consent to involve the informant. (2) Interview the informant separately where safe. (3) Compare explanations; note where client and family disagree. A published Bolivian case of an Aymara patient with schizophrenia describes the family consulting a yatiri, a kallawaya and a ch'amakani in turn, with the father insisting on one option. [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]
Example language (illustrative): "What do you and the family think has happened to her, and what have you tried so far?"
Watch for: one relative's view overriding the client's; coercion into or away from treatment. Working when family and client can each state the other's view.

4.5 Kleinman's explanatory-model questions

Purpose / when: a short way to map the client's model, from Kleinman, Eisenberg and Good (1978, Annals of Internal Medicine 88:251–258). [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader] Use when there is no time for the full module, or as a follow-up.
Steps: ask, in your own words, about eight points: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment the client thinks they should get; what problems it has caused; what the client fears most about it. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] Record the answers next to your formulation.
Example language (illustrative): "What do you think started this, and why then?" / "What worries you most about it?"
Watch for: answers that combine models (for example, fright and a work stressor together); keep both. Working when you can explain your plan in terms of the client's model.

4.6 Asking about yatiri and qulliri consultations without judgement

Purpose / when: at assessment and at each review. Consultation is common and often undisclosed. Clients in La Paz, many of them migrants, consult yatiris when they have problems or illness. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357]
Steps: (1) Ask as a routine question, not a suspicion. (2) Ask what the healer said the problem was and what the client was advised to do, without asking for ceremony details. (3) Ask how it went and whether it helped. (4) Ask whether any advice conflicts with medical care (stopping medicine, avoiding hospital). (5) Note who recognises the healer (community, family, registry) if the client offers it. [synthesis]
Example language (illustrative): "Many people see a yatiri or a qulliri as well as coming here. Have you, or has your family? I'm not asking about the details, only what they told you and whether it helped."
Watch for: shame or a sense of being tested; reassure that it will not change your care. Working when the client mentions later consultations spontaneously.

4.7 Working with Aymara illness concepts and cultural concepts of distress

Purpose / when: when the client describes fright, soul loss or harm from a malevolent being. DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes, revised to avoid stigmatising or generalising language. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] Susto is among the DSM-5-TR examples. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] [uncertain: list from a secondary source]
Aymara concepts as published: a Bolivian psychology case report, drawing on Fernández Juárez (2004), describes ajayu as the main of three soul "shadows", alongside animu and kuraji; susto as common and serious if not attended to quickly, generally attributed to a saxra (a harmful being); and "madness" linked by Aymara families to loss of the animu, for which they turn to yatiris, kallawayas and ch'amakanis. [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92] In northern Chile, "soul pain", "fear" and "land grabbing" are named as Aymara ailments, with a language of damage, anger and transgression. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] Spellings and meanings vary by community; let the client define them.
Steps: (1) Use the client's term. (2) Explore it with the CFI and explanatory-model questions. (3) Assess symptoms, function and risk in parallel, since a cultural concept of distress can coexist with depression, PTSD, psychosis or a medical condition. (4) Record both the cultural concept and any diagnosis. (5) Agree which parts the healer addresses and which therapy addresses. [synthesis]
Example language (illustrative): "When you say your ajayu was frightened away, what has that been like day to day? Sleep, appetite, being with people?"
Watch for: using the term as a diagnosis or a stereotype; missing a trauma (an assault, accident or near-death event) behind the fright. Working when the client feels both the cultural meaning and the symptoms are taken seriously.

4.8 Distinguishing normative experience from disorder

Purpose / when: when a client describes a calling after a lightning strike, dreams or contact with protective beings, or spirits. Ethnography describes dreams and conversations with protective beings as central to a yatiri's training. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357]
Diagnostic anchors: DSM-5 DID allows identity disruption described as possession, but excludes a disturbance that is "a normal part of a broadly accepted cultural or religious practice"; dissociative trance (other specified dissociative disorder) excludes trance that is a normal part of collective cultural or religious practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] DSM-5-TR keeps these points in substance. [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] [uncertain: exact DSM-5-TR wording] ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require that the state is involuntary and unwanted and not part of accepted cultural or religious practice, with distress or impairment. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] A DSM-5-TR note on culturally sanctioned beliefs and psychotic symptoms is [uncertain: not verified].
Steps: (1) Ask whether the experience fits what the client's community expects and recognises. (2) Ask whether it is wanted, controllable and bounded in time and setting. (3) Assess distress, function, sleep, disorganisation, risk and substance use. (4) With consent, consult a cultural broker or community member. (5) Treat any physical injury from an actual lightning strike as a medical matter and ensure medical assessment. (6) Record uncertainty openly and review. [synthesis]
Example language (illustrative): "In your community, how would people understand what happened after the lightning? Does what you're going through now feel like that, or like something different?"
Watch for: pathologising a recognised calling; equally, accepting a spiritual frame when there is a rapid decline, disorganisation, command hallucinations or risk. Working when client, family and clinician agree on what is normative and what needs treatment.

4.9 Interpreters, intercultural facilitators and cultural brokers

Purpose / when: when Aymara or Spanish is the client's preferred language, or when the client wants someone from the community in the room. Chile's PESPI employs intercultural facilitators who are fluent speakers from an Indigenous people, know their community's health system, help users navigate services, address communication barriers and refer to Indigenous medicine; Quechua facilitators of Bolivian nationality were added in Arica and Iquique. [source: https://www.dipres.gob.cl/597/articles-212527_doc_pdf1.pdf]
Steps: (1) Ask language preference. (2) Use a trained interpreter or the local facilitator, not a child or the person who arranged a healer visit. (3) Brief them on confidentiality and on the aim of each session. (4) Debrief afterwards, including about cultural meaning. [synthesis]
Example language (illustrative): "Would you prefer to speak in Aymara, Spanish or both? We can have a facilitator here if that helps."
Watch for: facilitators who know the client socially; interpreting that softens or reframes spiritual content. Working when the client speaks at length in their preferred language.

4.10 Collaboration and referral with community-recognised healers

Purpose / when: only when the client wishes it, and where a legitimate route exists. Routes in the sources: Bolivia's registered traditional practitioners (RUMETRAB, or registration through Indigenous organisations inside recognised territories), whose law requires them to refer patients with complications or serious risk to health facilities [source: https://www.lexivox.org/norms/BO-L-N459.html]; Chile's PESPI, which pays for care by Indigenous healers, including qulliri and yatiri, through referral protocols, and has used joint mental health work by healers and psychologists in some areas [source: https://www.dipres.gob.cl/597/articles-212527_doc_pdf1.pdf]; Peru's policy asking traditional medicine practitioners to take part in health services [source: https://busquedas.elperuano.pe/normaslegales/aprueban-la-politica-sectorial-de-salud-intercultural-decreto-supremo-n-016-2016-sa-1363166-6/].
Evidence from other regions (context only): in Nigeria and Ghana, the COSIMPO cluster trial (Gureje et al., The Lancet 2020) found collaborative shared care between traditional and faith healers and primary care workers reduced psychosis symptoms more than usual care, and harmful practices fell. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In a Ghanaian prayer camp (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication to usual care lowered 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] No equivalent Andean trial is cited here. [uncertain: none verified]
Steps: (1) Ask whether the client wants any link between you and the healer, and what kind (none, a letter, a call, a joint meeting through a programme). (2) Get explicit, documented consent naming what is shared. (3) Use the programme route where one exists (facilitator, health service agreement, registered practitioner). Do not find or recommend healers yourself. (4) Agree roles: what therapy offers, what the healer offers, what medical care offers. (5) Agree who acts if risk rises. (6) Review the arrangement with the client. [synthesis]
Example language (illustrative): "Would it help if the yatiri and I knew about each other's part? It's completely your choice, and nothing is shared unless you agree."
Watch for: a healer's advice to stop medication or avoid hospital (route to the prescriber, see 4.15); confidentiality in small communities; tourism-oriented offerings presented as community healing. Working when the client experiences one coordinated plan.

4.11 Working with family and caregivers

Purpose / when: when family organises help-seeking, as in the Bolivian case where relatives moved between yatiri, kallawaya and ch'amakani. That case report recommends including family and patient beliefs about cause because they can affect adherence, assessing expressed emotion (criticism, hostility, over-involvement) and family warmth, and giving emotional as well as financial support. [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92] Researchers advise assessing caregivers' beliefs before applying a standard model. [source: https://ideas.repec.org/a/sae/socpsy/v61y2015i1p82-91.html]
Steps: (1) With consent, invite the people the client names. (2) Use the CFI Informant Version or Caregivers module. (3) Map each person's explanation and help-seeking. (4) Use standard family psychoeducation adapted to the family's model, presenting it as one view alongside theirs. (5) Address criticism and blame, including blame tied to transgression or sorcery accusations. [synthesis]
Example language (illustrative): "Each of you has tried hard to help. Can we look at what each of you thinks is going on, and what has helped most so far?"
Watch for: blame of the client for a transgression; pressure on the client to follow one path. Working when family criticism falls and the client has more say.

4.12 Integrating healing experiences into therapy

Purpose / when: after the client has seen a yatiri or qulliri and wants to make sense of it, or when the advice given affects relationships, work or travel. Yatiris advise on work, travel and business as well as illness. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357]
Steps: (1) Invite the client to say what the consultation meant to them, without asking for ritual content. (2) Note any change in symptoms, hope, relationships. (3) Link the meaning they took from it to therapy goals. (4) If the client felt worse, frightened or exploited, explore that. (5) Do not interpret the healer's diagnosis yourself. [synthesis]
Example language (illustrative): "What did you take away from seeing the yatiri? Has anything changed since?"
Watch for: fear produced by a diagnosis of sorcery or a harmful being; demands for repeated payment. Working when the client draws on both sources of help with less conflict.

4.13 Addressing collective, territorial and colonial harm

Purpose / when: when distress is tied to land, water, mining, displacement, migration or discrimination. In northern Chile, Aymara participants place these at the centre of health. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf] Ethnography in Bolivia links colonialism with illness and decolonisation with healing. [source: https://www.lunduniversity.lu.se/lup/publication/710a2d74-c3e8-42a5-aa8a-5a77c1c24a17] The CFI's last domain covers the clinician-patient relationship, including perceived racism and language barriers. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Ask about community conflicts, land and water, and experiences of racism, including in health services. (2) Include these in the formulation as causes, not as background. (3) Name power differences in the room. (4) Connect the client with community, legal or advocacy supports when they ask. [synthesis]
Example language (illustrative): "Some people tell me that what's happening to their land or community is part of why they feel unwell. Is that true for you?" / "Have you been treated badly in clinics because you're Aymara?"
Watch for: turning structural harm into an individual deficit. Working when the client feels the formulation reflects their life.

4.14 Migration and urban contexts

Purpose / when: with Aymara clients who have moved to cities (La Paz, El Alto) or abroad. Ethnography in La Paz describes many yatiri clients as Aymara migrants. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] Users in northern Chile seek care across borders in Peru and Bolivia. [source: https://repositorio.udd.cl/bitstream/11447/5253/1/Living%20Well%20and%20Health.pdf]
Steps: (1) Use the CFI Immigrants and Refugees module. (2) Ask about access to recognised healers at home and in the new place. (3) Ask about cross-border travel for care. (4) Address legal status, work and discrimination stressors. [synthesis]
Example language (illustrative): "Since you moved, has it been harder to get the kind of help you'd have had back home?"
Watch for: reliance on unknown practitioners in the new setting; isolation. Working when the client has a care network they trust.

4.15 Coca, herbs and medicines: a neutral, safe stance

Purpose / when: when coca chewing, coca use in healing, or herbal remedies come up. Coca leaf chewing is legal in Bolivia under its 2013 reservation to the 1961 Convention, which still treats coca leaf as a narcotic drug. [source: https://unodc.org/unodc/en/frontpage/2013/January/bolivia-to-re-accede-to-un-drug-convention-while-making-exception-on-coca-leaf-chewing.html] Its status in other countries is [uncertain: not verified].
Steps: (1) Treat traditional coca use as cultural practice, not as a substance-use problem by default. (2) Assess any substance use by standard methods if there are signs of harm. (3) Do not advise on preparing, using or obtaining coca or herbs. (4) Route any question about starting, stopping or combining medicines with herbs to the prescriber or doctor. (5) Where a client travels with coca, suggest they check the law of the destination country. [synthesis]
Example language (illustrative): "That's a question for your doctor, who can check it against your medication. Would you like help bringing it up with them?"
Watch for: stopping prescribed medication; conflating cultural coca use with cocaine. Working when the client discloses use openly and medicine decisions go through the prescriber.

4.16 Safeguarding

Purpose / when: whenever any practice, from any source, harms the client or others: restraint, beating, starvation, sexual contact, harm to a child, exploitation, or delay of urgent medical care. [synthesis] Bolivian law requires traditional practitioners to refer complications and serious risk, and provides for sanctioning malpractice. [source: https://www.lexivox.org/norms/BO-L-N459.html]
Steps: (1) Screen for harm at assessment and after any consultation. (2) If harm is present, follow your jurisdiction's safeguarding and reporting rules, as with any other harm. (3) Separate the abuse from the tradition when talking with the client and family. (4) In Bolivia, unregistered practice and malpractice fall under Law 459; local reporting routes are [uncertain: not verified]. (5) Document clearly. [synthesis]
Example language (illustrative): "I respect that you've sought help from a yatiri. What you're describing, though, put you in danger, and I need to act on that to keep you safe."
Watch for: fear of community backlash; a child's welfare. Working when the client is safe and remains in care.

5. Handling problems

The sources give little direct guidance on these difficulties. Unless a source is cited, the guidance below is [synthesis].

Client will not discuss healers or Aymara illness terms. Respect it; the help-seeking questions can return later. Name that you ask everyone. Fear of being judged backward or reported (for example, over coca) is likely. [synthesis]
Client asks you to explain or judge the yatiri's diagnosis. Decline gently. Say it belongs to the yatiri and the client's community, and offer to explore what it means to the client. [synthesis]
Client asks you to recommend a yatiri or qulliri. Do not recommend anyone. Point to community and family, and to programme routes where they exist: Bolivian registration through RUMETRAB or Indigenous organisations [source: https://www.lexivox.org/norms/BO-L-N459.html]; Chilean PESPI facilitators and healer agreements [source: https://www.dipres.gob.cl/597/articles-212527_doc_pdf1.pdf].
Competing explanations in the family (biomedical, spiritual, psychosocial). Map each one (4.4, 4.11). Seek a plan acceptable to all that keeps the client safe. Researchers recommend assessing beliefs before applying a standard model. [source: https://ideas.repec.org/a/sae/socpsy/v61y2015i1p82-91.html]
Non-adherence to medication or therapy because healing is under way. Explore the client's model of how the two fit. Present therapy and medicine as addressing different parts of the problem; some yatiris themselves see biomedicine as effective for the body. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] Route medication decisions to the prescriber. [synthesis]
Rupture after the therapist seemed dismissive or exoticising. Name it, apologise specifically, ask what would help, and use the CFI patient-clinician relationship questions. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [synthesis]
Stuck: symptoms persist despite healing and therapy. Revisit the formulation with the CFI. Check for missed trauma, depression, psychosis, substance use or medical illness; check for structural stressors (land, work, discrimination). [synthesis]
Overwhelm or fear after a diagnosis of sorcery, a harmful being or soul loss. Stabilise first (grounding, sleep, safety). Then explore meaning without contesting it, and involve trusted family or community. [synthesis]
Uncertain whether a calling or spirit contact is normative or a disorder. Hold the uncertainty openly, consult a cultural broker with consent, monitor function and risk, and review on a set date (4.8). [synthesis]
A healer advises against hospital or medication during a crisis. Safety comes first. Bolivian law itself requires traditional practitioners to refer complications and serious risk. [source: https://www.lexivox.org/norms/BO-L-N459.html] Use standard crisis and risk procedures. [synthesis]
Suicide risk. Use standard risk assessment and safety planning. Include the client's spiritual and community meanings of death and of protective ties, and family and healer support if the client wishes. [synthesis]
Confidentiality in small communities. Agree who may know what. Check whether an interpreter or facilitator knows the client. [synthesis]
Exploitation by a practitioner (repeated payments, fear-based demands). Ethnography reports unqualified practitioners competing for clients. [source: https://dra.revistas.csic.es/index.php/dra/article/download/349/353/357] Help the client check recognition through their own community; where harm occurs, follow safeguarding (4.16). [synthesis]
The therapist's own pull to take part in or learn ceremonies. Do not. Address it in supervision. [synthesis]

Sources

Web sources

Books and theses

Huanca L., T. (1987). The Yatiri in Aymara Communities. Thesis, University of Florida. [uncertain: not verified]
Fernández Juárez, G. (2004). Salud e Interculturalidad en América Latina: Perspectivas Antropológicas. Quito: Abya-Yala [uncertain: not verified]
Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.

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