Kallawaya healers (Bolivia)

1. Introduction

Version followed: the Kallawaya tradition as UNESCO describes it in the "Andean cosmovision of the Kallawaya" (proclaimed 2003, inscribed on the Representative List 2008) and as Bolivian law frames traditional ancestral medicine (Ley 459 of 19 December 2013 and its regulation, Decreto Supremo 2436 of 1 July 2015). Scholarly ethnography is used as attributed, outsider context. The therapist's tools follow the APA's DSM-5-TR Cultural Formulation Interview (CFI).

What it is. The Kallawaya are an Andean people of the mountainous Bautista Saavedra province north of La Paz, Bolivia (communities around Charazani, Curva and Amarete). UNESCO describes their ancestral medicine as the basis of the local economy. In UNESCO's words, it is practised by "exclusively male itinerant healers" who combine knowledge of plant, animal and mineral remedies with ritual practice, inside a cosmovision that fuses native and Christian religion. UNESCO calls their botanical pharmacopoeia (about 980 species) one of the richest in the world [source: https://ich.unesco.org/en/RL/andean-cosmovision-of-the-kallawaya-00048]. In UNESCO's account, women take part in rites, care for pregnant women and children, and weave textiles that carry the cosmovision. Bolivia's Ministry of Health registry, however, listed 65 practitioners under the specialty "Kallawaya" in 2019–2021, 19 of them women. The registry's categories and UNESCO's description are not the same thing, and how the registry assigns the specialty is [uncertain] [source: https://geoserver.minsalud.gob.bo/images/web/BOLETIN_MEDICINA_ANCESTRAL_BOLIVIANA_final_06102022.pdf].

An anthropologist's account (Fernández Juárez 2001) describes Kallawaya as Quechua-speaking healers who also speak Aymara and Spanish. It adds that some healers use a specialist language of their own. It describes wide-ranging travel with remedies as a late-colonial or republican development rather than an unchanging feature. In that account, illness categories such as susto (fright), loss of the ajayu (a soul component), mal aire and illnesses attributed to the gentiles or chullpas do not map onto biomedical categories. Patients often combine Kallawaya, other Andean healers and biomedical care [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177].

How change happens (as the tradition holds it, attributed). Bolivian law defines traditional ancestral medicine as ancestral knowledge and practice that uses material and spiritual resources to prevent and cure illness, in harmony with nature and the cosmos [source: https://www.wipo.int/wipolex/es/legislation/details/14436]. In Andean accounts, health is balance and harmony, including the unity of spirit and body, and illness can come from a disturbed relationship with beings and forces that share the world with people [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]. These are the tradition's own explanations, reported here without endorsing or dismissing them.

Your role. This is a living medical and spiritual system with its own healers, communities and authorities. It is not a psychotherapy, and a psychotherapist does not practise it. This guide covers the psychotherapist's culturally responsive work alongside it. That means understanding what the client's Kallawaya or Andean frame means to them, assessing with the CFI, telling culturally normative experience apart from disorder, and collaborating with recognised practitioners when the client wishes. It also means integrating what the client brings back from that care, and safeguarding. No ceremony, ritual, remedy, preparation or divination is described or recommended here.

2. Framework

The Kallawaya tradition is a cultural heritage and a medical system, not a staged treatment protocol. The phases below organise the psychotherapist's own work [synthesis]. The institutional facts inside them are sourced.

Who holds authority

Communities. The Kallawaya communities of Bautista Saavedra hold the knowledge. UNESCO reports that eight Kallawaya communities worked with Bolivia's Ministry of Cultures and Tourism, the municipalities of Curva and Charazani and a Committee for the Safeguarding of the Intangible Cultural Heritage of the Kallawaya Cosmovision. Together they produced an inventory publication, Tejiendo los saberes kallawayas (2017). Its distribution is restricted to Kallawaya communities, to support transmission to younger generations [source: https://ich.unesco.org/en/news/kallawaya-communities-document-their-traditional-healing-and-cultural-practices-for-safeguarding-purposes-00254].
Transmission. Scholars describe knowledge passed orally from master to apprentice through practice, and within families [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307]. At a 2015 UNESCO and Ministry of Cultures certification of 30 young Kallawaya trainees, participants spoke of learning from fathers and grandparents. One said a Kallawaya "no se hace, nace" (is born, not made) [source: https://www.andesacd.org/wp-content/uploads/2015/11/UNESCO-da-reconocimiento-a-30-kallawayas.pdf].
Practitioner associations. Scholars report that the Sociedad Boliviana de Medicina Tradicional (SOBOMETRA) has members who are Kallawaya doctors in La Paz and has received state recognition [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177] [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307]. Its current status and activity are [uncertain: scholarly sources only; no current statement by the society is cited]. Separately, Ley 928 of 9 April 1987 created a state Instituto Boliviano de Medicina Tradicional Kallawaya to research native medicinal flora, identify its active principles and preserve its cultivation, and declared Bautista Saavedra province the capital of Bolivian traditional medicine [source: https://www.pixilegal.com/normativa/ley-928-1987-04-09]. Whether that institute operates today is [uncertain].
State. Under Ley 459 (2013), the Ministry of Health (Viceministry of Traditional Medicine and Interculturality) runs the Registro Único de la Medicina Tradicional Ancestral Boliviana (RUMETRAB). Practitioners working outside Indigenous territories must register. Those inside their own territories may register through their own organisational mechanisms. Practising without registration is defined as illegal practice. A national council (CONAMETRAB), departmental councils (CODEMETRAB) and a standing commission of spiritual guides advise on policy. The law recognises four categories: traditional doctors, spiritual guides, traditional midwives and naturists [source: https://www.wipo.int/wipolex/es/legislation/details/14436]. DS 2436 (2015) sets out registration through the Departmental Health Service (SEDES). It provides for referral and counter-referral (referencia y contrarreferencia) between traditional practitioners and public, social-security and private health staff. Among its listed infractions is usurping the regional names of specialties [source: https://www.lexivox.org/norms/BO-DS-N2436.html].
Health-system policy. Traditional medicine sits inside Bolivia's SAFCI policy (Salud Familiar Comunitaria Intercultural). The Ministry reported that standardised referral and counter-referral forms exist, but referrals in both directions fell sharply over six years. It named dialogue between health staff and traditional practitioners as the basis for restoring them [source: https://geoserver.minsalud.gob.bo/images/web/BOLETIN_MEDICINA_ANCESTRAL_BOLIVIANA_final_06102022.pdf]. A 2023 review judged that official recognition has not yet produced serious policies for joining the two systems [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307].

Phases of the psychotherapist's work [synthesis]

Preparation (before or alongside the first contact). Goal: know the basic institutional landscape above and check your own assumptions. Move on when you can describe the client's tradition in its own terms without exoticising it.
Cultural assessment (sessions 1–3). Goal: the core CFI, the relevant supplementary modules and the explanatory model, plus a standard risk and mental-state assessment. Move on when you can state the client's own name for the problem, its cause, the help they have sought and their expectations of you.
Formulation and differential (by session 3–4). Goal: decide what is culturally normative experience or idiom, what meets criteria for a disorder, and what is both. Move on when the formulation has been shared with the client in their own terms and they agree with it or correct it.
Collaboration plan (when the client wishes). Goal: agree whether and how you will relate to their healer, with consent, confidentiality limits and clear roles. In Bolivia, use registered practitioners and formal referral channels. Move on when roles and information flow are agreed in writing.
Treatment and integration (ongoing). Goal: deliver your evidence-based treatment, invite the client to bring their healing experiences into therapy, and review the plan at agreed intervals. The CFI modules can be repeated during care [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Safeguarding (throughout). Goal: act on any risk to life, any delay of urgent care or any harm, whatever its cultural framing.

Format. Individual sessions, with family or informant sessions as needed. Use an interpreter for Quechua or Aymara speakers where needed. No session count has been published for this work [uncertain]. The CFI's duration is not given in the APA forms [uncertain].

3. Guiding principles

You work alongside the tradition, not inside it. Never perform, imitate or direct Kallawaya healing. Your interventions are psychotherapeutic [source: https://ich.unesco.org/en/RL/andean-cosmovision-of-the-kallawaya-00048] [synthesis].
Authority rests with the communities and the bodies they recognise. Point clients toward recognised practitioners (community recognition, RUMETRAB registration in Bolivia), not toward self-described healers [source: https://www.wipo.int/wipolex/es/legislation/details/14436] [source: https://www.lexivox.org/norms/BO-DS-N2436.html].
Restricted knowledge stays restricted. The communities restrict their own inventory, and Ley 459 protects practitioners' ancestral knowledge as intellectual property. In practice, do not record, request or pass on remedy names, recipes or ritual details beyond what is clinically necessary [source: https://ich.unesco.org/en/news/kallawaya-communities-document-their-traditional-healing-and-cultural-practices-for-safeguarding-purposes-00254] [source: https://www.wipo.int/wipolex/es/legislation/details/14436].
Attribute, do not adjudicate. Describe ajayu loss, susto or spirit causation as the client and the tradition hold them, neither as fact nor as superstition. In practice, use the client's words in notes and formulation [synthesis].
Plural care is normal. Patients commonly combine Kallawaya, other Andean healers and biomedicine. In practice, ask about all care without implying the client must choose [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177].
The client's explanatory model guides the conversation; your clinical judgement still governs risk. In practice, the CFI supports decisions but is not the sole basis for diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Neither pathologise nor miss illness. Culturally sanctioned experience is not a symptom, and a cultural frame can also hide a serious disorder or delay care. In practice, run a full differential every time [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92].
Consent and the client's choice drive collaboration. No contact with a healer or family without explicit consent [synthesis].
Stay out of remedies and medicines. Do not advise on herbs, preparations or prescribed medicines. Route medicine questions to the prescriber [synthesis].
Hold the history. Marginalisation of Indigenous medicine, migration and loss of transmission are part of the context. In practice, name them when relevant and check for racism within services [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them reproduces or substitutes for Kallawaya healing. Example language is illustrative unless quoted.

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with a client who uses or comes from the Kallawaya or wider Andean tradition. It reduces the risk of exoticising ("the mystical medicine men") or dismissing ("folk superstition") [synthesis].
Steps: (1) Write down your own beliefs about spirit causation, herbal medicine and Indigenous healers. (2) Note where those beliefs came from (training, media, religion). (3) Read the community's and state's own descriptions: UNESCO's element page, Ley 459 and the Ministry bulletin [source: https://ich.unesco.org/en/RL/andean-cosmovision-of-the-kallawaya-00048] [source: https://www.wipo.int/wipolex/es/legislation/details/14436]. (4) Take cases to supervision, ideally with a colleague who has Andean or intercultural-health experience. (5) Revisit after each phase [synthesis].
Example language (to yourself or in supervision, illustrative): "What did I assume about this client's healer before they told me anything?" "Would I ask a Catholic client these questions in this tone?"
Watch for: curiosity that turns into collecting exotic detail; reflexive referral to psychiatry whenever spirits are mentioned; romanticising (assuming all Indigenous care is safe or that the client wants it). It is working when your questions follow the client's priorities rather than your interest [synthesis].

4.2 Orienting to the client's place in the tradition

Purpose / when: early on. The aim is to learn the client's relationship to the tradition, not to learn the tradition. A client may be from a Kallawaya family, an Aymara or Quechua person who consults Kallawaya healers, an urban mestizo patient, or a migrant who keeps some practices abroad [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177] [source: https://revistas.usp.br/rlae/article/view/134969].
Steps: (1) Ask how the client describes their heritage and languages (Spanish, Quechua, Aymara). (2) Ask whether healing in their family comes from Kallawaya practitioners, other Andean healers (scholars note other specialists such as yatiri), church, biomedicine or a mix. (3) Ask what that tradition means to them now: pride, ambivalence, loss. (4) Record the answers in the client's own words [synthesis].
Example language (illustrative): "When people in your family get ill, whom do they usually go to first?" "Is the Kallawaya tradition part of your own family's history, or someone you consult?"
Watch for: assuming every Bolivian client relates to Kallawaya medicine (most do not); conflating Kallawaya with all Andean healing; a client's shame about "old customs" after migration or racism. It is working when the client corrects your assumptions freely [synthesis].

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

Purpose / when: the structured backbone of the cultural assessment, at intake or when cultural factors appear relevant. The APA describes it as a set of questions that clarify the problem from the perspective of the person and their social network: what the problem means, possible sources of help and what they expect from services. It has 16 questions in four domains: (1) cultural definition of the problem; (2) cultural perceptions of cause, context and support (including the role of cultural identity); (3) cultural factors affecting self-coping and past help seeking; (4) cultural factors affecting current help seeking, including the clinician–patient relationship. It supports clinical decisions and is not to be the sole basis for diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. APA states it is designed for "any clinician providing services to any individual in any care setting" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: (1) Obtain the official APA form. It may be reproduced without permission by clinicians for use with their patients; translation or modification needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (2) Introduce it as a way to understand the problem from the client's side. (3) Work through the four domains in order, in the client's language or through an interpreter. (4) Under past help seeking, ask explicitly about traditional healers (see 4.7). (5) Under the clinician–patient relationship, ask about language barriers and experiences of discrimination in services. (6) Note which domains need a supplementary module (4.4). (7) Summarise back in the client's words. Do not reproduce the form's items in your notes; paraphrase [synthesis on sequencing].
Example language (illustrative): "I'd like to understand this the way you and your family see it, not only the way doctors see it. Is that all right?" "Some people from the Andes describe this kind of trouble in their own words. How would you describe it?"
Watch for: rushing the interview as a checklist; translating the client's term (e.g. susto) into a diagnosis too early; clients who give "biomedical" answers because they expect disapproval. How long it takes is not given in the APA forms [uncertain]. The DSM-5 field trial found later interviews took less time [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. It is working when the client volunteers their own explanation and help-seeking history.

4.4 CFI supplementary modules and Informant Version

Purpose / when: to go deeper where the core CFI shows a need. The APA lists 12 modules. Those most relevant here are Explanatory Model; Spirituality, Religion, and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Social Network; Psychosocial Stressors; Patient–Clinician Relationship; Immigrants and Refugees; plus modules for school-age children and adolescents, older adults and caregivers. They can be used as add-ons or standalone, at first evaluation, later, or repeatedly during care. The Informant Version (17 questions) is used with a family member or friend [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) From the core CFI, pick the modules indicated. Spirituality and explanatory model are usual when the client describes soul loss, fright or spirit causation; Immigrants and Refugees for migrants. (2) Schedule them across sessions rather than all at once. (3) With consent, use the Informant Version with a relative when the client cannot give a history or when family decisions drive help seeking. (4) Repeat modules when treatment stalls or the client's view shifts [synthesis on sequencing].
Example language (illustrative): "You mentioned your faith and the healer your family trusts. Can we spend some time today on that side of things?" To a relative: "I'd like to hear how the family understands what has been happening to them."
Watch for: module fatigue; informant views overriding the client's; a relative's account that reveals pressure toward or away from treatment. It is working when the formulation includes both biomedical and the client's frames without contradiction.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: to elicit how the client understands their illness and what they expect from treatment. It is essential when the client uses Andean illness categories. The approach comes from Kleinman, Eisenberg and Good (1978), Annals of Internal Medicine 88:251–258 [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]. The eight questions, paraphrased, cover: the client's name for the problem; its cause; why it started when it did; what it does and how it works; its severity and expected course; what treatment they think they should get; the main problems it has caused; and what they fear most about it [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf].
Steps: (1) Ask the questions conversationally, spread over the session. (2) Record the client's terms (e.g. susto, ajayu, animu, mal aire) without translating them into diagnoses. (3) Ask how a Kallawaya or other healer explained it, if they have consulted one. (4) Compare with your formulation and identify overlap (e.g. both see fear and sleeplessness as central) and difference. (5) Negotiate a shared plan in language the client accepts [synthesis on steps 3–5].
Example language (illustrative): "What do you call what has been happening?" "What do you think started it, and why then?" "What are you most afraid this could lead to?" "What did the healer say it was? Did that fit for you?"
Watch for: scholarly accounts distinguish several soul components. One case study reports that losing the animu is considered recoverable through healers' rituals while losing the ajayu is described as gravely dangerous [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]. Usage varies between communities [uncertain], so let the client define the terms. A client who fears death from soul loss may need both urgent risk assessment and validation of that fear. It is working when the client sees their own explanation reflected in the plan.

4.6 Working with Andean cultural concepts of distress (e.g. susto)

Purpose / when: when the client describes fright, soul loss, aire or similar idioms. DSM-5-TR treats cultural concepts of distress as idioms, explanations or perceived causes, and syndromes [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. A secondary source lists susto among them [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. The exact DSM-5-TR text on susto is [uncertain]. In one ethnographic account, a Kallawaya healer explained susto as fear-induced illness with nervousness, poor appetite and sleeplessness [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177]. A study of Bolivian immigrants found susto, wayras, amartelo (sadness) and several kinds of pasmo kept after migration. Care for them combined home remedies, biomedicine and traditional medicine [source: https://revistas.usp.br/rlae/article/view/134969].
Steps: (1) Treat the idiom as meaningful communication about distress, not a diagnosis. (2) Ask about the precipitating event: a fright, an accident, a death, an assault or a humiliation. (3) Screen for depression, anxiety, PTSD, psychosis and physical illness, since an idiom can accompany any of them. (4) Use the client's term alongside your diagnosis in the formulation (e.g. "susto after the accident; also meets criteria for PTSD"). (5) Ask what traditional care the client is receiving or wants (see 4.7), and whether they want it coordinated [synthesis].
Example language (illustrative): "When you say you got susto, what happened just before?" "Many people from the Andes describe this as a fright. Doctors might call parts of it trauma or anxiety. Can both be true for you?"
Watch for: reducing a traumatic event to "folk illness"; or diagnosing every idiom as a disorder. The ethnographic literature reports that untreated susto is seen within the tradition as potentially fatal [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]. Take the client's fear seriously and assess suicide risk and physical health. It is working when the client can talk about the precipitating event and accepts the parts of treatment you offer.

4.7 Asking about consultation with healers and remedies, without judgement

Purpose / when: at intake (CFI past help seeking) and at every review. Plural use is common, and scholars report that some illnesses are considered outside the doctor's competence [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177]. You need to know what care the client is receiving so you can coordinate it and keep it safe.
Steps: (1) Normalise: ask the question for every client. (2) Ask whom they have consulted (Kallawaya healer, other Andean healer, naturist, church, pharmacy, doctor) and what they were told. (3) Ask whether they take any plant, animal or mineral remedies. Record only that they do and the general type, not recipes. (4) If they also take prescribed medicines, ask consent to tell the prescriber, and refer all questions about combining remedies and medicines to the prescriber or pharmacist. (5) Never advise starting, stopping or changing any remedy or medicine. (6) Ask how the client felt after the consultation [synthesis].
Example language (illustrative): "Lots of people I see use both traditional healers and doctors. Have you seen anyone else about this?" "Are you taking any herbal or traditional remedies? I won't judge or ask for the recipe. I'd just like your doctor to know, so nothing clashes. Is that OK?"
Watch for: the client hiding traditional care because of past ridicule; any wish of yours to comment on a remedy (refer instead); products sold with "miraculous" claims, which DS 2436 lists as an infraction in Bolivia [source: https://www.lexivox.org/norms/BO-DS-N2436.html]. It is working when the client discloses traditional care spontaneously at later sessions.

4.8 Distinguishing culturally normative experience from disorder

Purpose / when: when the client reports experiences the tradition explains spiritually: soul loss, encounters with spirits or the gentiles, frightening visions, hearing voices. The task is neither to pathologise normative belief nor to miss psychosis, dissociation, mood disorder or organic illness.
Reference points:
- DSM: in DID, identity disruption may be described in some cultures as possession, and the disturbance must not be 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 broadly accepted collective cultural or religious practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. Exact DSM-5-TR wording is [uncertain]. A DSM-5-TR note excluding culturally sanctioned beliefs and experiences from psychotic symptoms is [uncertain].
- ICD-11: 6B62 Trance disorder and 6B63 Possession trance disorder both require the state to be involuntary and unwanted, not part of accepted cultural or religious practice, and distressing or impairing [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574].
Steps: (1) Ask whether the client's community would see the experience as expected, unusual, or a sign of illness. (2) Ask whether it is voluntary, bounded in time and setting, and shared by others. (3) Assess functioning, distress, insight, the course over time, and first-rank or negative symptoms. (4) With consent, ask a family informant (4.4) or a cultural broker (4.11) how it is viewed locally. (5) Rule out physical causes, substances and delirium through medical referral. (6) Record the cultural meaning and any diagnosis side by side [synthesis].
Example language (illustrative): "In your family or village, would people see this as something that happens to people, or as a sign that something is wrong?" "Does this come only at certain times, or is it with you all the time now?"
Watch for: a published Bolivian case study of an Aymara patient with schizophrenia found that hospitalisation was delayed while the family sought healers, which probably hindered treatment. The authors called for intercultural care [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]. Decline in function, withdrawal from family and community, and persistent hallucinations call for urgent psychiatric assessment whatever the framing. It is working when the formulation is shared and the family accepts both forms of help.

4.9 Checking legitimate, community-sanctioned pathways

Purpose / when: when a client wants to consult or involve a Kallawaya practitioner, or names one. The aim is to steer toward recognised practitioners and away from people who trade on the name.
Steps: (1) In Bolivia, the client (or you, with consent) can ask whether the practitioner holds RUMETRAB registration. DS 2436 requires the licence to be displayed, and failing to display it is an infraction. Practising outside Indigenous territory without registration is illegal under Ley 459. Inside their own territories, practitioners may be recognised through their communities' own mechanisms [source: https://www.wipo.int/wipolex/es/legislation/details/14436] [source: https://www.lexivox.org/norms/BO-DS-N2436.html]. (2) Ask the client how the practitioner is known in their community and family; community recognition carries weight within the tradition. (3) Be cautious with practitioners who make "miraculous" claims, sell unauthorised products, claim regional specialty names they do not hold, or claim competence outside their field. DS 2436 lists all of these as infractions [source: https://www.lexivox.org/norms/BO-DS-N2436.html]. (4) Outside Bolivia there is no equivalent registry. Rely on the client's community and family networks, and never recommend a specific practitioner yourself [synthesis]. (5) Do not encourage clients to seek ceremonies outside these pathways [synthesis].
Example language (illustrative): "How did your family come to know this healer?" "In Bolivia, traditional practitioners register with the Ministry of Health. Is that something you'd want to check?"
Watch for: fees that escalate, demands for secrecy from you or the family, instructions to stop medical treatment, and isolation of the client. It is working when the client chooses with full information and keeps you informed.

4.10 Collaboration and referral with a recognised practitioner (with consent)

Purpose / when: when the client wants their healer and their therapist to work in parallel or together. In Bolivia, DS 2436 (Art. 7) provides for referral and counter-referral between traditional practitioners and health staff, and the Ministry reports standardised forms for this [source: https://www.lexivox.org/norms/BO-DS-N2436.html] [source: https://geoserver.minsalud.gob.bo/images/web/BOLETIN_MEDICINA_ANCESTRAL_BOLIVIANA_final_06102022.pdf]. WHO's Traditional Medicine Strategy 2014–2023 promotes the safe, effective use of traditional medicine through regulation, research and integration of practitioners into health systems [source: https://www.who.int/activities/implementation-of-the-WHO-traditional-medicine-strategy-2014-2023].
Evidence context (not Kallawaya-specific): in Ghana and Nigeria, the COSIMPO cluster trial (Gureje et al., The Lancet, 2020) found that collaboration between traditional and faith healers and primary care gave a greater reduction in psychotic symptoms, and harmful practices fell more than in controls [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]. In the Ofori-Atta prayer-camp trial in Ghana (Br J Psychiatry 212(1)), adding psychiatric medication to usual prayer-camp care 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]. Whether any comparable trial with Kallawaya practitioners exists is [uncertain].
Steps: (1) Get explicit, written consent specifying what may be shared, with whom, and for what purpose. (2) Agree roles with the client: the healer's domain as the tradition defines it, your psychotherapeutic domain, and the doctor's medical domain. (3) In Bolivian services, use the official referral and counter-referral forms through the health network. Elsewhere, use a brief letter or call agreed with the client [synthesis]. (4) Share only what is needed: risk, current treatment and goals. Do not ask for healing methods. (5) Agree what happens in a crisis: urgent medical or psychiatric care comes first. (6) Review the arrangement with the client at set intervals.
Example language (illustrative): to the client: "Would it help if I spoke with the healer, or would you rather keep the two separate?" To the practitioner: "Thank you for speaking with me. I'm working with [client] on their worry and sleep. I'd like us to know how to reach each other if things get worse."
Watch for: confidentiality breaches through family channels; a power imbalance in which either side treats the other as subordinate; mistrust after decades of marginalisation of Indigenous medicine [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307]. It is working when both parties respond to each other's referrals and the client reports feeling held rather than split.

4.11 Interpreters and cultural brokers

Purpose / when: for clients more at ease in Quechua or Aymara, or when cultural meanings are unclear. Kallawaya people are described as Quechua-speaking, also using Aymara and Spanish [source: https://asclepio.revistas.csic.es/index.php/asclepio/article/download/179/175/177].
Steps: (1) Ask the client's preferred language for talking about feelings. (2) Use a trained interpreter, not a child or a family member, for assessment. (3) Brief the interpreter on confidentiality and on rendering terms like susto or ajayu as said rather than translating them. (4) With consent, consult a cultural broker (an intercultural-health worker or a respected community member) about local meanings without identifying the client. (5) Debrief the interpreter after emotionally heavy sessions [synthesis].
Example language (illustrative): "Which language feels closest when you talk about fear or sadness?" To the interpreter: "Please keep the client's own words for illnesses, and tell me afterwards if a word carries a meaning I might miss."
Watch for: interpreters from the same small community (a confidentiality risk); interpreters softening spiritual content; brokers acting as gatekeepers rather than advisers. It is working when the client's account becomes richer and more specific.

4.12 Working with families and communities

Purpose / when: decisions about care in Andean families are often collective. Use this when family beliefs shape help seeking or when the family is the main carer.
Steps: (1) Ask the client whom they want involved. (2) Use the CFI Informant Version or the Caregivers module [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (3) Elicit the family's explanatory model and the help they have already sought. (4) Look for common ground, e.g. everyone wants the person sleeping, eating and back with the family. (5) Agree a plan that respects the family's choice of traditional care while securing medical safety. (6) Plan relapse signs and a crisis route together [synthesis].
Example language (illustrative): "Everyone here wants [name] to recover. Let's write down what each of you is already doing, and where we can work together."
Watch for: the client's voice being lost to elders' decisions; disagreement between generations (younger members may have left traditional customs, as Kallawaya trainees themselves described [source: https://www.andesacd.org/wp-content/uploads/2015/11/UNESCO-da-reconocimiento-a-30-kallawayas.pdf]); delays of urgent care. It is working when the family brings concerns to you early.

4.13 Integrating healing experiences into therapy

Purpose / when: after a client has consulted a Kallawaya or other Andean practitioner and wants to make sense of it in therapy [synthesis].
Steps: (1) Invite, don't require, the client to talk about the experience. (2) Ask about meaning and effect, not method: what changed, what they understood, how they feel. (3) Link the gains to therapy goals (e.g. feeling "whole again" and returning to work). (4) If the experience was distressing or confusing, explore it as you would any significant event, and assess for retraumatisation. (5) Never interpret the healer's work or offer a rival explanation of it. (6) Record outcomes in the client's words [synthesis].
Example language (illustrative): "You saw the healer last week. What was that like for you, and has anything shifted since?" "You said you feel your spirit is back. What does that let you do now that you couldn't before?"
Watch for: the client expecting you to validate or judge the healer; disappointment if the problem has not improved, which can be met without blaming either system; new symptoms after the consultation, which need assessment. It is working when the client experiences their care as one story rather than two competing ones.

4.14 Migration, acculturation and loss of transmission

Purpose / when: for migrant or urbanised clients, and Kallawaya-descended clients cut off from their tradition. UNESCO identifies acculturation as a threat to Kallawaya medical knowledge [source: https://ich.unesco.org/en/RL/andean-cosmovision-of-the-kallawaya-00048]. Kallawaya trainees described young people migrating and forgetting their customs [source: https://www.andesacd.org/wp-content/uploads/2015/11/UNESCO-da-reconocimiento-a-30-kallawayas.pdf]. Reviewers report that the places Kallawaya once travelled to practise have shrunk and that mining concessions threaten the territory [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307]. Bolivian immigrants abroad keep culture-bound syndromes and adapt their care to new resources [source: https://revistas.usp.br/rlae/article/view/134969].
Steps: (1) Use the CFI Immigrants and Refugees and Cultural Identity modules [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (2) Map losses: land, language, healers, family roles. (3) Explore ambivalence about the tradition without pushing toward or away from it. (4) Identify which forms of help the client can actually reach where they live. (5) Address grief and identity as therapy targets in their own right [synthesis].
Example language (illustrative): "What did you leave behind that helped you when you were unwell at home?" "How is it for you that the old knowledge in your family isn't being passed on the way it was?"
Watch for: idealising or rejecting the past; isolation; clients turning to unregistered or online sellers when they cannot reach their own community's healers (see 4.9). It is working when the client can name what they want to keep and how.

4.15 Addressing historical marginalisation and racism in services

Purpose / when: when a client reports being mocked or dismissed for traditional beliefs, or mistrusts services. Reviewers note that Bolivia's official acceptance of Indigenous medicine (from 1984) has not yet been matched by university teaching or serious integration policies [source: https://agrovet.umsa.bo/index.php/AGV/article/download/146/135/307]. The CFI asks about 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 directly about past experiences with services. (2) Acknowledge harms without defending the system. (3) Ask what would make your service safer for them. (4) Repair concretely: an interpreter, your pace, how notes are written. (5) Raise patterns with your service [synthesis].
Example language (illustrative): "Some people from the Andes have told me doctors laughed at them for seeing a healer. Has anything like that happened to you?" "I'd rather know if I say something that feels dismissive."
Watch for: politeness masking mistrust; early dropout. It is working when the client challenges you openly.

4.16 Protecting the community's knowledge in your own practice

Purpose / when: whenever the client tells you about remedies or practices, and in any teaching, writing or research. The Kallawaya communities restrict their own inventory to the communities [source: https://ich.unesco.org/en/news/kallawaya-communities-document-their-traditional-healing-and-cultural-practices-for-safeguarding-purposes-00254]. UNESCO names insufficient legal protection against major pharmaceutical companies, and misappropriation, as threats [source: https://ich.unesco.org/en/RL/andean-cosmovision-of-the-kallawaya-00048]. Ley 459 gives practitioners intellectual protection of their individual and collective ancestral knowledge [source: https://www.wipo.int/wipolex/es/legislation/details/14436].
Steps: (1) Do not record plant names, recipes or ritual details beyond what clinical safety needs. (2) Do not share such details in supervision, teaching or publications. (3) Decline requests (from colleagues, students or wellness businesses) to "learn Kallawaya techniques" through you. (4) If you write about clinical work, de-identify fully, describe only the general cultural context, and consider consulting community representatives [synthesis].
Example language (illustrative): to the client: "You don't need to tell me what's in it, only whether you're taking something, so your doctor knows." To a colleague: "That's the community's knowledge to share, not mine."
Watch for: your own curiosity; therapists marketing "Andean healing" add-ons. It is working when clients see that you are not extracting knowledge.

4.17 Safeguarding

Purpose / when: throughout. Cultural framing never changes your duties around risk to life, delayed urgent care, or abuse [synthesis].
Steps: (1) Do a standard suicide and self-harm risk assessment at intake and when distress rises, including a fear of dying from soul loss. (2) If psychosis, severe depression, mania, delirium or a physical emergency is suspected, arrange urgent assessment, and explain it in the client's terms where possible. The delayed hospitalisation in the published Aymara case shows the risk [source: https://ajayu.ucb.edu.bo/a/article/download/59/57/92]. (3) Ask about any practice that restrains, starves, beats, or sexually exploits the client, or tells them to abandon medical care. Collaboration studies in other countries document harmful practices such as chaining [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]. The sources cited here do not document harms of this kind by Kallawaya practitioners [uncertain]. (4) For children, apply your jurisdiction's child-protection procedures. Do not name or identify minors in records shared with healers. (5) Follow local reporting law. In Bolivia, practice without registration and misleading claims fall under Ley 459 and DS 2436 sanctions [source: https://www.lexivox.org/norms/BO-DS-N2436.html]. (6) Document your reasoning, including the cultural context.
Example language (illustrative): "I respect the care your family has chosen. Right now I'm worried about your safety, and I need us to get a doctor involved today as well."
Watch for: reluctance to act for fear of seeming culturally insensitive; and, the other way, treating any traditional consultation as a safeguarding concern. It is working when risk is managed and the client's relationship to both forms of care is preserved.

5. Handling problems

The sources do not address problems in psychotherapy with Kallawaya-tradition clients, so all responses below are [synthesis] unless a source is cited.

Client won't discuss traditional care (fearing ridicule). Normalise it by asking every client. Disclose that you ask everyone. Go back to it later, and accept partial answers. Watch for ridicule from earlier services (4.15).
Client wants you to endorse or judge the healer. Reflect the question back to their own experience. State plainly that the healer's work is their own field and yours is talking therapy: "I can't speak to his work; I can help you think about what you noticed" (illustrative).
Client asks you for herbal or remedy advice, or whether to stop prescribed medicine. Decline kindly and route the question to the prescriber or pharmacist, with consent to share what they take. Never comment on doses or combinations.
Stuck: the explanatory models conflict. Find shared goals (sleep, appetite, work, family) and frame your treatment as one support among several. Use the Explanatory Model module again [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Overwhelm when discussing a fright or encounter. Slow down, ground in the present, and titrate. Treat the precipitating event as potentially traumatic, with the usual trauma-informed safety and consent steps.
Non-adherence to therapy or medication. Explore it through the explanatory model: does the client think the treatment fits the cause? Are there competing obligations to family or healer? Negotiate rather than lecture.
Rupture after a perceived dismissal. Name it, apologise specifically, and ask what would repair it. Revisit the CFI's clinician–patient relationship questions [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Family insists on traditional care only, while the client deteriorates. Hold a family meeting, acknowledge the family's choice, state the specific risk, and offer both together. If there is serious risk, follow emergency and safeguarding duties (4.17).
Practitioner of uncertain standing. Help the client check community recognition and, in Bolivia, RUMETRAB registration. Watch for "miraculous" claims, secrecy and demands to stop medicine [source: https://www.lexivox.org/norms/BO-DS-N2436.html].
Healer declines contact with you. Respect that. Continue your own work and keep the client as the bridge.
Client from a Kallawaya family who feels guilt about leaving the tradition, or is under pressure to take it up. Work on identity and ambivalence (4.14) without steering. Decisions about who learns the tradition belong to the family and community.
Therapist pressure to "learn the techniques" or offer Andean healing. Refuse. That knowledge belongs to the communities and is legally protected in Bolivia [source: https://www.wipo.int/wipolex/es/legislation/details/14436].
Interpreter or broker from the client's own small community. Offer an alternative and check consent. If none is available, agree limits on what is discussed with that interpreter present.
Outside Bolivia, with no recognised practitioner reachable. Help the client identify what forms of support from family, church or diaspora community are available. Avoid online sellers using the Kallawaya name. Do not seek ceremonies on the client's behalf.

Sources

Community, UNESCO and Bolivian state sources

Scholarship (outsider and Bolivian academic accounts)

Cultural assessment and diagnosis

APA, DSM-5-TR Cultural Formulation Interview (core)
APA, DSM-5-TR Section III (culture chapter excerpt)
APA, CFI Supplementary Modules (DSM-5)
APA, CFI Informant Version (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
DSM-5-TR webinar slides on cultural concepts of distress (UNMC BHECN)
Dissociative disorders and possession (PMC9199574)
ASWB exam prep: dissociative disorders (University of Missouri System Pressbooks, citing APA 2022)
ICD-11 6B62 Trance disorder (third-party mirror of WHO text)
Explanatory Models of Illness handout (Tanenbaum)
Dinos et al. 2017, citing Kleinman's explanatory-model questions (Cambridge Core)
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 [uncertain: page range differs between secondary sources].

Collaboration with traditional healers (non-Kallawaya evidence)

Further reading

Bastien J.W. (1987). Healers of the Andes: Kallawaya herbalists and their medicinal plants. Salt Lake City: University of Utah Press. Bibliographic details from a library catalogue record

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