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Falling, Dying Sheep, and the Divine: Notes on Thick Therapeutics in Peri-Urban Senegal

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Abstract

Peri-urban Senegal lies outside the influence of both the nation’s historic public mental health model and contemporary global mental health. This paper examines how cultural logics in this underserved region spill over from social domains to widen the therapeutic sphere of psychoses and epilepsy. Observations and 60 carer and/or patient interviews concerning 36 patients afflicted by one or both conditions illustrate how the “crisis of the uncanny”, a spectacular eruption of psychoses and seizures into the everyday, triggers trajectories across these domains. To resolve the crisis, patients and carers mobilize debts and obligations of extended kin and community, as well as a gift economy among strangers. The therapeutic and non-therapeutic are further linked through the semantics of falling, which associates this local term for the crisis with divine ecstasy and the slide from human to non-human forms of life. We introduce the concept of thick therapeutics to capture how the logics of sheep- other animal-human relationality, secular-divine politics of giving, and payment/sacrifice for healing imbue a therapeutic assemblage continually constructed through actions of patients, carers and healers. We ask what implications therapeutic thickening might have for mental health futures, such as monetized payment under global mental health.

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Notes

  1. “I” refers to P.M. Diagne, who conducted this interview. In this paper, “we” refers to A.M. Lovell and Diagne. All non-researcher names are aliases except for historical figures.

  2. Including the World Psychiatric Association’s Sub-Saharan Region activities, as was pointed out at the plenary level at the 2018 WPA regional conference in Addis Ababa (Ethiopia). (Ursula Read, personal communication, January 3, 2018). A former WHO Division of Mental Health Director highlighted the Anglophone bias of global mental health commissions which fail to “open avenues of different thinking about the practice of psychiatry” (Sartorius 2017). His examples, however, concerned French (not African) treatment modalities.

  3. We found no global mental health projects among the submissions to the Comité national d’éthique de recherche en santé (CNERS). Our interviews and conversations (2015–2017) with the Director of the Division of Mental Health of the Ministry of Health and Social Welfare; public health professors, senior and junior psychiatrists and other mental health professionals, indicated little awareness of global mental health, funding sources and notions (e.g. the global burden of disease (GBD), the mental health treatment gap) or claims (e.g. the high prevalence of depression worldwide). Senegalese epilepsy specialists do participate in global endeavours, but the few mental health aid projects in Senegal resemble more those of the international health and development era (e.g. bi-lateral rather than multi-lateral, small donors) rather than large global health-identified philanthropists and other organizations). Senegal and other Francophone African countries are not linked to the complex assemblage and particular ideologies of global mental health (Lovell, et al. 2019).

  4. J.A.D. Tine, psychiatrist with the Senegalese Military forces, personal communication, March 22, 2017)

  5. Ba 2015; interview with J.-P. Diallo, Deputy District Medical Chief, by A.M. Lovell and P.M. Diagne, May 15, 2017.

  6. The etymology of the vernacular (the informal, the non-standard, the “native”, from the Latin vernaculus: “domestic, slave, or home-born”) suggests a subordination to the cosmopolitan dominant of the vehicular.

  7. Kilroy-Marac, however, pays careful attention to the vernacular in her ethnography of Fann clinic (Kilroy-Marac 2010, 2014, 2019). Read, in Ghana, also interviewed and observed people with mental illnesses outside the clinic (Read, this issue;  Read, et al.  2009).

  8. For many people, no firm distinction exists between the origins of epilepsy and psychiatric illnesses, as both are supposedly caused by the same spiritual forces (Franklin, et al. 1996:133).

  9. J.A.D. Tine, personal communication, December 2015.

  10. These female volunteers, usually respected local figures, provide health education, interpret government policies for community members, refer people to services, and mediate between citizens and government representatives.

  11. J.A.D. Tine.

  12. As was culturally appropriate and met CNERS guidelines.

  13. Diagne conducted most patient and carer interviews alone and a few with Lovell. Diagne is fluent in Wolof and French. Lovell is fluent in French, with beginner-level Wolof.

  14. Although Freud developed a psychanalytic theory of the uncanny (Freud 1919), our analysis of the phenomenon as an experience of horror and dread before the familiar-become-unfamiliar does not require that framework.

  15. The third largest ethnic group in Senegal.

  16. Wolof and non-Wolof, Muslim and non-Muslim Senegalese men wear fine boubous and babouche slippers and women dress in elaborate brocade, lace, wax (batiked) attire on Fridays, formal occasions and at gatherings of national pride. Yére [clothes] Wolof are commonly tailored from imported cloth, principally Dutch-manufactured wax prints, thus complicating the “ethnic” designation.

  17. Overlapping economic, social and historical processes, including the decline of post-Independence grand development projects; planned and unplanned urbanization; the consequences of SAPs imposed by the International Monetary Fund (IMF) and World Bank (WB); the related suppression of national health protection and state-financed medicines following the Bamako Initiative in the 1980s; and the effect of recent global economic crises on a nation-state highly dependent on remittances from those out-migrating have aggravated local scarcity (Buggenhagen 2012; Collignon 1984; Diouf 1992). Moral economy disturbances parallel the negative effect of broader processes on the economic transformation of public goods, such as now impoverished (or absent) public mental health services, especially beyond Dakar (Diagne and Lovell 2019).

  18. “Feebaram bi daf ño daanel”: his illness made us fall into ruin. Some interviewees use the French, ruiné, implying financial deterioration and loss of health and energy. In Ghana, ruin can refer to the family’s reputation because of non-marriageability of the afflicted member (U. Read, personal communication).

  19. Hospital care and transport for treatment constituted emergencies for which women solicited their rotating credit association in Dakar (Buggenhagen 2012).

  20. This counters recent research in West Africa that suggests recourse to one or another modality takes place for pragmatic reasons, such as when indigenous treatments no longer work or psycho-pharmaceuticals produce side-effects (Read 2012). Furthermore, conjectures rather than convictions about what works and where to seek help shape where families of the mentally ill turn in the face of uncertainty (Read 2017).

  21. Arborio (2009) describes similar beliefs among Bambara communities of Mali.

  22. Note the resemblance to transverberation in Catholicism, in which God pierces the heart, establishing a contact between the spiritual and the material; and to ecstasy in other religions.

  23. The flicker of flames may trigger seizures, similar to the effect of flashing lights and high contrasts on photosensitive epilepsy. (We thank Leila Bordreuil for this remark).

  24. In ndëpp, the still-practiced Lebou-Wolof ancestral ceremony that fascinated Fann researchers, the community reintegrates the afflicted through the animal. Assistants tie the animal tie up, stretch it against the body of the afflicted and cover them with cloths (pagnes). This human-animal proximity allows the rab to leave the afflicted body and enter the animal’s. After the animal sacrifice, the now-healed person once again lies against it, feeling in its convulsive death throes manifestations the transactions undertaken with the rab. (Ndoye 2010). We do not have details on non-ndëpp rituals, such as that Omar’s family participated in.

  25. This section owes much to Bondaz’s and Bonhomme’s (2014) analysis of the gift and sacrifice in Senegal.

  26. One healer explained the process to us thusly: the plants he uses and the soura applicable to a particular affliction—the “diagnosis”—appear to him during a nocturnal trance. He then prepares a concoction (sangaat) from plant powder into which he pours the root-based ink with which he has written the soura on a tablet. The afflicted drinks the liquid, which materializes the God’s intervention. In other words, healers’ medicines are potentiated through the action of spiritual power. They are not mere materia medica.

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Acknowledgements

We thank Dr. Jean Augustin Diegane Tine for his valuable advice throughout the study. Cristiana Giordano, Helen Regis, Ursula Read, Claudia Lang and Sue Makiesky Barrow provided incisive comments. Thanks also to Didi Goldenhar and Bill Kornblum for their feedback and écoute.

Funding

Research for this study was funded by the Agence National de la Recherche (ANR-13-BSH1-0009-01) and the European Research Council (340510).

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  1. INSERM and CERMES (Research Center for Medicine, Health, Mental Health and Society) - UMR 8211, Paris, France

    Anne M. Lovell

  2. CERMES (Research Center for Medicine, Health, Mental Health and Society) - UMR 8211, Paris, France

    Papa Mamadou Diagne

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Correspondence to Anne M. Lovell.

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Research for this paper was approved by the Comité national d’éthique et de recherche en santé (CNERS) of Senegal. Informed consent was obtained accordingly from all individual participants included in the study.

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Lovell, A.M., Diagne, P.M. Falling, Dying Sheep, and the Divine: Notes on Thick Therapeutics in Peri-Urban Senegal. Cult Med Psychiatry 43, 663–685 (2019). https://doi.org/10.1007/s11013-019-09657-2

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