Lebou ndeup (Senegal)

1. Introduction

Version followed: ndëpp (also spelled ndeup, ndöp, n'doepp) as Lebou practitioners describe it in current Senegalese reporting (2026) and as the Fann school of Dakar documented it (Zempléni's 1960s work, revisited by him in 2022; de Jong 1986). The psychotherapist's inventory follows the DSM-5-TR Cultural Formulation Interview (APA 2022), DSM-5/DSM-5-TR possession and trance provisions, and ICD-11 6B62/6B63.

Ndëpp is a Lebou (and Wolof) healing tradition of Senegal's Cap-Vert coast, centred on Dakar's coastal neighbourhoods such as Yoff, Ngor, Ouakam and Soumbédioune. It belongs to the cult of the rab, spirits that the tradition holds to be ancestral and linked to the maternal lineage, some protective and some harmful [source: Zempléni 2022; Le 360 Afrique 2026]. Within the tradition, an affliction may be understood as a rab seeking recognition. Ndëpp is the collective, public, family-involving cure through which the afflicted person and the spirit are, in the tradition's own terms, brought back into right relation, so that people can live "en parfaite harmonie avec les génies protecteurs" (a practitioner quoted in Le 360 Afrique 2026). Practitioners present it as an inherited tradition: "L'exorcisme est une tradition, héritée de nos ancêtres" (another practitioner, ibid.). The Lebou are Muslim and continue this practice alongside Islam [source: Le 360 Afrique 2026].

This is a living ceremonial tradition, not a psychotherapy. The psychotherapist does not perform, prescribe or simulate ndëpp. Scholarly accounts come mainly from outsiders, especially the French-led psychiatric and ethnographic team at Fann Hospital, Dakar (1958/59 to the late 1970s). Under Henri Collomb, that team made ndëpp and the rab cult a reference case for cultural psychiatry [source: Wikipedia, Henri Collomb; Zempléni 2022; Read 2020]. The anthropological reading of how change happens is attributed, not established. Zempléni describes a "projective-persecutory" model in which suffering is placed in an external, socially located agent, so that the person's illness becomes a matter for the group: "son mal est d'emblée le mal de l'autre". In this reading, the cure works by mobilising family and community around the sufferer [source: Zempléni 2022]. De Jong (1986) analysed ndöp from anthropological, psychoanalytic and systemic angles as sharing therapeutic elements with Western therapies. For the psychotherapist, change comes from their own culturally responsive work: understanding the client's explanatory model, telling culturally normative experience apart from disorder, and coordinating with community healers and psychiatric care where the client wishes [synthesis].

2. Framework

2.1 The tradition as its holders and observers describe it (context only)

• Who holds authority. The officiant is the ndëpkat. De Jong (1986) reports the role is usually held by a woman who was herself once afflicted. Current reporting describes family lines of female officiants in Dakar, for example a woman whose mother and grandmother held the role before her [source: de Jong 1986; Le 360 Afrique 2026]. Authority comes from lineage, personal experience of affliction and community recognition, not from a state licence. Senegal has no enacted law on traditional medicine: a bill adopted by the Council of Ministers on 31 May 2017 had still not been voted by the National Assembly as of May 2026. A Fédération Nationale des Praticiens de la Médecine Traditionnelle (FNPMT) has been registered with the Interior Ministry since 2016 [source: Senego 2026 (opinion by Alioune Aw, former coordinator of the Cellule de Médecine Traditionnelle)]. Whether any federation or ministry body speaks for ndëpkat specifically is [uncertain: not verified].
• Decision-making. The family has to agree on the cause and on the course of action before a healer is engaged. Relatives take part, and the family bears costs that de Jong (1986) calls considerable [source: de Jong 1986]. One Senegalese community leader in France describes families consulting a healer as a matter of course for depression or "folie", and the whole family participating [source: Dieng interview, Écarts d'identité].
• What the tradition says it addresses. De Jong (1986) lists, in the tradition's terms, afflictions attributed to rab such as loss of appetite, paralysis, mutism, fertility problems and vivid dreams. Current practitioners speak of possession by harmful spirits, including in children [source: de Jong 1986; Le 360 Afrique 2026]. Lovell and Diagne (2019) found that in peri-urban Senegal, psychoses and epilepsy are often attributed to "the same spiritual forces" [source: Lovell & Diagne 2019].
• Form. Accounts describe a collective, public, multi-day ceremony with possession, led by the ndëpkat and involving the family. Some accounts say it lasts about a week [source: de Jong 1986; Dieng interview]. Current reporting also describes ndeup sessions held annually in coastal neighbourhoods [source: Le 360 Afrique 2026]. How these annual sessions relate to an individual's therapeutic ndëpp is [uncertain: not verified]. This guide deliberately gives no ceremony content.
• Fann Hospital history. Fann's psychiatric unit dates from about 1956 [source: Le Soleil 2026; Fall et al. 2007]. Collomb, a former French military doctor, arrived in Dakar in 1958 (Wikipedia) or was appointed in 1959 (Read 2020) [uncertain: date differs by source]. He led the service for about twenty years. His team was multidisciplinary (doctors, psychologists, sociologists, ethnologists, nurses, social workers, and sometimes traditional healers) and combined clinical and ethnographic case work [source: Zempléni 2022]. Practices associated with Fann include admitting a family accompagnant with the patient, the communal meeting called pénc, and incorporating traditional healing. The healer Daouda Seck worked with Collomb [source: Read 2020]. One community account says ndëpp ceremonies were held on hospital grounds [source: Dieng interview]. Whether this continues today is [uncertain: not verified]. Historians note that routine medication and electroconvulsive therapy at Fann are often left out of the culturalist legend. Today's Senegalese psychiatrists largely pursue universal psychiatry, and the accompagnant role has changed under neoliberal pressures [source: Read 2020, reviewing Kilroy-Marac 2019]. Fann now includes the Clinique Moussa Diop, the addiction centre Cepiad and the child service Keur Khaleyi, with an emphasis on rehabilitation and reintegration [source: Le Soleil 2026].

2.2 The psychotherapist's framework (the part you deliver) [synthesis, built on the CFI and the sources above]

The CFI can be repeated, and its supplementary modules can be used at any point during care [source: APA CFI Supplementary Modules].

3. Guiding principles

• You work alongside the tradition, never inside it. Do not lead, suggest, simulate or interpret ceremonies. Your tools are assessment, psychotherapy and coordination [source: framing per APA CFI; synthesis].
• Authority over ndëpp sits with ndëpkat, their lineages and the client's family. Questions about the ceremony belong to them, not to you [source: de Jong 1986; Le 360 Afrique 2026].
• Attribute, do not adjudicate. Say "in your family's understanding, a rab…". Never say "the spirit is real" or "it is just stress" [synthesis].
• The family is often the unit of decision. Ask who decides, who pays and who must agree before planning, and keep the client's own wishes in view [source: de Jong 1986; Zempléni 2022].
• Possession is not automatically pathology. DSM-5 excludes disturbances that are a normal part of broadly accepted cultural or religious practice. ICD-11 possession trance disorder requires the state to be involuntary and unwanted and outside accepted practice [source: PMC9199574 review; ICD-11 text via Find-A-Code].
• Neither pathologise nor miss illness. Families in Senegal may group psychosis and epilepsy together as spiritually caused. Make sure seizures, delirium and psychosis are medically assessed [source: Lovell & Diagne 2019].
• The CFI supports judgement but does not replace diagnosis. Use it to inform decisions, not as the sole basis for a diagnosis [source: APA CFI].
• Know the history. Fann's celebrated model sat inside colonial and postcolonial medicine. Clients may hold both pride and distrust towards psychiatry [source: Read 2020].
• Persecutory attributions have social meaning. Attributions to rab or sorcery can socialise suffering, but Zempléni also warns they can escalate into "guerres herméneutiques" (interpretive wars) within families. Watch for blame and conflict [source: Zempléni 2022].
• Consent governs every contact with healers. Contact a healer only if the client asks, with explicit consent and agreed limits on what is shared [source: synthesis; COSIMPO model, Gureje et al. 2020].
• Never advise on medicines or remedies. Send questions about medication or herbal remedies to the prescriber [source: synthesis].
• Safety overrides deference. Restraint, beating, food deprivation, harm to children, or delaying urgent medical care trigger safeguarding duties whatever the cultural frame [source: synthesis; COSIMPO and Ofori-Atta findings].
• Islam and the rab cult may coexist or conflict for your client. Ask, do not assume [source: Le 360 Afrique 2026].

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it reproduces or substitutes for ndëpp. Example language is illustrative wording, not taken from any source.

4.1 Cultural humility and self-examination

• Purpose / when: Before and during work with Senegalese clients, especially Lebou or Wolof clients, so that your own beliefs about spirits, Islam, Africa and psychiatry do not distort assessment.
• Steps: (1) Write down your assumptions about spirit possession and about "traditional healing". (2) Learn the basics of Fann's history, both its reputation for openness and the colonial context and medication practices historians describe [source: Read 2020]. (3) Notice whether you lean towards romanticising the tradition ("Fann proved it works") or towards dismissing it. (4) Bring cases to supervision with someone experienced in West African or transcultural work. (5) Tell the client openly that you are not part of their tradition [synthesis].
• Example language (illustrative): "I'm not from your tradition and I won't pretend to understand rab the way your family does. I'd like you to teach me what matters, and to tell me if I get something wrong."
• Watch for: feeling a pull to ask about ceremony secrets out of curiosity (do not); the client checking whether you will mock them. It is working when the client corrects you freely and brings up spiritual matters without being asked [synthesis].

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

• Purpose / when: At intake, or whenever the client or family frames the problem in terms of rab, jinne, sorcery or ancestors. It is a 16-question semi-structured interview in four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; cultural factors affecting current help-seeking [source: APA CFI]. It can be used by any clinician in any setting, and clinicians may reproduce it for use with their patients [source: APA DSM-5-TR Section III; APA CFI].
• Steps: (1) Explain that you will ask how the client and their family understand the problem. (2) Go through the four domains in order using the official form; paraphrase the questions in Wolof or French through an interpreter if needed. (3) Record the client's own terms verbatim (e.g. a rab name or family expression). (4) Under help-seeking, ask about every source of help: marabouts, ndëpkat, Qur'anic healers, prayer, clinics and family elders. (5) Under the clinician–patient relationship, ask about language, racism and past experiences with psychiatry. (6) Summarise back and check. Length in minutes is [uncertain: not verified]; field-trial clinicians found later interviews took less time [source: Lewis-Fernández et al. 2017].
• Example language (illustrative): "People explain problems like this in many ways. How would you describe what's happening to you? How would your mother or your aunt describe it?"
• Watch for: answers that change when a relative is in the room (offer time alone); the client giving the "medical" answer they expect you want; shame. It is working when the client uses their own vocabulary and describes the family's views, including disagreements [synthesis].

4.3 CFI Informant Version and supplementary modules

• Purpose / when: To deepen the core CFI. The Informant Version (17 questions) is for a relative or friend, which fits the family-centred decision-making described for ndëpp [source: APA CFI Informant; de Jong 1986]. Relevant modules here: Explanatory Model; Spirituality, Religion, and Moral Traditions; Social Network; Coping and Help-Seeking; Immigrants and Refugees (for diaspora clients); Caregivers; School-Age Children and Adolescents [source: APA CFI Supplementary Modules].
• Steps: (1) Get the client's consent before interviewing any family member. (2) Interview the informant separately at first. (3) Use the Spirituality module to map Islamic practice, the rab tradition and any tension between them. (4) Use Social Network and Caregivers to identify who decides, who pays and who is carrying the burden. (5) With migrants, use the Immigrants and Refugees module to explore obligations to family at home. (6) Compare the client's and informant's accounts and note where they differ, without taking sides [synthesis on sequencing].
• Example language (illustrative): To a relative: "Your sister has agreed I can ask how the family sees this. What do you think has caused her difficulties, and what do you think should be done?"
• Watch for: relatives speaking over the client; a family consensus that sidelines the client's wishes. It is working when you can map each person's view and where they diverge [synthesis].

4.4 Eliciting the explanatory model (Kleinman)

• Purpose / when: Early in therapy, and again when the meaning of the problem shifts (for example after a healer's consultation). It works through Kleinman's eight paraphrased questions: 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 they should receive, what problems it has caused, and what they fear most [source: Tanenbaum handout; Kleinman, Eisenberg & Good 1978].
• Steps: (1) Ask the questions conversationally over one or more sessions. (2) Ask also for the family's model and the healer's model if one was consulted. (3) Write a one-paragraph summary in the client's words. (4) Find shared ground with your own formulation (e.g. sleep, grief, conflict, a sense of being called) without reducing their model to it. (5) Put the overlap to use when setting goals [synthesis].
• Example language (illustrative): "You said this began after your grandmother died. Why do you think it started then? What does your family think needs to happen for it to settle?"
• Watch for: pluralism. A client may hold a rab explanation, an Islamic one and a medical one at the same time; Lovell and Diagne describe families acting on "conjectures rather than convictions" [source: Lovell & Diagne 2019]. Do not force a single model. It is working when goals make sense within the client's model [synthesis].

4.5 Asking about healer consultation without judgement

• Purpose / when: At intake and at every review. Clients may hide consultations with ndëpkat, marabouts or other healers, or plans for ndëpp (in Senegal or arranged on their behalf from abroad) [source: Dieng interview].
• Steps: (1) Normalise the question. (2) Ask what was done in terms of outcome and meaning, not ceremony content. (3) Ask whether any remedies were taken by mouth (so the prescriber can be told), without asking for details of their preparation. (4) Ask about costs and who paid. (5) Ask how the client felt afterwards. (6) Do not ask the client to describe songs, offerings or rites; let them share what they choose [synthesis].
• Example language (illustrative): "Many of my clients see a healer or a religious guide as well as coming here. Have you or your family done anything like that? I'm not asking you to share anything private, just whether it helped and how you felt afterwards."
• Watch for: fear of being judged or reported; disclosures of harm (go to 4.13). It is working when the client tells you about plans before they happen [synthesis].

4.6 Distinguishing culturally normative possession from disorder

• Purpose / when: When a client reports or shows possession, trance, hearing or seeing spirits, or a rab affliction.
• Diagnostic anchors: DSM-5 DID Criterion A notes identity disruption "may be described in some cultures as an experience of possession". Criterion D excludes a disturbance that is "a normal part of a broadly accepted cultural or religious practice". DSM-5-TR keeps both points in substance; whether it keeps the exact wording is [uncertain]. Dissociative trance under other specified dissociative disorder is excluded when it is part of accepted collective cultural or religious practice [source: PMC9199574 review; Lewis 2023 study guide]. ICD-11 6B63 possession trance disorder requires the customary identity to be replaced by an external "possessing" identity in a state that "is involuntary and unwanted". 6B62 trance disorder covers trance without an alternate identity, outside accepted practice, recurring or lasting days, with distress or impairment [source: ICD-11 text via Find-A-Code; PMC9199574 review]. DSM-5-TR lists cultural concepts of distress (e.g. kufungisisa, susto, maladi dyab). Rab affliction is not among the listed concepts [uncertain: DSM-5-TR list from secondary source]. Use the CFI rather than forcing a fit.
• Steps: (1) Ask whether the experience happens within a recognised context (ceremony, family expectation) or unpredictably. (2) Ask whether the client and community see it as expected, wanted or meaningful. (3) Assess distress, impairment, duration and loss of control. (4) Screen for psychotic features outside the possession frame (thought disorder, persistent delusions unrelated to shared belief, negative symptoms), mood disorder, substance use and trauma. (5) Ensure a medical work-up for seizures and delirium, since families may group epilepsy with spiritual illness [source: Lovell & Diagne 2019]. (6) Consult a cultural broker or community member about what is locally typical. Zempléni's team distinguished, by local criteria, delirium from socially validated persecutory ideas and pathological hallucinations from normal religious experience [source: Zempléni 2022]. (7) Record both the cultural account and any diagnosis [synthesis on sequencing].
• Example language (illustrative): "When the rab is with you, as your family puts it, do you know when it is coming? Is it something your family expects, or does it frighten them? What happens to your sleep and your work in between?"
• Watch for: two errors — diagnosing psychosis from shared belief alone, and accepting a spiritual frame that hides untreated psychosis, seizures, depression with suicidality, or abuse. It is working when the client and family accept a plan covering both their explanatory model and medical safety [synthesis].

4.7 Working with persecutory and relational meanings

• Purpose / when: When the client or family places the cause in an external agent, such as a rab offended or neglected, sorcery, or a jealous relative. Zempléni's projective-persecutory model holds that such attributions make the suffering social and bring the group in. He later criticised the model as too holistic and functionalist, and noted that such interpretations can turn destructive ("guerres herméneutiques") [source: Zempléni 2022].
• Steps: (1) Treat the attribution as meaningful and explore what it says about relationships: who is implicated, what obligations or grievances are involved. (2) Do not confirm or deny the spiritual claim. (3) Name the relational themes in neutral terms (e.g. duty to ancestors, a family rift, an inheritance). (4) Watch for blame falling on a vulnerable person, such as a co-wife, a child or an elderly woman. (5) Where accusations threaten safety, move to 4.13 [synthesis].
• Example language (illustrative): "Your family links this to the rab not being honoured. Leaving the spirit side to you and your family, what has been happening between people at home since this started?"
• Watch for: your own interpretation replacing theirs ("it's really family conflict"); escalating accusations. It is working when the client can talk about relational stress without dropping their spiritual frame [synthesis].

4.8 Involving the family (accompagnant-informed)

• Purpose / when: Fann admitted a relative, the accompagnant, with the patient, held communal pénc meetings, and treated the extended family as therapeutic in itself, a team Zempléni describes as "une sorte de famille à l'africaine" [source: Read 2020; Zempléni 2022]. In outpatient or diaspora psychotherapy, adapt the principle rather than the institution [synthesis].
• Steps: (1) Ask the client who should be involved and in what role. (2) Hold one or more family sessions with consent, with clear limits on confidentiality. (3) Map who decides, who pays, and who must agree on any healer consultation [source: de Jong 1986]. (4) Give the family a practical role, such as noticing early warning signs or helping with appointments. (5) Protect time alone with the client every session [synthesis].
• Example language (illustrative): "In many Senegalese families, decisions about healing are made together. Who would you like to be part of our conversations, and is there anything you want to keep just between us?"
• Watch for: pressure on the client to accept a costly or unwanted course; the client's voice disappearing; the accompagnant becoming a paid or coerced role, which Lovell and Diagne cite work on [source: Lovell & Diagne 2019]. It is working when family members support the plan and the client still speaks for themselves [synthesis].

4.9 Interpreters and cultural brokers

• Purpose / when: When the client is more comfortable in Wolof or French, or when local meaning is unclear. Zempléni's role at Fann was to explain local concepts, causal categories and rites to clinicians [source: Zempléni 2022].
• Steps: (1) Use a trained interpreter, not a family member, for assessment. (2) Brief the interpreter on confidentiality and on not editing spiritual content. (3) Check whether the interpreter's community ties are a concern for the client. (4) For cultural brokerage, consult a Senegalese colleague or community member, with the client's consent and without identifying details. (5) Debrief after sessions [synthesis].
• Example language (illustrative): To the interpreter: "Please translate exactly what she says, including words about spirits or healers, even if they seem hard to put in French. Tell me when a word has no good equivalent."
• Watch for: the interpreter softening or skipping spiritual material; the client fearing gossip. It is working when local terms are kept and explained, not dropped [synthesis].

4.10 Collaboration and referral with community-sanctioned healers, when the client wishes

• Purpose / when: When the client or family wants ndëpp or another healer's help alongside psychological and psychiatric care. Precedents: Fann's team sometimes included traditional therapists, and Daouda Seck worked with Collomb [source: Zempléni 2022; Read 2020]. A cluster trial in Nigeria and Ghana (COSIMPO) found collaborative shared care between traditional or faith healers and primary care workers reduced psychotic symptoms and harmful practices more than control conditions [source: Gureje et al. 2020]. A Ghana prayer-camp trial found that adding psychiatric medication reduced symptoms but did not significantly reduce days in chains [source: Ofori-Atta et al.]. Whether any formal referral programme for ndëpkat exists in Senegal or the diaspora is [uncertain: not verified].
• Steps: (1) Ask the client what they want; never propose ndëpp yourself. (2) Clarify that choosing and engaging a ndëpkat is for the client and family, through their own community pathways. (3) If the client wants you to liaise, get explicit written consent naming what may be shared. (4) Limit contact to coordination: timing, safety, medical needs, how to reach the psychiatric team. Do not ask about ceremony content. (5) Agree on safety limits (no stopping prescribed medication without the prescriber, no restraint, no withholding of food or water, urgent medical care first). (6) Document the arrangement [synthesis].
• Example language (illustrative): "If your family decides on a ndëpp, that's your family's decision and the ndëpkat's. What I can do is make sure your doctor knows the dates, so we can plan around your medication and your sleep. Would that help?"
• Watch for: the client feeling forced to choose between you and the healer; medication being stopped; financial strain. It is working when the client stops hiding plans and the care is coordinated [synthesis].

4.11 Liaison with psychiatric and medical care

• Purpose / when: Whenever there is psychosis, seizures, severe depression, mania, substance use, or the client takes medication or remedies.
• Steps: (1) Refer for medical assessment of seizures and acute confusion. (2) Do not give any advice about starting, stopping or combining medication or remedies; refer to the prescriber. (3) With consent, tell the prescriber about any planned ceremony or remedy so they can review interactions and timing. (4) Coordinate crisis plans [synthesis].
• Example language (illustrative): "That's an important question for Dr X, who prescribes your medication. Shall we call together so you can ask?"
• Watch for: clients asking you to endorse stopping medication for a ceremony. It is working when the prescriber knows about the healing plans [synthesis].

4.12 Integrating ceremonial or healing experience

• Purpose / when: After the client has taken part in ndëpp or a similar cure, or if they now carry ongoing obligations to a rab [source: de Jong 1986 on lasting obligations to the household spirit].
• Steps: (1) Invite the client to share whatever they wish, without probing details. (2) Explore meaning, relief, changes in family relationships, new obligations and any distress. (3) Explore whether ongoing duties fit with work, migration, Islamic practice and the client's finances. (4) Build on gains (e.g. renewed family support) in therapy goals. (5) Screen for worsening or new symptoms [synthesis].
• Example language (illustrative): "You went through something important with your family. What has changed for you since, and what, if anything, has been hard?"
• Watch for: interpreting the ceremony yourself; disappointment or self-blame if symptoms persist; conflict between religious authorities and the family. It is working when the client links the experience to the life changes they want [synthesis].

4.13 Safeguarding

• Purpose / when: When any healing response involves restraint or chaining, beating, food or water deprivation, sexual contact, coercion, accusations against children, or delay of urgent medical care. Current practitioners speak of spirits taking possession of children ("prennent possession de nos enfants"), so a child's "possession" needs careful assessment [source: Le 360 Afrique 2026]. COSIMPO and the Ghana prayer-camp trial document harmful practices in healing settings elsewhere in West Africa [source: Gureje et al. 2020; Ofori-Atta et al.].
• Steps: (1) Ask directly and calmly about physical safety in any healing setting. (2) If a child is involved, follow local child-protection procedures, assess medically, and work with the family without accepting harm as tradition. (3) For adults, discuss risks, make a safety plan, and act on duty-to-protect laws where they apply. (4) Do not equate the tradition itself with abuse, but do not treat abuse as tradition either. (5) Document and consult [synthesis].
• Example language (illustrative): "I respect your family's healing traditions. Because I care about your safety, I ask everyone this: has anyone tied you, hit you or kept food from you as part of treatment?"
• Watch for: minimisation, fear of the family, children presented as "possessed" after a family conflict. It is working when the client can tell you about risks and accept protective steps [synthesis].

4.14 Diaspora, migration and remote obligations

• Purpose / when: With Senegalese clients abroad. One community account describes families arranging N'Doepp in Senegal on a migrant's behalf, convalescence at home to see a healer, and seeking the spirits' permission before leaving and on returning [source: Dieng interview].
• Steps: (1) Use the Immigrants and Refugees CFI module. (2) Ask about obligations to family and spirits at home and their costs. (3) Explore the stress of remittances and expectations. (4) Plan care around trips home, including continuity of medication and crisis contacts. (5) Address racism and access barriers in local services [synthesis].
• Example language (illustrative): "Does your family back home have views about what you should do? Are there things you feel you owe them, or the ancestors, that weigh on you here?"
• Watch for: guilt and conflicting loyalties; treatment interrupted by long stays in Senegal. It is working when the client can plan both obligations and care [synthesis].

4.15 Risk assessment

• Purpose / when: At intake and whenever distress, psychosis or family conflict increases.
• Steps: Standard suicide and violence risk assessment, plus questions about command experiences attributed to spirits, exposure to harmful practices, and family pressure. Lethal-means counselling covers safe storage and removal only. Make a crisis plan that names both clinical contacts and the people the client trusts in their community [synthesis].
• Example language (illustrative): "Some people, when a spirit or voice is troubling them, have thoughts of ending their life. Has anything like that happened to you?"
• Watch for: risk hidden behind a spiritual explanation ("it's the rab, not me"). It is working when the client can talk about risk openly [synthesis].

5. Handling problems

The sources do not discuss psychotherapy problems directly. All guidance below is [synthesis] unless a source is tagged.

• Client won't talk about spiritual matters (fear of ridicule or of breaking a confidence). Say explicitly that you will not judge, and that you do not need ceremony details. Come back to it later through the CFI help-seeking questions. Respect what is secret: lineage and ceremony knowledge belong to the community, and holding back is not resistance.
• Client asks whether you believe in rab. Answer honestly and briefly, without arguing for or against. (Illustrative: "I don't hold that belief myself, but I take seriously that it's true for your family and matters to how you heal.")
• Client or family asks you to recommend a ndëpkat, or to say whether ndëpp will work. Decline both. Explain that the decision and the choice of healer belong to them and their community. Offer to help them think it through and to coordinate safety and medical care.
• Family pushes for ndëpp while the client is ambivalent. See the client alone. Explore their wishes, fears and finances. If they want, support them to say what they want to the family, perhaps in a family session. Costs can be considerable and the family usually decides together [source: de Jong 1986], so pressure on the client may be real.
• Stopping medication for a ceremony. Do not advise. Bring in the prescriber promptly with consent. Explore the reasons, which may be side effects, stigma, or the healer's or family's beliefs. Help the client bring these to the prescriber.
• Symptoms persist after ndëpp. Expect disappointment, self-blame, or a new attribution (another rab, sorcery). Review the formulation and check for an untreated medical or psychiatric condition. Avoid "I told you so". Keep the relationship open whatever path the client takes.
• Escalating accusations (sorcery, a blamed relative or child). Zempléni warns that interpretations can become "guerres herméneutiques" [source: Zempléni 2022]. Assess safety for the accused person, especially children and older women. Work with the family to slow the conflict down, and follow safeguarding routes if needed.
• Overwhelm or acute dissociation in session. Use grounding in the client's preferred language, with permission. Do not interpret the episode as a spirit or as a symptom in the moment. Afterwards, explore with the client and, with consent, family about what usually helps. If episodes are frequent, unwanted and impairing, review against DID, OSDD and ICD-11 6B62/6B63 criteria [source: PMC9199574 review; ICD-11 text via Find-A-Code].
• Psychosis framed as rab affliction and family refuses psychiatry. Respect their framework, set out the risks clearly, and offer to coordinate rather than replace their healing plan. The COSIMPO trial supports shared care [source: Gureje et al. 2020]. If there is serious risk, follow your legal duties.
• Rupture over psychiatry's colonial history or racism. Acknowledge the history openly, including Fann's place within colonial medicine and its medication and ECT practices alongside the culturalist image [source: Read 2020]. Apologise for any specific mistake you made. Repair the CFI clinician–patient relationship question by revisiting it.
• Conflict between Islamic identity and the rab tradition. Explore without taking sides. Lebou communities have held both [source: Le 360 Afrique 2026], but individual clients or religious advisers may see a conflict. Offer to include a religious adviser the client trusts.
• Non-attendance during long stays in Senegal. Plan in advance: remote sessions where licensing allows, a medication supply arranged with the prescriber, local crisis contacts, and a plan for coming back.
• The therapist's own over-identification or exoticising. Signs include asking for ceremony details, wanting to attend, or presenting the client as a "fascinating case". Take it to supervision and refocus on the client's goals. Never attend or seek out a ceremony through the client.
• Interpreter or community-member breach of confidentiality. Address it immediately, offer a different interpreter, and review consent arrangements.

Sources

Ndëpp, the rab tradition and Fann

• Dakar. Génies malfaisants, ancêtres bienveillants: dans les secrets d'un rituel lébou, le ndeup (Moustapha Cissé, Le 360 Afrique, 7 Feb 2026)
• de Jong, J.T.V.M. (1986). Palmwijn in nieuwe zakken: enkele gedachten naar aanleiding van een Ndöp-ritueel. Tijdschrift voor Psychiatrie 28(1)
• Zempléni, A. (2022). La socialité des médecines africaines. Transculturale 1/2022
• Read, U.M. (2020). Review of Kilroy-Marac, An Impossible Inheritance. Medical Anthropology Quarterly 34(4)
• Lovell, A.M. & Diagne, P.M. (2019). Falling, Dying Sheep, and the Divine: Notes on Thick Therapeutics in Peri-Urban Senegal. Culture, Medicine, and Psychiatry 43, 663–685
• Henri Collomb (Wikipedia)
• Fall, L. et al. (2007). Près de quarante ans de pratique de pédopsychiatrie au Sénégal. Perspectives Psy 46(4) (abstract)
• Le rôle central du pôle psychiatrique (Le Soleil, 7 Aug 2026)
• La complémentarité des médecines moderne et traditionnelle chez les Sénégalais (interview with Bity Dieng, Écarts d'identité 72–73; year [uncertain])
• Médecine traditionnelle au Sénégal : 9 ans d'inaction parlementaire (Alioune Aw, Senego, 18 May 2026)
• Bullard, A. (2022). Spiritual and Mental Health Crisis in Globalizing Senegal: A History of Transcultural Psychiatry. Routledge (publisher page; further reading)
• Books cited: Kilroy-Marac, K. (2019). An Impossible Inheritance: Postcolonial Psychiatry and the Work of Memory in a West African Clinic. University of California Press (as described in Read 2020). Zempléni, A. (1966), on the therapeutic dimension of the rab cult, Psychopathologie africaine (as cited in Zempléni 2022) [uncertain: full title and pages not verified].

Cultural assessment, diagnosis and collaboration

• APA DSM-5-TR Cultural Formulation Interview
• APA DSM-5-TR Section III (culture chapter)
• APA CFI Informant Version
• APA CFI Supplementary Modules
• DSM-5-TR concepts of distress webinar slides (Szepe & Fritson, UNMC BHECN)
• Review on possession and dissociation (PMC9199574)
• Lewis (2023), dissociative disorders study guide, University of Missouri System Pressbooks
• Teodoro & Afonso (2020), on DSM-5 cultural concepts of distress, Revista Portuguesa de Psiquiatria e Saúde Mental
• ICD-11 6B62 Trance disorder (Find-A-Code mirror of WHO text)
• WHO FAQ: ICD-11 traditional medicine chapter
• WHO Traditional Medicine Strategy 2014–2023
• Explanatory Models of Illness handout (Tanenbaum)
• Dinos et al. (2017), Cambridge Core, citing Kleinman et al. 1978
• Lewis-Fernández et al. (2017), CFI field trial, Br J Psychiatry 210(4):290–297 (UMN record)
• Lewis-Fernández et al. (2017), edoc Basel record
• Gureje et al. (2020), COSIMPO trial, The Lancet (PubMed 32861306 record)
• COSIMPO summary, Centre for Global Mental Health
• Ofori-Atta et al., Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial, Br J Psychiatry 212(1) (year [uncertain])
• Book/article cited: 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.