Atlas›Domain XVI · Historical, discredited & harmful›Guide 009
Guide XVI-009

Trepanation

A 27 · L 64 · M 920 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the archaeological and historical record as summarised by André (2017, Arquivos de Neuro-Psiquiatria) and Kushner, Verano and Titelbaum (2018, World Neurosurgery, as reported by the University of Miami); the Hippocratic treatise On Injuries of the Head in Francis Adams's public-domain translation; the art-historical reading of "stone of madness" imagery by González Hernando (2012); the modern self-trepanation revival as André (2017) describes it; and modern injuries as a 2025 Cureus case report and Deseret News (2001) document them. This guide covers the psychotherapist's own work. It does not describe, and must never be used to teach, how trepanation is done.

Trepanation (also trephination) is the deliberate opening of a hole in the living skull; a 2001 news report on an unlicensed operation in Utah called it "skull drilling" [source: Deseret News 2001]. André describes it as one of the oldest surgical practices, dating back roughly 7,000 to 10,000 years and documented in Europe, Africa, Asia and the Americas [source: André 2017]. Historians and archaeologists identify head injury as a main reason; ritual or religious purposes, headache, seizures and "madness" or the expulsion of perceived spirits are proposed as other reasons, and these remain interpretations from bone evidence rather than established facts [source: André 2017; Kushner et al. 2018 via University of Miami News]. In the Hippocratic corpus it appears as a response to serious skull injury, not as a treatment for mental disorder [source: Hippocrates, On Injuries of the Head, Adams trans.]. In early-modern Netherlandish painting, the "extraction of the stone of madness" became a satirical image of folly and quackery, which art historians read as separate from real cranial surgery [source: González Hernando 2012; Strahov Monastery collection page].

Since the 1960s a small movement has promoted self-trepanation to enhance consciousness or brain function, a claim André judges scientifically unproven [source: André 2017]. Modern self-inflicted skull injuries, sometimes driven by psychotic beliefs, appear in peer-reviewed case reports [source: Bhatt et al. 2025]. Trepanation is not a treatment for any mental or physical condition and is not recommended.

How change happens, for the psychotherapist: the work changes things by (a) giving accurate history so that myths ("ancient people cured madness by letting it out") are replaced by attributed evidence; (b) recognising when interest in trepanation signals risk (psychosis, self-harm, suicidality, a plan to self-operate or travel for the operation) and routing urgently to medical care; and (c) helping clients meet the needs behind the interest (altered consciousness, wellbeing, relief from intrusive bodily sensations, meaning) through safe, supported means [synthesis].

2. Framework

Historical phases in outline (for orientation, not instruction)

  • Prehistory and the Neolithic. Trepanned skulls are found worldwide; Faria (2015) cites over 1,500 such skulls and reports that in most series 5-10% of Neolithic skulls show trepanation [source: Faria 2015, Surgical Neurology International, abstract]. André reports estimates of up to 6% of some populations and survival of about 40% in early procedures [source: André 2017]. Why it was done remains debated; Faria discusses a unifying hypothesis proposed by the historian Plinio Prioreschi [source: Faria 2015, abstract; details [uncertain: not verified]].
  • Andean South America. More than 800 prehistoric Peruvian skulls show trepanation, the earliest from about 400 BCE. Judged by bone healing, survival improved over time, averaging about 75-83% in the Inca period, against mortality of about 46-56% for cranial surgery in the American Civil War. The procedure was mainly used for head trauma; headaches, seizures, mental illness or expelling perceived demons are suggested but speculative [source: Kushner, Verano and Titelbaum 2018, via University of Miami News].
  • Classical medicine. The Hippocratic On Injuries of the Head deals with scalp wounds, fractures and contusions of the skull, and considers trepanning for serious, possibly hidden fractures after a forceful blow with signs such as dizziness, stupor or collapse [source: Hippocrates, On Injuries of the Head, Part 14, Adams trans.]. Adams, in his 1886 edition, comments that Hippocrates operated fearlessly and, by modern judgement, sometimes unnecessarily [source: Adams, The Genuine Works of Hippocrates, vol. 1, Preliminary Discourse].
  • Medieval and early-modern Europe. The "stone of madness" image (Bosch's panel in the Prado; later followers such as Marcellus Coffermans) shows a sham operation to remove a stone thought to cause folly. González Hernando finds no medieval text describing such an operation, cites Rhazes's warning against charlatans who faked cranial operations, and reads the paintings mainly as satire of quacks; the Dutch phrase for having a stone in the head meant being foolish [source: González Hernando 2012; Strahov Monastery collection page]. Survival of trepanation itself rose to about 80% in the 16th-17th centuries [source: André 2017].
  • Decline. Use declined in the late 19th century as care moved into hospitals [source: André 2017].
  • Modern revival (1960s onward). A Dutch advocate, Hugo Bart Huges, circulated a manuscript in 1962 claiming trepanation would permanently raise brain blood volume and consciousness and trepanned himself in 1965; early followers included Amanda Feilding, who later stood twice for the UK Parliament on a platform including public funding for trepanation. Peter Halvorson founded the International Trepanation Advocacy Group (ITAG) in 1997, which ran a small study in Mexico and later organised trips to Central and South America for the operation [source: André 2017]. In 2001 Halvorson and another Utah man pleaded guilty to practising medicine without a licence after trepanning a woman from England in Utah [source: Deseret News 2001].
  • Today. André describes dozens of people seeking it for spiritual and cognitive reasons and an uncertain future as the main proponents age [source: André 2017]. Self-inflicted skull injury in psychosis is reported as rare and possibly under-recognised [source: Bhatt et al. 2025].

Phases of the psychotherapist's work [synthesis]

Pace and number of sessions are set by risk and the client's needs [synthesis].

  1. Recognition and engagement. Goal: notice the topic (historical curiosity, family or heritage interest, online advocacy, an attempt or plan, a wound) and keep the client talking. Move on when you know which of these it is.
  2. Medical safety and risk. Goal: if there is any injury, plan, recent attempt, or travel booked for the operation, route to emergency medical care and assess suicide and self-harm risk the same day. Move on only when medical safety is in place.
  3. Assessment and formulation. Goal: understand the motives (consciousness expansion, spiritual seeking, bodily delusions, intrusive sensations, despair), screen for psychosis, mania, substance use, head injury and suicidality, and note cultural and spiritual framing. Move on when you have a shared formulation.
  4. Psychoeducation, meaning and alternatives. Goal: give the evidence status in plain terms, work with the needs behind the interest, and agree safe alternatives. Move on when the client's plan no longer includes the practice.
  5. Repair, coordination and follow-up. Goal: work with injury sequelae, shame and family strain; coordinate care; act on safeguarding or reporting duties; keep follow-up in place.

For purely historical interest, phases 1 and 4 are usually enough; screen lightly for risk anyway.

3. Guiding principles

  • History, not instruction. Discuss trepanation historically and never supply procedure, tool or aftercare information. In practice: decline any request for how-to detail and say why [synthesis].
  • Attribute and qualify. Purposes of prehistoric trepanation are inferences from bone; say "archaeologists think" rather than "they did it to cure madness" [source: Kushner et al. 2018; André 2017].
  • Separate the stone of madness from surgery. Present the paintings as satire and folklore as art historians read them, not as records of a cure [source: González Hernando 2012].
  • Unproven means unproven. State André's conclusion that the scientific case for enhancement is unproven and that a funded pilot imaging study could not show physiological change [source: André 2017].
  • Any skull wound or plan is a medical emergency. In practice: same-day emergency routing; do not wait for the next session [synthesis; source for the severity of injuries: Bhatt et al. 2025].
  • Think psychosis and self-harm. Self-trephination has been reported in schizophrenia with foreign-body delusions; assess beliefs about the head and body [source: Bhatt et al. 2025].
  • Respect the need, question the method. Wishes for expanded consciousness or relief are legitimate; the method is the problem. In practice: explore the goal without ridicule [synthesis].
  • Safe messaging. Talk about self-harm and suicide without method detail or glamorising, and give crisis resources (988 in the US; Samaritans 116 123 in the UK and Ireland) [synthesis].
  • Never provide, supervise or refer. The psychotherapist never provides, supervises or refers anyone to trepanation, at home or abroad [synthesis].
  • Act on colleagues' conduct. Unlicensed operations have led to criminal convictions; report practitioners through licensing and legal routes [source: Deseret News 2001; synthesis].
  • Cultural humility. Clients of Andean, or other, heritage may hold this history with pride; honour it as heritage while being clear about modern risk [synthesis].
  • No medicine advice. Never advise starting, stopping or changing a medicine; leave that to prescribers [synthesis].
  • Avoid moralising. Facts carry the weight; do not deride advocates or clients drawn to the idea [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building your own historical literacy

  • Purpose and when to use: before any client work on the topic, so that you can correct myths accurately and without overstating.
  • Steps: (1) Learn the four sourced anchors: worldwide prehistoric practice; head injury as the main documented reason, with other purposes inferred; the Hippocratic link to skull injury; the stone-of-madness paintings as satire [source: André 2017; Kushner et al. 2018; Adams trans.; González Hernando 2012]. (2) Learn the modern revival and its evidence status [source: André 2017]. (3) Keep the standard reference to hand: Arnott, Finger and Smith (eds), Trepanation (2003), which covers prehistoric cases across continents, identification of trepanned skulls and theories of purpose [source: Routledge/CRC Press page]. (4) Note what you cannot confirm and say so to clients [synthesis].
  • Example language (illustrative): "What archaeologists can say for sure is that people survived it, because the bone healed. Why they did it is mostly educated guesswork."
  • Watch for: repeating popular claims ("ancient cure for madness") as fact; your own fascination drawing the session away from the client [synthesis].

4.2 Responding to a client's historical or cultural interest

  • Purpose and when to use: a client raises trepanation from a documentary, museum visit, art or reading, with no stated wish to undergo it.
  • Steps: (1) Ask what caught their interest. (2) Offer accurate, attributed history at their pace. (3) Ask lightly whether the interest connects to anything personal (head injury, mental-health history, spiritual seeking). (4) If nothing personal emerges, return to the client's agenda [synthesis].
  • Example language (illustrative): "It is a remarkable piece of history. I am curious what it stirred up for you."
  • Watch for: fascination that is shifting from "what did they do" to "what would it be like for me"; that shift calls for 4.4 [synthesis].

4.3 Working with heritage and family history

  • Purpose and when to use: a client with Andean or other heritage where trepanation is part of a national or family story, or a client whose relative had cranial surgery or psychosurgery and who links the two.
  • Steps: (1) Invite the story as the client holds it (pride, unease, curiosity). (2) Share the sourced picture, including the high survival in the Inca period as Kushner and colleagues report it [source: Kushner et al. 2018]. (3) Distinguish ancient practice, Hippocratic injury surgery and 20th-century psychosurgery, which are different histories [synthesis]. (4) Help the client hold heritage with respect while being clear that the practice is not a modern therapy [synthesis].
  • Example language (illustrative): "The skill in those Andean communities is a real achievement. Honouring it is different from treating it as medicine for today."
  • Watch for: the client feeling their culture is being judged; conflation with relatives' psychiatric surgery, which may need its own grief or anger work [synthesis].

4.4 Screening a client who is drawn to the practice

  • Purpose and when to use: a client says they are considering trepanation, self-trepanation, or travel abroad for it, or is reading advocacy material.
  • Steps: (1) Stay calm and curious; do not lecture first. (2) Ask directly: whether they intend to do it, whether they have a plan, a date, a provider or a trip; whether they have ever tried. (3) Ask what they hope it will change (consciousness, energy, mood, spiritual state, a sensation in the head). (4) Screen for psychosis, mania, substance use, head injury and suicidality (4.6, 4.7). (5) Decide urgency: any plan with means or a date, or any prior attempt, moves to 4.5 the same day [synthesis].
  • Example language (illustrative): "I want to understand this properly, not judge it. Are you planning to have this done, and if so, how close is that?"
  • Watch for: secrecy, a booked trip, references to a group or provider, recent scalp wounds or headwear hiding the head, and talk of something trapped in the skull [synthesis; source for travel and groups: André 2017; for delusions: Bhatt et al. 2025].

4.5 Urgent medical routing

  • Purpose and when to use: any self-inflicted or unlicensed skull injury, a scalp wound, signs of infection or neurological change, or an imminent plan.
  • Steps: (1) Treat it as an emergency: direct the client to the emergency department or call emergency services. (2) If the client is with you and has neurological signs (confusion, drowsiness, fluid from a wound), do not let them leave alone. (3) Tell the receiving team what you know, with consent where possible and without consent where life is at risk, following your local confidentiality rules. (4) Follow up the same day or next day [synthesis]. Injuries in documented cases included brain-fluid leakage, bleeding inside the skull, bone infection and brain abscess [source: Deseret News 2001; Bhatt et al. 2025].
  • Example language (illustrative): "This needs a doctor today, not next week. I am going to help you get there now."
  • Watch for: minimisation ("it is healing fine"); delayed presentation, since the documented 2025 case involved a long-standing wound [source: Bhatt et al. 2025].

4.6 Assessing for psychosis and somatic delusions

  • Purpose and when to use: the wish to open the skull is linked to beliefs that something is inside it, pressure that must be released, or commands.
  • Steps: (1) Ask open questions about sensations and beliefs about the head. (2) Explore conviction, distress and any voices or commands. (3) Ask about past psychiatric care and current treatment engagement without advising on medicines. (4) Arrange same-day psychiatric assessment if beliefs are fixed and linked to self-injury [synthesis]. Bhatt and colleagues describe a woman in her fifties with schizophrenia and foreign-body delusions who repeatedly injured her own scalp and skull to stop a crawling sensation, and who improved after surgical and psychiatric care [source: Bhatt et al. 2025].
  • Example language (illustrative): "Some people feel there is something in their head that has to come out. Has anything like that been happening for you?"
  • Watch for: commands to self-injure, rising conviction, and disengagement from psychiatric care; these call for urgent psychiatric involvement [synthesis].

4.7 Suicide and self-harm risk assessment with safe messaging

  • Purpose and when to use: at every disclosure of intent, attempt or injury, and wherever despair underlies the interest.
  • Steps: (1) Ask directly about suicidal thoughts and self-harm, separately from the trepanation wish. (2) Assess intent, plan, access to means, protective factors and prior attempts using your service's standard approach. (3) Discuss means only as safety requires (storage, removal, who can help), never method detail. (4) Give crisis resources: 988 (US) and Samaritans 116 123 (UK and Ireland) [synthesis].
  • Example language (illustrative): "Sometimes wanting to change your brain this drastically comes with feeling you cannot go on as you are. Are you having thoughts of ending your life?"
  • Watch for: framing a dangerous act as harmless self-improvement; hopelessness; isolation [synthesis].

4.8 Safety planning

  • Purpose and when to use: after risk assessment, when the client still holds the wish or has a history of self-injury.
  • Steps: (1) Agree warning signs (urges, research binges, contact with advocates). (2) Agree coping steps and people to contact. (3) Agree reducing access to anything the client links to self-injury, in general terms. (4) Write crisis numbers into the plan. (5) Review at each session [synthesis].
  • Example language (illustrative): "Let's write down what you would do, and who you would call, if the urge gets strong between sessions."
  • Watch for: a plan agreed only to end the conversation; refusal to involve anyone [synthesis].

4.9 Psychoeducation on evidence status

  • Purpose and when to use: the client believes advocacy claims about brain blood volume, consciousness or wellbeing.
  • Steps: (1) Ask what they have read and from whom. (2) Summarise the evidence as André states it: the supporting research is mostly studies co-authored by advocates; the one funded imaging pilot could not show physiological change, though participants reported satisfaction; the scientific case is unproven [source: André 2017]. (3) Name the documented harms (4.5). (4) Leave space for the client's reaction [synthesis].
  • Example language (illustrative): "The people who felt better were satisfied, but the scans did not show the change the theory predicts. That gap matters when the risk is brain injury."
  • Watch for: a debate that hardens the client's position; switch to exploring needs (4.10) [synthesis].

4.10 Exploring the needs behind the interest and supported alternatives

  • Purpose and when to use: the client wants expanded consciousness, more energy, spiritual growth, relief from low mood or from head sensations.
  • Steps: (1) Name the goal in the client's words. (2) Explore what has helped before. (3) Discuss evidence-based routes for the underlying problem (assessment and treatment for depression, psychosis or head-injury sequelae through appropriate services) and safe routes for the spiritual or experiential goal (contemplative practice within the client's tradition, community, meaning-centred work) [synthesis]. (4) Agree a next step.
  • Example language (illustrative): "If what you want is to feel more awake and alive, let's look at ways of getting there that do not put your brain at risk."
  • Watch for: substituting another unproven or risky practice; do not present any alternative as a cure [synthesis].

4.11 Media and community literacy

  • Purpose and when to use: the client's interest comes from advocacy groups, films, books, forums or charismatic advocates.
  • Steps: (1) Map where the information comes from. (2) Note, as André does, that early advocates publicised their own experiences and co-authored the research cited in support [source: André 2017]. (3) Explore the pull of belonging to the group. (4) Help the client judge sources by who funds and authors them [synthesis].
  • Example language (illustrative): "Who is telling you this works, and what would they lose if it didn't?"
  • Watch for: isolation from other relationships; financial pressure; plans to travel with a group [synthesis].

4.12 Medical-tourism risk conversation

  • Purpose and when to use: the client plans to travel abroad for the operation; André reports that an advocacy group organised such trips to Central and South America [source: André 2017].
  • Steps: (1) Ask about the plan, dates and companions. (2) Discuss risks qualitatively: serious brain injury, infection, no follow-up care at home, and legal exposure [synthesis]. (3) Assess risk (4.7) and involve supporters with consent. (4) If the plan is imminent and the client lacks capacity or is at risk, follow your safeguarding and emergency routes [synthesis].
  • Example language (illustrative): "If something goes wrong after you fly home, who will look after you, and will they know what was done?"
  • Watch for: the trip being kept from family; pressure from organisers [synthesis].

4.13 Coordinating with medical and psychiatric colleagues

  • Purpose and when to use: any injury, psychosis, or ongoing wish; and after hospital discharge.
  • Steps: (1) Obtain consent to share information, explaining the limits of confidentiality where risk is serious. (2) Contact the GP or primary care, psychiatry and, after injury, neurosurgical or neurological follow-up. (3) Agree who leads on risk. (4) Ask for neuropsychological assessment where cognition may be affected [synthesis]. The 2025 case shows the combined surgical, infection, psychiatric and rehabilitation care such injuries can need [source: Bhatt et al. 2025].
  • Example language (illustrative): "I'd like your doctor and I to be on the same page. Can I share what we've talked about?"
  • Watch for: fragmented care; the client telling different services different things [synthesis].

4.14 Safeguarding minors and adults at risk

  • Purpose and when to use: a young person expresses interest, an adult with psychosis or impaired capacity plans the act, or someone else plans to operate on them.
  • Steps: (1) Assess immediacy. (2) For a minor, follow mandatory reporting and child-protection procedures and involve carers unless that increases risk; seek the young person's assent to steps where possible. (3) For an adult, assess capacity for the specific decision and follow adult-safeguarding procedures. (4) Record decisions and reasons [synthesis].
  • Example language (illustrative): "Because I'm worried about your safety, I need to involve other people. I'll tell you what I'm doing and why."
  • Watch for: online contact with adults encouraging the act; a third party offering to operate [synthesis].

4.15 Duties when a practitioner or colleague offers or promotes it

  • Purpose and when to use: you learn that a practitioner, colleague or group offers, performs or refers people for trepanation.
  • Steps: (1) Do not participate or refer. (2) Where a client is at risk, act on safeguarding first. (3) Report to the relevant licensing board, regulator or police; unlicensed operations have been prosecuted as the unlicensed practice of medicine, as in the 2001 Utah case [source: Deseret News 2001]. (4) Consult your professional body's ethics guidance and a colleague; document [synthesis]. Where the practitioner is someone you also relate to in another role, consider the APA Ethics Code Standard 3.05 (Multiple Relationships) [source: APA Ethics Code, Standard 3.05].
  • Example language (illustrative), to a colleague: "I can't be part of this, and I have to raise it with the board because people can be badly hurt."
  • Watch for: pressure to stay quiet; your own reluctance to report a friend [synthesis].

4.16 Working with a client who was injured

  • Purpose and when to use: after self-trepanation or an unlicensed operation, once medically stable.
  • Steps: (1) Address shame and self-blame non-judgementally. (2) Track cognitive, emotional and physical sequelae with medical and neuropsychological input. (3) Revisit the beliefs that led to the act. (4) Support adjustment and any legal or practical consequences. (5) Re-assess risk regularly [synthesis].
  • Example language (illustrative): "You made the choice that made sense to you then. Now we can work on what you need going forward."
  • Watch for: delayed complications (route medically), depression, and renewed attempts [synthesis; source for complications: Bhatt et al. 2025; Deseret News 2001].

4.17 Supporting families

  • Purpose and when to use: a relative attempted it, plans it, or holds advocacy beliefs.
  • Steps: (1) Offer a space for fear, anger and confusion. (2) Give sourced facts about evidence and risks. (3) Help the family keep connection rather than ultimatum. (4) Teach recognition of warning signs and emergency routes [synthesis].
  • Example language (illustrative): "Staying close to him is the most protective thing you can do, even when you strongly disagree."
  • Watch for: family conflict pushing the person toward the group; carer burnout [synthesis].

4.18 Spiritual and cultural framing

  • Purpose and when to use: the interest is spiritual (enlightenment, opening the "third eye", contact with spirits) or tied to tradition.
  • Steps: (1) Use the Cultural Formulation Interview with its supplementary module on spirituality, religion and moral traditions. (2) Where the problem centres on spiritual seeking or crisis, the DSM-5-TR "Religious or Spiritual Problem" may be recorded (ICD-10-CM Z65.8, "Other specified problems related to psychosocial circumstances") [source: ICD-10-CM Z65.8 (Unbound Medicine); DSM-5-TR wording [uncertain: not verified]]. (3) Use spiritual and religious competencies (Vieten et al. 2013) [uncertain: not verified]. (4) Distinguish spiritual experience from psychosis carefully, with psychiatric input when unsure [synthesis].
  • Example language (illustrative): "Tell me what this would mean for you spiritually. I want to understand it in your terms."
  • Watch for: dismissing faith; or, at the other extreme, missing psychosis [synthesis].

4.19 Drawing the field's lessons with clients and trainees

  • Purpose and when to use: teaching, supervision, or clients interested in the history of mental-health treatment.
  • Steps: (1) Use the stone-of-madness paintings, which González Hernando reads as satire of quacks exploiting belief in a physical seat of folly, to discuss how promises of a simple physical cure for madness attract exploitation [source: González Hernando 2012; synthesis for the lesson]. (2) Contrast the Hippocratic use for injury with later claims [source: Adams trans.]. (3) Connect to the need for evidence before invasive interventions [synthesis].
  • Example language (illustrative): "Painters five hundred years ago were already mocking people who sold a quick cure for madness."
  • Watch for: presentism, ridiculing ancient people; keep the respect for prehistoric skill that the archaeology supports [synthesis].

4.20 Documentation and follow-up

  • Purpose and when to use: every case involving intent, attempt, injury or reporting.
  • Steps: (1) Record what was disclosed, risk judgements, actions, consultations and reports. (2) Set follow-up contacts. (3) Re-assess at each contact [synthesis].
  • Example language (illustrative): "I'll check in with you on Thursday to see how things are."
  • Watch for: missed follow-up after a crisis appears to settle [synthesis].

5. Handling problems

All responses below are [synthesis] unless a source is given.

  • The client asks you for how-to information or aftercare advice. Decline plainly, explain that you will not give information that could lead to brain injury, and return to what they hope to gain (4.10). If they persist, reassess risk (4.4, 4.7).
  • The client is set on going ahead. Avoid escalating argument. Keep the relationship, state your concern once clearly, give the documented harms [source: Bhatt et al. 2025; Deseret News 2001], complete a safety plan (4.8), and act on safeguarding or emergency routes if risk is imminent or capacity is in doubt (4.14).
  • Stuck in debate about the evidence. Move from "who is right" to "what do you want your life to feel like"; the evidence statement (4.9) only needs saying once.
  • The client feels ridiculed or pathologised. Repair openly: acknowledge that you reacted strongly, that their goal is legitimate, and that your concern is about injury. Do not mock advocates [synthesis].
  • Overwhelm after an injury or hospital stay. Slow down, focus on stabilisation and practical needs, and coordinate with medical teams (4.13, 4.16).
  • Non-adherence to medical or psychiatric follow-up. Explore barriers without advising on medicines; liaise with the prescriber or care team with consent (4.13). The 2025 case notes that missed psychiatric treatment preceded the injuries [source: Bhatt et al. 2025].
  • Possible psychosis versus spiritual seeking. If unsure, seek psychiatric assessment while keeping a respectful stance toward the client's beliefs (4.6, 4.18).
  • Rupture after you breach confidentiality to protect life. Explain what you did and why, acknowledge the client's anger, and keep the door open.
  • A third party or group pressures the client. Explore the relationship, support the client's own decision-making, and follow safeguarding routes if coercion is present (4.11, 4.14).
  • Family conflict escalates. Hold a family session or refer for family support (4.17); keep the person connected.
  • You discover a colleague involved. Do not keep it informal where clients are at risk; report through the licensing or legal route (4.15).
  • Your own fascination or revulsion. Take it to supervision; both can distort risk judgement.
  • Historical interest becomes rumination about the brain or madness. Gently name the pattern and explore underlying fears (for example, of losing one's mind).

Crisis resources: 988 (US); Samaritans 116 123 (UK and Ireland).

Harm account

What was actually done

  • Unlicensed operation in Utah. In 2001 Deseret News reported that two Utah men, one of them Peter Halvorson, founder of the International Trepanation Advocacy Group [source: André 2017], pleaded guilty in 5th District Court in Parowan to practising medicine without a licence, a third-degree felony, after trepanning a 30-year-old woman from England who had travelled to the US at Halvorson's request. The operation was done by the two men in a private home in Beryl, west of Cedar City; no licensed medical staff are reported, and the only pain relief reported is a local anaesthetic the woman gave herself. It was recorded on video. The newspaper notes that proponents claimed the operation increased blood flow and restored "mental capacity and youth". Each received three years' supervised probation, a fine and a mental-health evaluation, and was barred from taking part in or encouraging such procedures in the US [source: Deseret News 2001]. André reports that they were jailed [source: André 2017]; the two sources differ on this point [uncertain].
  • Self-trepanation by advocates. André reports that the 1960s advocate Hugo Bart Huges trepanned himself in 1965, that early followers did the same, and that advocacy groups later organised operations abroad [source: André 2017].
  • Self-injury in psychosis. Bhatt and colleagues report a woman in her fifties with schizophrenia and foreign-body delusions who repeatedly injured her own scalp and skull to stop a sensation of something crawling inside her head [source: Bhatt et al. 2025].

How it caused harm

  • The woman in the Utah case suffered side effects including leakage of brain fluid, according to the prosecutor [source: Deseret News 2001].
  • In the 2025 case the injuries included bleeding inside the skull and brain, air inside the skull, bone infection and a brain abscess with brain swelling; she needed repeated surgery, prolonged treatment for infection, psychiatric treatment and rehabilitation [source: Bhatt et al. 2025].
  • André reports failed attempts, fainting and repeat procedures among advocates, and expects emergency departments to see complications of self-operation [source: André 2017].
  • Historically, survival was far from assured: about 40% in early prehistoric procedures by André's account, and worse than Civil War outcomes in early Peru by Kushner and colleagues' account [source: André 2017; Kushner et al. 2018].

Recognising it today

  • Talk of increasing "brain blood volume" or permanent higher consciousness through an opening in the skull; references to advocacy groups or trips to Central or South America for the operation [source: André 2017].
  • Beliefs that something inside the head must be released or removed; repeated scalp wounds; concealed head injuries; non-engagement with psychiatric care [source: Bhatt et al. 2025].
  • Offers of the operation by people without medical licences [source: Deseret News 2001].
  • Stone-of-madness imagery or ancient trepanation used online as proof of a cure for mental illness, contrary to how art historians and archaeologists read it [source: González Hernando 2012; Kushner et al. 2018].

What to do instead and how to help those harmed

  • Medical care first: any wound, plan or recent attempt goes to emergency medical care (4.5).
  • Supported care for the underlying problem: psychiatric assessment and treatment for psychosis, mood disorders or substance use; neurological and neuropsychological follow-up after injury; the 2025 patient recovered with surgical, infection, psychiatric and rehabilitation care [source: Bhatt et al. 2025].
  • Psychological support: risk assessment, safety planning, shame and adjustment work, family support (4.7, 4.8, 4.16, 4.17) [synthesis].
  • Reporting and legal routes: report unlicensed operations to licensing boards, regulators or police; in the Utah case prosecution was for practising medicine without a licence [source: Deseret News 2001].
  • Crisis support: 988 (US); Samaritans 116 123 (UK and Ireland).
  • No survivor organisation specific to trepanation injuries is known [uncertain: not verified].

Sources

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