During the winter of 2023 and the spring of 2024, I took part in a qualitative research project, together with two colleagues from the Mamre Onlus Foundation, which has been working in Turin for years on psychological support and migration, at the Centre Psyquiatrique Moussa Diop of the National University Hospital Centre (CHNU), located in the Fann district of Dakar, Senegal, a symbolic place for international ethnopsychiatry and today a focal point in the field of psychiatry for the whole of French-speaking Africa (Collignon, 1978).
The clinic, founded in the mid-1950s with the specific aim of caring for people with mental disorders, was directed in the early years of its establishment by the French psychiatrist Henry Collomb, who aimed to establish it not on the outskirts of the city, far from the pulsating life of the urban fabric, but in the heart of the city (Pisani, 2017), along the edges of that colonial psychiatry which, with its indisputable bio-medical representations of madness, represses any possible local contribution, relegating this concept to universal traits extendable and valid for every human being and imposing a limited geography of the definitions of health and illness.
Collomb laid the foundations for an experimental project on the themes of mental health and transculturality and found support in a diverse group of psychologists, ethnologists, and anthropologists who collaborated to build a research and operational center that would go down in the annals of ethnopsychiatry history as the École de Dakar.
Supported by a prodigious vitality and endowed with an intense presence, Collomb was attracted by Africa, by the diversity and vigor of its ways of living in society [1] (Zempleni, 1980; 85-90), and by the various interpretations of mental pathology that this culture produces.
He intuits that in order to try to open new paths to healing processes, it is necessary to kill the most solid prejudices (Senghor, 1979) and explore new discourses on malaise and its treatment, in a system of thought in which the individual is not conceived as unique and separate from society but as constantly connected with his surroundings (Miramonti, 2021).
The relational substance of which it is made makes it impossible to treat it in isolation from the context in which it is inserted and the term individual itself is not representative of a human being, as described by Western culture, perceived as separate from the environment in which he is immersed.
In this scenario, the concept of person has a group matrix: man not only acts through bonds but is himself made of bonds and therefore in continuity with the earthly and present universe, but also with the invisible and ancestral one.
Relationships connect him to the world and at the same time contribute to shaping and forming him as a human to the point that personal recognition starts from this intertwining rather than from his own uniqueness.

It is not simply a matter of inserting or placing individuals in a relational context and arguing that they cannot do without it; rather, it is a matter of conceiving humans more radically as intrinsically social beings, in that, far from being individuals, they coincide with the bundle of relationships that form them (Remotti, 2019; 259-260).

It is therefore within this dual holistic and group perspective that we must trace not only the multiple meanings that this ethnic group attributes to what biomedicine defines as psychiatric disorders but also the processes of care and healing within the possession cults and divinatory rituals put into practice to heal the complex forms of malaise.
During his stay in Fann, Collomb will try to translate the dysfunctions that Western psychiatry interprets from an individual perspective into communal terms, placing their origin not in the meanders of the psyche, in the immaterial internal courtyard (Macaluso, 2023) of the person, the seat of the soul and the ego, but in the places of the ethnos in which the world of humans and the magic of another world coexist, the home of spirits and ancestors, a space in which the origin and causes of malaise must be traced.
The traditional relationship between inside and outside, intimate and collective, is disrupted to the point of becoming unrecognizable (Jullien, 2014) and the inversion of this dichotomy changes the perspective on which psychotherapy has designed its investigative tools.
The object of interest is not so much the exploration and expression of the individual’s interiority, of the inside of me, through the therapeutic relationship, but rather the questioning of everything that makes up that individual’s universe, subordinating any personal approach to the needs of the group, where subjectivity is constructed.
Collomb tries to position himself as a liminal figure between these ways of interpreting the human and tries to invest Fann’s psychiatric clinic with a complementarist gaze [2] (Collignon, 1978; Devereux, 1972) to try to read, as one would do with a bifocal lens in which the two dioptric powers are simultaneously present in a separate and distinct form, the mental problems present in the Senegalese population.

Complementarism does not exclude any valid method or theory, it coordinates them.

This dual perspective seeks to bring together different approaches to understanding people and their distress, and their encounter does not occur through the incorporation and fusion of these different readings, but through the activation of both in a non-simultaneous, complementary, dialogical, and non-totalitarian manner.

Collomb’s experimental goal is to weld two medicines, European and African, so that both benefit from each other’s expertise (Ellenberger, 1968). The former must moderate the arrogance of its unrelated superiority, historically imposed “at gunpoint,” while the latter is invited to open the treasure chest of centuries-old secrets. (Inglese, Dia, 2022).

Collomb allows himself to be contaminated by a social system that places the group at the centre of the world and increasingly increases the number of scholars who, fascinated by his observations, integrate the research with new contributions and follow him willing to dedicate a prolonged time and an unconditional, almost missionary dedication to the project of profoundly transforming existing psychiatric institutions (English, Dia, 2022).
His aim is to experiment with a clinic that does not curl up around the theories of colonial psychiatry that dissects and breaks down the patient through a diagnostic framework, intervening mainly with the use of a drug in an aseptic room, far from any external contamination. The imported psychiatrist, whatever his training, should first of all put his own culture aside and open himself to listening to this other psychiatry to try, at a second stage, to adapt his own schemes and techniques to the reality of mental illness within the culture from which it originates and of which he is a witness (Collomb, 1970).

He seeks an open and flexible healthcare intervention that can harmonize with the patient’s environment, open to being influenced by the readings and interpretations that local tradition attributes to psychiatric disorders, and curious about the way Senegalese society interprets and translates madness and treatment.
During his twenty years of work at Fann, Collomb proposed new tools to the hospital to simultaneously bring families and patients closer to the medical and scientific lexicon. He experimented with the role of the “accompagnant” (Diagne et al., 2019), opening up the possibility for patients to be supported during their hospital stay by a family member (who will live with them throughout their stay) to strengthen the connection between the inside and outside of the hospital and allow family members to be fully involved in hospital life.
Taking inspiration from the arbre à palabre [3] that he came to know during his travels in other parts of Africa, he introduces the Penc [4] device (Dia, 1976; 1977), a group of verbal expression on themes concerning hospitalisation and therapeutic practices which involves, on the same level, doctors and patients who periodically meet thanks to the guidance of a jaaraf, a patient who facilitates the circulation of words.
He draws inspiration from the territorial and community work that the psychiatrist Thomas Adeoye Lambo is carrying out in parallel in Nigeria (Collignon, 1978) and seeks the collaboration of marabouts [5] (Collomb 1970) and magician specialists (Ortigues & Ortigues, 1966) present in the area.
The partnership with Daouda Seck, one of the most expert traditional Lebou healers, is the most important driving force for the construction of his experimental practice within the walls of the clinic which perhaps for the first time opens its doors to traditional medicine, allowing him to outline a profile of what will be defined African psychopathology [6].

Henry Collomb dedicated twenty years of his life to this project before dying in 1979.

When we set out in November 2023 for these territories so steeped in history and meaning, we know that the work of transcultural psychiatry is part of a past that no longer exists.
Many others before us have walked the corridors of Fann hospital in search of some trace of Collomb’s work and, apart from his ghost which seems to still haunt the long corridors of the clinic, few are the instruments of the multidisciplinary vision that have survived the domination of the Western scientific gaze, in the current context of the evolution of sciences, the emergence of a new generation of psychiatrists shines a light on ethnopsychiatry in favor of a strictly medical focus [7] (Ndoye et al., 2022).
Today, the Fann Hospital Center, divided into four divisions, follows a strictly biomedical approach and does not seek collaboration with traditional health care systems, despite the fact that almost all Senegalese families turn to a traditional healer if a member of their family suffers from mental disorders, and only in a few cases also seek a consultation at the Fann clinic.
A psychiatric visit is seen by families and doctors as a last resort when symptoms are out of control and the person’s aggression can no longer be managed without pharmacological sedation. Once the emergency situation has subsided, the family member is taken home, also to limit hospitalization costs, until the next emergency.
During our weeks there, we managed to collect 18 semi-structured interviews with healthcare personnel (psychiatrists, residents, nurses, psychologists, and accompagnant), 19 clinical histories (of patients admitted to the Fann clinic), and 16 narrative interviews (thematic and more in-depth discussions with some patients on topics of interest to us).
The focus of our work is on observing the phenomenon of return migration, the experience of those Senegalese who, having left to seek their fortune abroad, had to return to their native country at a certain point in their migration journey, only to end up in the clutches of local psychiatric services following various types of suffering and mental distress that arose during or after their migration journey.
While much has been written about the principles governing the need for mobility of peoples and, specifically, about the Senegalese diaspora in Europe, the United States, and Africa, less has been said about the phenomenon of repatriation (Teti, 2022), of those who find themselves forced to repatriate to their homeland without having planned it.
These are unplanned returns, resulting from failed migrations, movements that did not have the desired outcome, returns defined as silent (Gueye, 2022) because they were not negotiated with national and international bodies and therefore remain unrecorded in statistical data.
The plurality of the concept of individual and person that we mentioned previously helps us to understand the form that the failure of a migratory journey takes, which is almost never the result of an individual choice but more often than not the product of a economic strategy (Gueye, 2007) entirely cared for by the family circle or community group..
The journey involves the family, and in particular the mothers, who demonstrate great determination in finding the resources necessary to finance their child’s journey. They are therefore strongly involved in these migration projects and most often sell their possessions or ask for help from other family members. In all cases, these mobilizations are strategies developed by the families, with the aim of improving their living conditions through cash transfers from the applicant, if he or she manages to leave. Whether through the sale of jewelry or livestock, or through associations (particularly tontines [8]), many mothers have managed to finance their child’s journey. Some of them, once they have collected their share of tontines, have been able to support their children in their migration project. (Ngom, 2017).

The expected outcome is to see the migrant, for whom resources have been mobilized, send remittances from the destination country to meet some of the family’s needs, with the expectation that they will participate in one way or another in improving the living conditions of those who remained and supported their expatriation.
The investment, not only financial but also in ties and family networks, that the group activates in the individual designated for departure must somehow be repaid.
The people we meet tell us during our interviews about the drama of defeat, the tragedy of those who have failed in their migratory venture and are forced to return empty-handed (Gueye, 2022) to their village and community.

Il n’a pas rempli ses devoirs envers la communauté de son village, il devait envoyer de l’argent régulièrement à sa famille famille élargie, apporter des cadeaux tout le monde [9]. (Collomb, 1962)

When the migratory pact between family, community, and migrant breaks down, returning becomes stigmatizing, and the extremely hostile environment pushes people toward social marginalization, which often translates, in Western eyes, into psychiatric disorders.
Our research [10] has tried to intersect the data on the migratory return with the hospitalisation in the Fann clinic to try to shed light not so much on the meanings linked to the departure, but on the sense of the return and on how much this has an influence on the mental health of the hospitalised people.
This trip raised new questions about the multiple meanings of mental illness among some ethnic groups in Senegal and about the validity and effectiveness of our clinical tools in constructing the diagnostic and therapeutic process with people from elsewhere.
What contribution can the Gestalt paradigm make to these issues from a theoretical and practical point of view?
How can the notions that form the basis of our clinical perspective contribute to the construction of a doctrine that takes into account cultural complexity?
My reflections, born during my stay in Senegal, start from one of the fundamental Gestalt principles: the indissoluble relationship between the organism and the environment.
According to the Gestalt vision, these two entities cannot be separated as they are in constant exchange and interdependence.
They represent a single interacting ecosystem that self-regulates and grows according to each element that is part of it: they exist and influence each other simultaneously.
In the name of this postulate, therefore, man or woman do not exist as separate figures; the meaning of the human must always be inscribed within the organism/environment field and in this bubble, the boundary between organism and environment does not separate the organism from its environment; rather, it fulfills the function of limiting the organism, of containing and protecting it, and at the same time places itself in contact with the environment (Perls et al. 1971).
Interpersonal traiality (Salonia 2012) anchors the individual to his context, roots him to the earth and, by connecting him, lifts him out of isolation, allowing him to experience what flows at the contact boundary.
In this constant process, the organism encounters the environment and withdraws from it, making choices and following a pattern that gives priority to the need in question, the one that most urgently presses for its satisfaction, and temporarily leaving the others in the background.
This perpetual organismic functioning that allows the individual to learn, assimilate and grow on a daily basis is the same one on which the therapeutic alliance is built within a psychotherapeutic setting.
Therapist and patient are each other’s environment, and within this emotional bond, the therapist is the audience, the living context that gives new meaning to the patient’s words. In front of the therapist, the other’s story is recognized; the patient knows himself only by virtue of this recognition (Gecele, 2002).
But how does this recognition, this translation of the other, occur in the encounter between people with different cultural backgrounds?
Culture is not a costume that can be removed from the body, a well-stocked warehouse (Gramsci, 2014) that each person possesses within themselves, or an ornament of human existence (Remotti, 2013).
Culture is a transformative process that shapes the human being and, through its anthropopoietic force, shapes his emotions, behaviors, and thoughts. It intervenes in his incompleteness and anatomical deficiency, thus making him whole and finite.
Culture is a transformative process that shapes the human being and, through its anthropopoietic force, shapes his emotions, behaviors, and thoughts. It intervenes in his incompleteness and anatomical deficiency, thus making him whole and finite.
What might be the experience of a therapist who places himself as an environment facing the otherness of the other?
On what basis does the encounter rest when subjectivities correspond to such alien human constructions?
In Gestalt therapy, the term sympathetic relationship is used to define the type of relationship that therapist and patient build within the therapy room.

Perls’ definition of this relationship is enlightening:

There are usually three paths open to the therapist: one is sympathy, or involvement in the total field, awareness of both the self and the patient. Another is empathy: a kind of identification with the patient that excludes the therapist himself from the field and therefore excludes half the field. In empathy, the patient’s interest focuses exclusively on the patient and his reactions […]. Finally, there is apathy, disinterest. […] (Perls, 1978)

In the sympathetic relationship, therefore, the focus is more on the therapist, who acts as a sounding board for the patient and, through self-sharing, reflects on the effect he or she has on the environment and the consequences that his or her actions can have on his or her surroundings. This allows the patient to increase self-awareness, a key concept of Gestalt therapy and an essential requirement for therapeutic work, and to become more responsible and free in his or her life choices.
A similar focus on the therapist’s position and experiences is found in the theoretical assumption of cultural countertransference developed by G. Devereux, a Hungarian anthropologist and psychoanalyst, considered one of the leading exponents of ethnopsychiatry.

I maintain that it is countertransference, rather than transference, that constitutes the crucial data in any behavioral science, because the information provided by transference can generally be obtained by other means, while this is not the case with countertransference […]. Simply, the analysis of countertransference is scientifically more fertile, and provides more data on the nature of man. (Devereux, 1984).

His insight emphasizes the importance of analyzing, in working with otherness, not so much the transference dynamics, the emotional and affective investments that the patient deposits in the therapist, as is standard practice in psychoanalysis, but rather the countertransference ones, which are more valuable in providing useful elements for interpreting the other’s distress originating from elsewhere.
Although there are similarities between cultural countertransference and the sympathetic relationship, there remain important theoretical divergences between psychoanalysis and Gestalt Therapy, and many open questions remain about how to structure therapeutic approaches capable of avoiding the dangers of ethnocentrism that threaten the integrity and completeness of ethnic heterogeneity.
Continuing to question and challenge one’s own approach to therapy when faced with different cultural backgrounds is a necessary process to avoid the evaluative attitude that inevitably arises when confronted with diversity.
The ever-increasing number of international migrants and asylum seekers in our country has made it increasingly necessary for professionals, psychologists, and psychiatrists to specifically train them to care for those with culturally specific backgrounds who require mental health services and local psychological support.
In recent years, our school has approached these issues by incorporating ethnopsychiatry into its curriculum to raise students’ awareness of a multiethnic clinic that prepares them for intercultural encounters by providing new tools and a more pluralistic perspective.
In line with these transformations, we have decided to dedicate a section of our journal to the role of cultures in therapy. Our aim is to co-construct, through the theoretical contributions that will follow, new clinical languages ​​that can help us shift our boundaries towards other ways of understanding otherness.

Notes

[1] He never ceased to marvel at Africa, at its diversity, its vigor, its ability to live together, in groups, in society.

[2] Similar to the famous figure of the vase visible from two different perspectives, conceived by Edgar Rubin in 1915 as an example of the “figure-ground” principle of perception that forces the eye to focus on one element at a time, the principle of complementarity theorized by physicist Niels Bohr (Rubin’s cousin) requires the conceptual effort of accepting the presence of multiple levels of explanation, all essential to explain a phenomenon ‘completely’ but which are mutually exclusive.

[3] The talking tree (usually a baobab) is a traditional meeting place, under which people discuss social life, village problems and politics.

[4] In Wolof meeting, assembly.

[5] The marabout, a spiritual leader of the Islamic faith, primarily manipulates the magical rather than the sacred, like the fetish maker of non-Islamic countries. He may also use verses from the Qur’an and benevolent or malevolent spirits to aid him in his “work.”

[6] Psychopathologie Africaine is also the name of a journal created by Moussa Diop and Henri Collomb in 1969 within the Société de Psychopathologie et d’Hygiène Mentale in Dakar.

[7] In the current context of scientific development, the emergence of a new generation of psychiatrists is sounding the death knell for ethnopsychiatry in favor of strictly medical care.

[8] The tontine is a rotating savings and investment system that requires periodic contributions from each member.

[9] He failed to fulfill his duties to the village community: he was supposed to regularly send money to his extended family to bring gifts to everyone.

[10] The research findings are presented in an article that will be submitted to an academic journal of transcultural psychiatry. They will be reported in that journal at a later date.

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