Marabout healing (Senegal, Casamance)

1. Introduction

Version followed: marabout (Muslim cleric) healing and Joola (spelled "Diola" in most sources cited here) and other non-Muslim healers in Senegal, especially Casamance, as Senegalese health institutions, practitioners' own federations and attributed scholarship describe them. The therapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI, APA 2022 core version; supplementary modules and Informant Version as published for DSM-5, 2013) and Kleinman's explanatory-model questions.

What it is. This is not a single therapy. It is a plural healing landscape that many Senegalese clients use alongside, before or instead of biomedical and psychological care. Two broad kinds of healers are described in Casamance:

Marabouts. Muslim religious figures. A Dakar pharmacognosy text describes authentic marabouts as religious leaders who "rarely practise medicine" as such. They are sought for protection and healing through Qur'an-based means such as written amulets (often called gris-gris in French usage). The same text distinguishes them from self-styled marabouts and from people who practise "maraboutage", meaning harm done on someone's behalf. Senegalese speakers themselves distinguish "real" from "fake" marabouts. [source: Kerharo, IRD text; Dieng interview]
Joola and other non-Muslim ("animist" in older sources) healers. These are healers rooted in Joola religion and its shrine priests and elders, and in Serer, Lébou and other traditions. In the Joola account given by Kerharo, health is a balance of vital forces, and illness is the disturbance of that balance. Healers combine plant knowledge with ritual. [source: Kerharo, IRD text] Robert Baum describes leaders of Joola traditional religion (awaseena) as holding authority that the French colonial administration "never controlled". [source: Baum 2009]

Core idea of how change happens (as the traditions hold it, attributed). In the sources, illness, including mental distress, can be attributed to spirits (Muslim djinn and malevolent seytané; Wolof and Serer ancestral spirits, rab and pangol), to sorcery or maraboutage, to the evil eye, or to offending spirits. Healing is described as restoring right relations: with God, through Qur'anic protection; with spirits and ancestors; and with family and community. [source: Kerharo; Dieng interview] These are the traditions' own accounts. This guide neither states them as fact nor dismisses them.

Your role. You do not perform marabout or shrine healing, write amulets, divine, or arrange ceremonies. Your work is your own culturally responsive psychotherapy alongside the client's healers: assessment with the CFI, the client's explanatory model, telling culturally normative experience from disorder, collaboration with community-sanctioned healers when the client wishes it, integration, and safeguarding. Safeguarding includes the documented abuse of some talibé children in some Qur'anic boarding schools (daaras). [source: APA CFI; HRW 2017, 2019]

2. Framework

There is no published phase model for psychotherapy alongside marabout or Joola healing. The structure below is [synthesis], built on the CFI's own structure and Senegalese service facts.

Context to know before you start

Regulation. Senegal has no adopted law regulating traditional medicine. A bill was approved by the Council of Ministers in 2016 and then stalled. Practitioners have waited for a law "since 2006", in the words of the president of the Fédération des tradipraticiens du Sénégal, Gaoussou Sambou. The bill was opposed by the Inter-ordre of health professions. A traditional-medicine unit (cellule médecine traditionnelle) was set up in 2014 in the Ministry of Health and Social Action, coordinated by Professor Emmanuel Bassène, who says practitioners are recognised by their communities. About 80% of the population is reported to use plants or traditional practitioners. [source: SenePlus, traditional-medicine actors article] Later developments (e.g. 2025 draft decrees on marketing of traditional-medicine products) were seen only as a headline. [uncertain: not verified]
Who holds authority. For marabouts: Islamic learning and the Sufi brotherhoods and communities in which a marabout is recognised. The specific brotherhoods' published positions on healing were not verified. [uncertain: not verified] For Joola religion: shrine priests and elders (awaseena) and the communities that recognise them. [source: Baum 2009] For practitioners as a professional group: the Fédération des tradipraticiens du Sénégal and its community and regional structures. [source: SenePlus] Recognition is community-based, not a state licence. A therapist cannot verify a healer through a public register. [synthesis]
Psychiatric services in Casamance. Care began in 1974 at the Kénia psychiatric village, Ziguinchor. It was rehabilitated in 2006 as the Centre Psychiatrique Emile Badiane. In 2019 it saw 1,456 patients, mostly Joola. 82.3% were brought by relatives, many consulted late, and psychotic disorders were the most frequent diagnosis (40.9%). [source: UASZ repository record] Clinicians from the Kénia village published interviews with six animist healers and marabouts as part of a long effort to build collaboration with traditional healers. [source: Baldé and Sterck, World Health Forum]
Conflict context. Casamance has lived with sporadic armed conflict since the early 1980s. A 2010 IRIN report describes landmine injuries, witnessed killings and rape, and post-traumatic symptoms. Many people attribute their suffering to a curse and consult marabouts. Stigma attaches to the psychiatric centre. [source: IRIN 2010]
Diaspora. In France, a Senegalese community leader describes families consulting healers at home by post or phone, convalescing in Senegal for a healer's confirmation, and holding the two medicines to be complementary. [source: Dieng interview]

Phases (synthesis)

Phase	Goal	Typical format	Move on when
A. Engagement and cultural assessment	Safety screen; core CFI; explanatory model; map help-seeking, including marabouts and healers	1–3 sessions, 50–90 min; family or informant session if the client agrees	Shared working definition of the problem; known healer involvement; risk assessed
B. Differential and formulation	Tell normative spiritual experience from disorder; consult cultural broker; written cultural formulation	1–2 sessions plus consultation	Formulation agreed with client; medical or psychiatric referral made if needed
C. Plan and collaboration	Agree goals; decide with client whether and how to coordinate with a marabout, healer, family or psychiatrist	1–2 sessions; signed consent for any contact	Consent documented; roles clear; no safety conflict between plans
D. Treatment alongside healing	Evidence-based treatment for the agreed problem, adapted to the explanatory model; integrate healing experiences	Weekly, typically 8–20 sessions depending on the condition treated	Goals reviewed; repeat CFI modules if the picture shifts
E. Consolidation and ending	Relapse plan that names both healers and services	1–3 sessions, spaced	Client knows when to use which help

Safeguarding (section 4) overrides every phase: act on it whenever it arises. [synthesis]

3. Guiding principles

[source: APA CFI and Supplementary Modules for CFI-related principles; others marked]

Plurality is normal. Expect clients to use marabouts, healers and clinics in sequence or together; ask about all of them early. [source: Dieng interview; McKinley 2012; synthesis]
The client defines the problem first. Start from their words (curse, spirits, "thinking too much") before your diagnostic terms. [source: CFI]
Attribute, do not adjudicate. Describe spirits, djinn, rab, sorcery and maraboutage as the client and tradition hold them; neither confirm nor dismiss. [synthesis]
Authority lies in the community. Marabouts are recognised by their religious communities, Joola religious leaders by their shrines and elders, practitioners by their federation and communities. You hold no authority over these, and no therapeutic role in them. [source: Baum 2009; SenePlus]
Not every marabout or daara is the same. Senegalese speakers distinguish authentic from fake marabouts. HRW stresses that not every daara is abusive. Avoid both romanticising and blanket suspicion. [source: Dieng interview; HRW 2017]
Normative experience is not disorder by default. Possession or trance within accepted collective practice is excluded from DSM and ICD disorder definitions. Assess distress, impairment and whether the person wants the state. [source: PMC9199574 (DSM-5 criteria); Lewis 2023 study guide (DSM-5-TR, in substance); findacode ICD-11 mirror (6B62, 6B63)]
Do not miss serious illness. Late presentation with psychosis is common in Casamance. Healing contact must not delay urgent assessment. [source: UASZ record; synthesis]
Family is a care unit. Most patients are brought by relatives. Involve family with consent, using the CFI Informant Version where useful. [source: UASZ record; APA CFI Informant Version]
Consent governs every contact with a healer. You contact no marabout, healer or imam without explicit, specific, written consent. [synthesis]
Medicines and remedies go to the prescriber. You do not advise on starting, stopping or combining medicines or remedies. Route questions to the prescriber or pharmacist. [synthesis]
Safeguarding comes before cultural deference. Beating, chaining, sexual abuse, forced begging and neglect are harms, whatever setting they occur in. [source: HRW 2019]
Trauma and history shape trust. Conflict, colonial history and stigma towards psychiatry affect help-seeking. Be welcoming and confidential, and do not push. [source: IRIN 2010, Dr Mamadou Lamine Diouf's advice]
Humility about your sources. Much published description is by outsiders (colonial-era pharmacognosy, foreign anthropologists). Let the client and community correct it. [source: Kerharo; Baum; synthesis]

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them involves performing, imitating or arranging marabout or Joola healing. Example language is illustrative, in English; adapt it to French, Wolof, Joola, Pulaar, Mandinka or another language, through a trained interpreter where needed.

4.1 Cultural humility and self-examination

Purpose / when: Before and throughout work with any client who uses marabouts or Joola healers. It checks your own assumptions about Islam, "animism", "superstition", Africa and psychiatry. [synthesis]
Steps: (1) Write down your first reactions to terms like gris-gris, maraboutage, djinn, rab or shrine. (2) Note where your knowledge comes from: often outsider sources such as colonial-era texts, tourist media or diaspora fraud stories. (3) Separate the client's tradition from scams, which Senegalese speakers themselves call fake marabouts. (4) Take one question to supervision per case: "Where might I be pathologising, or missing illness?" (5) Review your service's record on racism, Islamophobia and interpreter access.
Example language (illustrative): "I don't know your tradition the way you and your family do. Please correct me if I get something wrong."
Watch for: Mocking or exoticising in case notes. Treating every marabout as a fraud, or every healer as wise. Signs it is working: the client corrects you freely and brings up healing contacts without being asked.

4.2 Asking about marabouts, healers and remedies without judgement

Purpose / when: At intake and at each review. Many clients will not mention healers unless you ask, because of stigma attached to both psychiatry and "superstition". [source: IRIN 2010; Dieng interview; synthesis]
Steps: (1) Normalise plural care before asking. (2) Ask open questions about who else they have consulted: marabout, imam, Joola healer or shrine, family elder, church, clinic. (3) Ask what each said the problem was and what was advised, without asking for ritual details. (4) Ask about anything taken by mouth, applied to the skin, or worn, so the prescriber can be informed. Do not comment on the remedy. (5) Ask whether any advice conflicts with medical treatment, e.g. being told to stop medicines. (6) Record with consent.
Example language (illustrative): "Many people from Senegal see a marabout or a healer as well as a doctor. Have you, or has your family, consulted anyone like that about this?" "You don't need to tell me what was done. I'm interested in what they said was happening, and whether it helped."
Watch for: Guarded or minimising answers, which suggest fear of judgement. Disclosure of remedies taken alongside psychiatric medication: pass this to the prescriber with consent and give no advice yourself. Advice to stop treatment, which you should explore and route to the prescriber. Working signs: open disclosure, and the client returns to the topic later.

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

Purpose / when: The first or second session, with any client whose distress may be framed in spiritual, religious or community terms. The CFI clarifies the problem from the perspective of the person and their social network, possible sources of help, and expectations of services. It supports clinical decisions and is not the only basis for diagnosis. [source: APA CFI]
Steps: (1) Use the official APA form, which clinicians may reproduce for their own patients. Translating or modifying it needs APA permission. (2) Work through its four domains in order. Cultural definition of the problem: their words for it, and what troubles them most. Cultural perceptions of cause, context and support: causes (including curse, spirits, God's will, worry), stressors (conflict, poverty, migration, family), supports, and the role of cultural identity. Self-coping and past help-seeking: this is where marabouts, Joola healers, prayer, clinics and barriers come in. Current help-seeking: what they want from you, and their experience of clinicians, including racism and language. (3) Paraphrase back after each domain. (4) Mark which supplementary modules to add (4.4). (5) The APA forms give no administration time, and the field trial reports only that later interviews took less time [source: Lewis-Fernández et al. 2017]; allow generous time, especially with an interpreter. [uncertain: no figure in minutes]
Example language (illustrative): "Sometimes people describe their problem in their own way, which may differ from how doctors describe it. How would you describe it?" "What do you think caused this? What do the people close to you think?"
Watch for: Differing explanations between client and family; note both. Barriers such as cost, distance, stigma or past coercive treatment. Working signs: you can state the problem in the client's own terms and they agree.

4.4 CFI supplementary modules relevant here

Purpose / when: Add-ons to the core CFI, or stand-alone for in-depth assessment, at first evaluation or later. Choose based on what the core CFI raised. [source: APA CFI Supplementary Modules]
Steps: Select from the 12 APA modules. Explanatory Model when the cause is framed as curse, spirits or maraboutage. Spirituality, Religion and Moral Traditions for Islamic practice, brotherhood affiliation, Joola religion, or conflict between them. Coping and Help-Seeking for the full itinerary of marabouts, healers and clinics. Cultural Identity for ethnicity (Joola, Wolof, Pulaar, Mandinka, Serer and others), language, religion and migration. Social Network and Psychosocial Stressors for family, conflict and economic pressure. Immigrants and Refugees for diaspora or displaced clients. School-Age Children and Adolescents for minors. Caregivers for the relative who brought the patient. Patient-Clinician Relationship after a rupture. Use the Informant Version (17 questions) with a relative, with consent.
Example language (illustrative): "You mentioned your faith helps you. Can I ask a few more questions about the role religion plays in your life and in this problem?"
Watch for: Overloading the client. Spread modules across sessions. Working signs: a coherent cultural formulation you can write in a paragraph.

4.5 Explanatory-model questions (Kleinman)

Purpose / when: To understand, in a brief and conversational way, how the client and family understand the illness. Use it when explanations diverge from biomedical ones, or when engagement is fragile. [source: Kleinman, Eisenberg and Good 1978, as paraphrased in the Tanenbaum handout]
Steps: Cover the eight areas in your own words: what they call it; 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 think they should receive; the main problems it has caused; and what they fear most. Then summarise their model back and ask where your approach could fit alongside it.
Example language (illustrative): "Why do you think this started now, rather than earlier?" "What do you fear most about this illness?"
Watch for: Fear of being targeted by maraboutage or sorcery, which is a cause attributed in the sources, and fear that psychiatry means being labelled "crazy". [source: Kerharo; Dieng interview; IRIN 2010] Working signs: the client accepts a plan described in terms that sit beside their model, e.g. "treatment for the sleeplessness and fear while your marabout addresses what you see as the spiritual side".

4.6 Mapping the therapeutic itinerary

Purpose / when: To chart the sequence of help-seeking: family remedies, marabout, Joola healer, prayer, clinic, psychiatric centre. Senegalese clients often move between these, and urban, rural and diaspora clients follow different paths. [source: Dieng interview; McKinley 2012; UASZ record] The timeline format is [synthesis].
Steps: (1) Draw a timeline with the client, from first sign of the problem to now. (2) For each contact, note who, when, what they said the problem was, the outcome, cost, and who decided. (3) Note gaps and delays, and whether any contact discouraged medical care. (4) Identify the help the client trusts most. (5) Use the map in planning (4.10).
Example language (illustrative): "Let's draw out everyone you've gone to for help since this began, in order. Who did you see first?"
Watch for: Large costs or repeated payments, which may point to financial exploitation (4.15). Long delays before psychiatric assessment of psychosis. Working signs: the client names who they would turn to next, and why.

4.7 Working with cultural concepts and idioms of distress

Purpose / when: When distress is expressed through idioms of curse, spirit affliction, maraboutage, the evil eye, or "illnesses of the spirit". DSM-5-TR defines cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: APA DSM-5-TR Section III] No Senegalese entry in the DSM-5-TR glossary is confirmed in the sources cited here. Treat these as local idioms and explanations, not as DSM-5-TR syndromes. [uncertain: not verified] An American Journal of Psychiatry paper reports three Serer "illnesses of the spirit". Its authors and year were not confirmed. [uncertain: not verified]
Steps: (1) Identify the idiom in the client's words. (2) Clarify whether it is an explanation (cause), an idiom (way of expressing distress), or a recognised local illness. (3) Explore what it means for status, marriage, family obligations and blame. (4) Assess the symptoms underneath it: sleep, mood, fear, perception, functioning. (5) Formulate on two tracks: the cultural meaning, and the clinical picture.
Example language (illustrative): "When you say someone 'worked' against you, what changed for you after that? What do people in your family say about it?"
Watch for: Blame idioms that lead to conflict, accusations or violence against a named person. Explore these carefully and assess risk to others. Working signs: the client can talk about symptoms without feeling their explanation is being attacked.

4.8 Distinguishing normative spiritual experience from disorder

Purpose / when: When the client reports spirit possession, djinn or rab affliction, voices or visions, trance, or being targeted by sorcery. The aim is to avoid both pathologising accepted religious experience and missing psychosis, mania, dissociative disorder, delirium or substance effects. [source: APA DSM-5-TR Section III; UASZ record]
Steps: (1) Ask whether the experience occurs within an accepted collective religious or cultural practice, and whether the person and their community regard it as normal. DSM-5 dissociative identity disorder (possession form) and dissociative trance exclude states that are a normal part of broadly accepted cultural or religious practice. DSM-5-TR keeps these points in substance [source: PMC9199574; Lewis 2023 study guide]; its exact wording is [uncertain: not verified]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted, and outside accepted cultural or religious practice. (2) Assess distress, impairment, duration and recurrence. (3) Screen for features beyond the cultural frame: disorganisation, persistent beliefs that the client's own community regards as abnormal, self-neglect, agitation, risk, cannabis or other substance use (12.6% of 2019 Ziguinchor patients used drugs, mainly cannabis). (4) Ask how the family and community see it. Ask the client's permission before consulting a cultural broker or a recognised religious figure. (5) Arrange medical and psychiatric assessment for possible psychosis or organic causes. In Casamance this is the Centre Psychiatrique Emile Badiane. (6) Document the reasoning on both tracks.
Example language (illustrative): "In your family and community, is this kind of experience something people know and accept? Does it come when you want it, or does it take you over against your will?" "Even if this has a spiritual side, I'd like a doctor to check that nothing physical is adding to it. Would that be all right?"
Watch for: Agitation, incoherence and late presentation, the most common pattern at the Ziguinchor centre. [source: UASZ record] Do not use cultural framing to dismiss urgent illness. Working signs: the client and family accept assessment, and the formulation is shared.

4.9 Interpreters and cultural brokers

Purpose / when: When language or religious and cultural knowledge limits understanding. [source: APA CFI, clinician–patient relationship domain; synthesis]
Steps: (1) Use trained interpreters, not children. Check the interpreter's language: Joola has several varieties; Wolof, Pulaar, Mandinka and French may each be needed. (2) Check for community ties. In small diaspora communities, an interpreter may know the family or the marabout; offer the client the choice. (3) Brief the interpreter on confidentiality and on reporting religious terms without paraphrasing them. (4) A cultural broker, such as a community worker or a religious scholar the client trusts, may advise on meaning, only with the client's consent and without identifying details unless agreed. (5) Debrief the interpreter after emotionally heavy sessions.
Example language (illustrative): "Before we start, is it all right for you that the interpreter is from the same community? If not, we can change."
Watch for: Interpreters softening talk of spirits or sorcery, or adding their own religious views. Working signs: the client's own terms appear in your notes.

4.10 Collaboration and referral with community-sanctioned marabouts and healers

Purpose / when: When the client wants their marabout, imam, Joola healer, or the elders and shrine authorities involved, or wants both forms of help to proceed without conflict. [source: Baldé and Sterck; Dieng interview; Gureje et al. 2020 (COSIMPO); Ofori-Atta et al. (prayer-camp trial)]
Context: In Senegal, collaboration has a history. The Fann hospital in Dakar is reported to have worked alongside healers, with families bringing the healer's prescriptions while doctors gave medication. [source: Dieng interview] Clinicians at the Kénia psychiatric village interviewed marabouts and animist healers to build collaboration. [source: Baldé and Sterck] There is no state register or formal referral programme for healers. [source: SenePlus; synthesis] Evidence from Ghana and Nigeria: the COSIMPO cluster trial of shared care between traditional and faith healers and primary care for psychosis showed greater symptom reduction and fewer harmful practices. A Ghana prayer-camp trial found that adding medication reduced symptoms but did not significantly reduce days in chains. [source: Gureje et al. 2020, The Lancet; Ofori-Atta et al., Br J Psychiatry 212(1)]
Steps: (1) Ask whether the client wants any contact; never assume it. (2) Agree the purpose (e.g. coordinating timing, aligning messages about medication, sharing a safety plan) and the limits on what is shared. (3) Obtain written, specific consent naming the person, the content and the duration. (4) The client chooses whom; you do not recommend particular marabouts or healers. (5) In contact, respect the healer's role and ask how they see the problem. State clearly what your service does and does not do, and agree non-negotiables: no stopping prescribed medicine without the prescriber, and no restraint, beating or deprivation. (6) Record the agreement and review it.
Example language (illustrative): "Would it help if your marabout and I understood each other's role? I would only speak to him if you agree, and only about what you choose." To a healer: "I'm here to help with the sleeplessness and fear. I'd like to understand how you see the problem, so we don't pull in different directions."
Watch for: Pressure on the client from family to choose one path. A healer advising against medication or psychiatric care. Requests for large payments. Working signs: the client feels both kinds of help are respected, and the plans do not conflict.

4.11 Coordinating with the prescriber on medicines, remedies and amulets

Purpose / when: When the client takes psychiatric or other medication and also uses remedies, Qur'anic water preparations or plant medicines, or wears protective amulets. [source: Kerharo; Dieng interview; synthesis]
Steps: (1) Record what the client reports using, in their own words. (2) With consent, inform the prescriber or pharmacist, who advises on any interactions. You give no advice on starting, stopping or combining anything. (3) Treat protective amulets as the client's religious and personal property. Never ask them to remove one; if a clinical procedure requires removal, the clinical team discusses it with the client. (4) If a healer's advice conflicts with medical treatment, help the client take the question to the prescriber.
Example language (illustrative): "I'm not the right person to advise on medicines or remedies, but your doctor should know everything you take. Shall we write it down together for them?"
Watch for: Unexplained side effects, sedation or physical deterioration: refer for urgent medical review. Working signs: the prescriber has a full list, and the client is not hiding anything.

4.12 Integrating healing experiences into therapy

Purpose / when: After the client has consulted a marabout or healer, or taken part in a family or community ceremony, and wants to make sense of it alongside therapy. [synthesis]
Steps: (1) Invite the client to share only what they wish, without ritual detail. (2) Explore what changed in meaning, relationships, hope and symptoms. (3) Link those changes to therapy goals, e.g. reconciliation with family, or a sense of protection that reduces fear. (4) If the experience was frightening or harmful, process it as you would any distressing event, and assess for safeguarding (4.15). (5) Do not interpret the spiritual content in psychological terms unless the client asks.
Example language (illustrative): "What has been different since you saw him? What do you want to carry forward from that?"
Watch for: Disappointment or shame when healing did not help. Validate the effort without disparaging the healer. Working signs: the client integrates both kinds of help into one coherent story.

4.13 Family and community work

Purpose / when: When relatives brought the client, make treatment decisions, or hold different explanations. In Ziguinchor in 2019, 82.3% of patients were brought by relatives. [source: UASZ record; Dieng interview]
Steps: (1) Get the client's consent about which family members to involve, and what to share. (2) Use the CFI Informant Version or the Caregivers module with the key relative. (3) Map family explanations and decisions, including who funds and chooses healers. (4) Agree on a shared plan that names both healing and clinical steps. (5) Address stigma and fears about psychiatric care. (6) Watch for blame directed at a family member accused of sorcery.
Example language (illustrative): "Your family clearly cares a lot. What does each of you think is happening? What would you each like to see change?"
Watch for: Coercive decisions made over the client's objection. Accusations of sorcery that endanger a relative (assess risk to others). Working signs: the family supports attendance, and conflict reduces.

4.14 Trauma work in the Casamance conflict context

Purpose / when: With survivors of the Casamance conflict, including landmine injuries, witnessed killings and sexual violence, displacement, and diaspora clients with that history. Many attribute their suffering to a curse, and symptoms such as migraines, nightmares and poor concentration are often not recognised as treatable. [source: IRIN 2010]
Steps: (1) Establish safety and a welcoming, confidential setting, and do not push disclosure; this follows the advice of Dr Mamadou Lamine Diouf, head of the Ziguinchor psychiatric centre. [source: IRIN 2010] (2) Use the CFI and the Psychosocial Stressors module to place trauma within the client's explanatory model, e.g. curse and trauma at once. (3) Offer psychoeducation framed as one explanation among others. (4) Deliver an evidence-based trauma treatment the client accepts, with pacing and consent at each step. (5) Support social reintegration and work, which ASVM (the Senegalese Association of Mine Victims) describes as essential. [source: IRIN 2010] (6) Coordinate with religious support if the client wishes (4.10).
Example language (illustrative): "You've said this may be a curse. Many people who lived through what you did also have nightmares and headaches like yours, and there are ways to ease them. Can we work on that alongside what your marabout is doing?"
Watch for: Re-traumatisation through rushed exposure. Hopelessness and suicidal thoughts (4.17). Working signs: better sleep, less avoidance, and more social contact.

4.15 Safeguarding adults: harmful practices, exploitation and delayed care

Purpose / when: When an adult client describes, or is at risk of, restraint or chaining, beating, deprivation of food or water, sexual abuse, financial exploitation by someone presenting as a marabout, or a delay to urgent medical care. [source: Gureje et al. 2020 and Ofori-Atta et al. for restraint in West African healing settings; Kerharo and Dieng for fake marabouts; synthesis] None of the sources cited here documents chaining in Senegalese or Casamance healing settings specifically. [uncertain: not verified] Historically, Kerharo describes poison ordeals formerly practised in Casamance as causing many deaths. [source: Kerharo]
Steps: (1) Ask directly and neutrally about restraint, violence, payment and pressure. (2) Assess capacity, coercion and immediate risk. (3) Follow your jurisdiction's adult-safeguarding procedure. Report crimes, such as assault, sexual abuse or fraud, as local law requires, and inform the client of the limits of confidentiality. (4) Distinguish the harm from the tradition. Name the behaviour, not the religion. (5) Arrange urgent medical care where physical health is at risk. (6) Support the client's choice of safer religious support.
Example language (illustrative): "Some people have been hurt or pressured during treatment by anyone, doctors included. Has anyone held you down, tied you, hit you, or asked for money you couldn't afford?"
Watch for: Injuries, weight loss, fear of a specific person, and escalating payments. Diaspora clients paying for distance consultations. Working signs: the client is safe, and keeps the faith-based support they value without the harm.

4.16 Safeguarding children: daaras, talibés, consent and assent

Purpose / when: With any child or adolescent, or any adult client describing a child, who attends or attended a daara (Qur'anic boarding school), or who has been taken to a healer. [source: HRW 2017, 2019]
Facts to know (HRW, factually): Many daaras teach the Qur'an without abuse, and HRW notes that many Qur'anic teachers respect children's rights. HRW also documented serious abuse in some daaras. In 2017 it estimated about 50,000 talibé children in Dakar forced to beg daily, and over 100,000 nationally in its 2019 report. Its 2017-2018 research found beatings (61 cases, most for failing to bring the begging quota), chaining or confinement (14 cases), rape or sexual abuse (15 cases), and 16 deaths from abuse, neglect or endangerment. Senegal's 2005 anti-trafficking law criminalises the exploitation of begging. A draft daara law was approved by the Council of Ministers in 2018 but had not been passed by early 2019. Senegal had not adopted a Children's Code. The 2019 report lists abuses in eight regions; Ziguinchor, Sédhiou and Casamance are not among them, and Kolda is named as a place where talibés are brought from Gambia. [source: HRW 2017; HRW 2019] The current status of the daara law is [uncertain: not verified].
Steps: (1) Never name minors in records shared outside the clinical file, or in any external communication beyond what safeguarding requires. (2) Obtain parental consent and the child's assent, explained at the child's developmental level. See the child alone for part of the session where it is safe and lawful. (3) Use the CFI School-Age Children and Adolescents module. (4) Ask neutrally about daily life at the daara: food, sleep, health care, begging, punishment, contact with family. (5) If abuse, forced begging, chaining or sexual abuse is disclosed or suspected, follow your child-protection procedure and report to the statutory agency without delay. Do not investigate yourself. (6) Distinguish religious education, which is legitimate, from exploitation. Do not frame the family's faith as the problem. (7) For adult clients who were talibés, assess trauma, attachment and shame, and treat it with the family's religious identity respected.
Example language (illustrative): To a child: "Can you tell me what a normal day is like where you study? What happens if someone doesn't bring something back?" To a parent: "Studying the Qur'an is important to your family. I need to make sure every child is safe and cared for, wherever they study."
Watch for: Malnutrition, skin infections, injuries, fear of returning, running away, and chaining marks; HRW documented these. A family under community pressure not to report. Working signs: the child is safe, the family is engaged, and the child's religious education continues where safe.

4.17 Suicide and self-harm risk assessment

Purpose / when: With every client. Hopelessness is reported among conflict survivors, e.g. an elderly landmine survivor said "Sometimes I want to kill myself". [source: IRIN 2010] Religious prohibitions can make disclosure harder. [synthesis]
Steps: (1) Ask directly about suicidal thoughts, plans, intent, past attempts and protective factors, in line with current standard practice. (2) Explore religious meanings of suicide without judgement, and faith as a protective factor. (3) Do lethal-means counselling (safe storage and removal). (4) Make a safety plan that can include trusted religious contacts and family, if the client wishes. (5) Escalate per protocol.
Example language (illustrative): "Sometimes people who carry this much think about ending their life, even when their faith forbids it. Have you had thoughts like that?"
Watch for: Shame-based denial. Statements that a curse cannot be lifted. Working signs: an honest disclosure and a safety plan the client owns.

4.18 Consent, confidentiality and documentation

Purpose / when: Throughout. Applies to any information sharing with family, marabouts, healers, interpreters or cultural brokers. [synthesis]
Steps: (1) Explain confidentiality and its limits, including safeguarding. (2) Get separate written consent for each external contact. (3) Record the explanatory model and healer involvement factually, in the client's terms and without derogatory language. (4) Do not record ritual content beyond what is clinically needed. (5) Review consent at each phase.
Example language (illustrative): "I'll write down that you see your marabout, in your words. I won't share it with anyone without asking you first, unless someone is at risk of harm."
Watch for: Records that later stigmatise the client, e.g. "superstitious". Working signs: the client reads, or is told, what is recorded and agrees.

4.19 Relapse planning across both systems

Purpose / when: At consolidation and ending (phase E). [synthesis]
Steps: (1) List early warning signs in the client's and family's terms. (2) Name who to contact first for which sign: marabout or healer, family, GP, psychiatric centre, crisis line. (3) Agree on the signs that always need medical care: e.g. not sleeping for days, agitation, confusion, suicidal thoughts. (4) Share the plan with family and other contacts only with consent. (5) For diaspora clients, include what to do while visiting Senegal, e.g. how to keep medicines and how to reach the Centre Psychiatrique Emile Badiane or another psychiatric service.
Example language (illustrative): "If the old signs come back, who will you go to first? And which signs mean we also need a doctor straight away?"
Watch for: Plans that rely only on one system. Working signs: the client and family can describe the plan without notes.

5. Handling problems

The sources address few of these problems directly. Except where a source is cited, the guidance below is [synthesis].

The client will not discuss healers at all. Do not press. Normalise plural care once, say the door is open, and return to it at review. Explain that you ask in order to coordinate, not to judge. [synthesis]
The client asks whether you believe in djinn, rab or sorcery. Answer honestly and briefly, and return the focus to the client's experience. Example (illustrative): "I don't hold your tradition's knowledge, but I take seriously what you're living through, and what it means to you and your family." [synthesis]
The client is stuck: "Nothing will help until the curse is lifted." Do not argue with the explanation. Work on the parts the client agrees are within reach, such as sleep, fear and family conflict, while the client pursues religious help. Revisit the explanatory model; ask what would show that the spiritual side is improving. [synthesis]
The family insists on healing only and refuses psychiatric assessment of possible psychosis. Use the Caregivers and Informant tools to understand their fear: stigma, the Ziguinchor centre being seen as "strictly for crazy people", or a past bad experience. [source: IRIN 2010] Frame assessment as complementary, which is how Senegalese speakers themselves describe the two medicines. [source: Dieng interview] If there is acute risk, follow your emergency and legal procedures. [synthesis]
A healer advises stopping medication. Do not criticise the healer to the client. Help the client take the question to the prescriber. With consent, clarify your roles with the healer (4.10). [synthesis]
Non-adherence after a healing contact. Explore what was meant and what the client understood. Some families see the need for medicine ending once a healer confirms recovery. Ask, and refer the question to the prescriber. [source: Dieng interview on convalescence for a healer's confirmation; synthesis]
Rupture: the client feels you dismissed their faith or tradition. Name it, apologise for the specific behaviour, and use the CFI Patient-Clinician Relationship module. Ask what would help. [source: APA CFI Supplementary Modules; synthesis]
Overwhelm during trauma work or when discussing sorcery fears. Slow down, use grounding, and return to safety and stabilisation. The client controls pacing. [source: IRIN 2010 on not pushing; synthesis]
A fear of maraboutage makes the client suspicious of you or of the interpreter. Offer choice over interpreter and setting. Be transparent about records and who sees them. [synthesis]
The client wants you to recommend a marabout or a healer. Decline to recommend individuals. Encourage the client to seek one through their own family, religious community or the traditional practitioners' structures they trust. Recognition is community-based, and there is no state register. [source: SenePlus; synthesis]
Financial exploitation by a self-styled marabout, especially in the diaspora. Name the pattern without disparaging the religion. Senegalese speakers themselves distinguish fake marabouts. Support the client to stop payments, and report fraud if the client agrees or the law requires. [source: Dieng interview; Kerharo; synthesis]
A disclosure of child abuse in a daara. Follow child protection procedure immediately (4.16). Do not delay for cultural consultation. [source: HRW 2019; synthesis]
Accusation of sorcery against a family member. Assess risk to the accused person, including children and older people. Work with the family on conflict without endorsing the accusation, and follow safeguarding procedure where violence is threatened. [synthesis]
Your own discomfort or over-identification. Take it to supervision. Watch both for distancing ("superstition") and for romanticising ("ancient wisdom that needs no medicine"). [synthesis]
Conflict between Islamic and Joola explanations within one family. Some sources note debates over which healing is legitimate within Islam. [source: Kerharo on spirit work considered forbidden; Pettigrew 2014, a Mauritanian case, as regional context] Do not take sides. Help family members state their views and agree on a shared safety plan. [synthesis]

Sources

Senegal, Casamance and regional sources

Cultural assessment and collaboration

Books and articles cited by author

Baldé S.S., Sterck C.C. Traditional healers in Casamance, Senegal. World Health Forum 15(4). Listed as 1995; the year-volume match is [uncertain: not verified].
Kerharo J. La médecine et la pharmacopée traditionnelles sénégalaises. Year and publisher [uncertain: not verified].
Baum R.M. (2009). Concealing Authority: Diola priests and other leaders in the French search for a suitable chefferie in colonial Senegal. Cadernos de Estudos Africanos 16-17: 35-51. doi:10.4000/cea.181.
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.
Lewis-Fernández R., Aggarwal N.K., Lam P.C., et al. (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview. British Journal of Psychiatry 210(4): 290-297.
Gureje O., Appiah-Poku J., et al. (2020). COSIMPO cluster randomised trial. The Lancet.
Ofori-Atta A., et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. British Journal of Psychiatry 212(1). Year [uncertain: not verified].
American Psychiatric Association (2022). DSM-5-TR.

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