Garifuna dügü

1. Introduction

Version followed: the dügü as Garifuna (Garinagu) community scholars in Belize and Honduras describe it, mainly I. Myrtle Palacio and Belize Glessima Research (2011–2022) and Tesla Quevedo, Asociación ECOSALUD, Honduras (2022). The UNESCO listing and outsider ethnography (Kerns, Staiano, Johnson) are used as attributed context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What it is. The dügü is a Garifuna ancestral ceremony. It is not a psychotherapy, and a psychotherapist does not perform, lead or imitate it. The Garinagu are a people of mixed Indigenous Caribbean and African origin. In the 18th century they were forced out of Saint Vincent and settled along the Atlantic coast of Central America. UNESCO inscribed "Language, dance and music of the Garifuna" on the Representative List in 2008, after its proclamation in 2001. The listing is shared by four countries: Belize, Guatemala, Honduras and Nicaragua. It does not mention the dügü, the buyei or healing, so the UNESCO listing is not a listing of the ceremony itself. [source: https://ich.unesco.org/en/RL/language-dance-and-music-of-the-garifuna-00001]

How the community describes it.

Palacio calls the dügü a "sacrosant ceremony" made up of linked rituals based on lineal kinship. She describes it as rooted in the spiritual health of the Garifuna people. It is conducted by a buyei (plural given as buyenu) in a dabuyaba. She notes that Garifuna usage keeps these terms rather than "Temple" or "Priest/Priestess". [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/What-is-Dugu.pdf]
Garifuna spirituality, as these sources hold it, teaches that the ancestral spirits (áhari) of deceased blood relatives stay in a reciprocal relationship with the living. They communicate with and protect living family members through dreams and trance. An ancestor who comes forward in this way is called gubida. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf] [source: https://www.belize-glessimaresearch.org/?p=1673]
Honouring the ancestors is part of everyday life. Most observances are voluntary. When obligations to the ancestors are neglected, the ancestors may require a formal process (adügürahani). The dügü is its most elaborate form and is described as an option "when all else fail[s]". [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/]

How change is understood within the tradition. Change is not described in psychological terms. In these accounts, well-being and healing come from restoring the reciprocal relationship between living kin and their ancestors. Palacio summarises the principle as au búni amürü núni, "I for you and you for me". The process is overseen by the buyei and carried out by the extended family. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf] Quevedo, writing from Honduras, presents Garifuna spirituality as a source of unity, physical and mental healing, and family harmony. She speaks of healing "los padecimientos del alma" (sufferings of the soul). [source: https://revistas.una.ac.cr/index.php/tdna/article/view/17430/25910] These are the tradition's own accounts. This guide attributes them and does not state them as fact or dismiss them.

The therapist's role. The psychotherapist works alongside the tradition. This means understanding the client's explanatory model, telling culturally normative ancestral experience apart from disorder, supporting the client through family obligations, and collaborating with a buyei only when the client wants it, through the client and family. It also means guarding against harm and against misappropriating a private family rite. [synthesis]

2. Framework

A. The tradition's own structure (as community sources describe it; no procedure given here).

Everyday honouring: remembrance woven into daily life, such as prayer or Mass, music and dance, and sharing food with the living and the dead. Garifuna Catholics have combined Christian and Garifuna practice. [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/]
Signs from the ancestors: dreams and trance, which the buyei helps interpret. Formal séances are held only with a buyei. [source: https://www.belize-glessimaresearch.org/?p=1673]
Formal obligation and the dügü: when obligations have been neglected and the ancestors ask for repayment, a formal preparatory process may lead to a dügü held in the dabuyaba under a buyei. Sources call it the most time-consuming obligation. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf] The dügü's length, structure and contents belong to the buyei and families and are not described in this guide.
Who holds authority: the buyei, described as chosen or called by the ancestors, and the families who hold the obligation. [source: https://revistas.una.ac.cr/index.php/tdna/article/view/17430/25910] [source: https://amandala.com.bz/news/?p=269055] Older women organise ancestral rituals and are central to keeping the culture alive (Kerns, Women and the Ancestors, 2nd ed., University of Illinois Press, 1997). [source: https://www.press.uillinois.edu/books/?id=p066658] Quevedo describes families as matrifocal, with grandmothers (nagoto) leading spiritual gatherings. [source: https://revistas.una.ac.cr/index.php/tdna/article/view/17430/25910] Community bodies include the National Garifuna Council, which is named on the UNESCO page. Its role in ceremonial matters is [uncertain: not verified].

B. The psychotherapist's work alongside (phases are [synthesis]; no source sets session counts).

Phase	Goal	Typical format	Move on when
0. Preparation	Examine your own assumptions; learn the basic terms (áhari, gubida, buyei, dabuyaba, dügü) and the history of displacement and discrimination	Before contact; supervision	You can describe the tradition without exoticising or pathologising it
1. Engagement and cultural assessment	Core CFI plus relevant modules; the client's explanatory model; the role of ancestors, family and church	1–3 sessions; an interpreter or cultural broker if needed	You can state the client's own account of the problem, its cause and the help they prefer
2. Differential formulation	Separate normative ancestral communication (dreams, trance within accepted practice) from psychosis, dissociative, mood, trauma or medical conditions	1–2 sessions; informant with consent; medical review	Risk is assessed; the diagnosis or non-diagnosis is reasoned, with cultural input
3. Collaborative plan	Agree goals that respect family obligations; plan any contact with a buyei or elders only if the client asks; coordinate medical care	Ongoing; family sessions if wished	The client agrees to the plan; consents are documented
4. Alongside and after a family ceremony	Support through preparation, cost, travel, family conflict and grief; integration afterwards	Flexible; pause or space out sessions around the event	The client can place the experience in their life story and functioning is steady
5. Maintenance and safeguarding	Relapse planning; continuing review of risk and medical needs	Spaced sessions	Goals are met or care is handed over

[source for the CFI structure: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

3. Guiding principles

The tradition belongs to the Garinagu. Never lead, stage, adapt or recommend the dügü. Your work is assessment, therapy and liaison. [synthesis]
Authority lies with the buyei and the family. Questions about whether an obligation exists or a ceremony is needed belong to them, not to you. [source: https://amandala.com.bz/news/?p=269055]
The dügü is private. A Belizean editorial objecting to a 2013 cruise-tourism plan called the dügü a private family ritual: "It is not a public cultural event." Do not ask to attend, observe or record it. Do not encourage clients to bring outsiders in. [source: https://amandala.com.bz/news/?p=269055]
Attribute, do not adjudicate. Describe ancestors, dreams and trance as the client and tradition hold them. Do not assert them as fact or dismiss them. [synthesis]
Normative experience is not illness. DSM-5 and DSM-5-TR exclude disturbances that are a normal part of broadly accepted cultural or religious practice from dissociative identity disorder and dissociative trance. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]
Do not miss illness either. Cultural explanation and psychiatric or medical disorder can coexist. Assess both. [synthesis]
Use the CFI as an aid to understanding, not a diagnostic test. The APA states the CFI is not meant to be the only basis for a diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Reciprocity and kinship are the unit of meaning. Palacio puts the principle as au búni amürü núni. Formulate with the family and the ancestors in view. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf]
Respect blended practice. Many Garinagu combine Catholic and ancestral observance, and Quevedo writes "La espiritualidad garífuna no es religiosidad". Do not force a choice between church, ancestors and clinic. [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/] [source: https://revistas.una.ac.cr/index.php/tdna/article/view/17430/25910]
Hold the history. UNESCO records centuries of discrimination and linguistic domination, and Amandala notes colonial and missionary suppression. Expect mistrust of services and name it. [source: https://ich.unesco.org/en/RL/language-dance-and-music-of-the-garifuna-00001] [source: https://amandala.com.bz/news/?p=269055]
Consent governs every contact with healers or family. Contact happens only through the client, with written consent and a defined scope. [synthesis]
Medical care is never delayed. No ceremony is presented as a treatment for physical disease. Route physical symptoms and all medicine questions to the physician or prescriber. [synthesis]
Do not name individuals. In records and consultations, refer to "the family's buyei" and similar, not to named private persons. [synthesis]

4. Intervention inventory

All of the interventions below are the psychotherapist's own work. None of them reproduces or replaces any part of the dügü or the buyei's role. Example language is illustrative wording unless it is quoted.

4.1 Cultural humility and self-examination

Purpose: to stop your own assumptions (e.g. "possession equals psychosis", or "exotic ritual") from shaping assessment. Do this before and throughout work with Garifuna clients. [synthesis]
Steps: (1) Write down what you believe about ancestors, trance and spirit mediums, and where those beliefs come from. (2) Learn the basic terms and history from Garifuna-authored sources, such as Palacio's writings and the UNESCO account of displacement and discrimination. (3) Notice tourist, media or "voodoo" stereotypes. In 2013 Garifuna community members publicly opposed a cruise-marketing plan to use the dügü. (4) Take cases to supervision or consultation with a Garifuna cultural adviser, with the client's consent and without identifying details. [source: https://amandala.com.bz/news/?p=269055] [source: https://ich.unesco.org/en/RL/language-dance-and-music-of-the-garifuna-00001]
Example language (illustrative): "I know a little about Garifuna traditions from reading, but you're the expert on your family's way. Please correct me if I get something wrong."
Watch for: curiosity that turns into wanting to observe a ceremony; using Garifuna terms to show off; the client teaching you at their own expense. It is working when the client corrects you freely and brings up ancestral matters without being asked.

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

Purpose: to set out the client's own definition of the problem, its causes, stressors and supports, cultural identity, coping, past help-seeking and current preferences. Use it at intake, or whenever culture seems relevant to the problem. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Explain the purpose. (2) Work through the four APA domains in your own words: cultural definition of the problem; perceptions of cause, context and support; self-coping and past help-seeking; current help-seeking. That last domain covers preferences and the clinician–patient relationship, including perceived racism and language barriers. (3) Use the client's words for the problem in your notes. (4) Note which supplementary module expands each topic (see 4.3). (5) Summarise back and check. The APA permits clinicians to reproduce the CFI for use with their patients. Modifying or translating it needs APA permission. APA's CFI forms give no time estimate for the interview [uncertain: not verified]. A field trial found later interviews took less time. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]
Example language (illustrative): "Sometimes people describe their troubles in their own way, or with words from their community. How would you describe what's been happening?" Later: "Has anyone in your family, your church or the community given you a view on why this is happening?"
Watch for: answers that stay guarded about ancestors, which is common where practices have been stigmatised; the client hinting at the problem through family or church terms. It is working when the client gives their own causal account, which may be ancestral, medical, social or mixed, and names the help they want.

4.3 CFI supplementary modules relevant to Garifuna clients

Purpose: to go deeper where the core CFI points. APA lists 12 modules. They can be used as add-ons or on their own, at the first evaluation, later in care, or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps (choose by need): (1) Spirituality, Religion and Moral Traditions: ancestral relationships, Catholic or other church involvement, and how the two fit together. (2) Explanatory Model (see 4.4). (3) Cultural Identity: Garifuna identity, language (Garifuna, Spanish, English, Kriol), and the effects of discrimination. (4) Social Network: extended kin and the role of older women and grandmothers. (5) Immigrants and Refugees: migration and diaspora. Johnson's ethnography estimates that about one-third of Garinagu moved to New York City over fifty years, and it describes ancestral practice continuing across diaspora sites. (6) Coping and Help-Seeking: buyei, church, clinic. (7) Caregivers and the Informant Version: a family member's view, with consent. [source: https://muse.jhu.edu/book/25566] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Example language (illustrative): "Some families keep a close relationship with relatives who have passed. Is that part of your family's life? How does it fit with your church, if you go to one?"
Watch for: pressure to give "church" answers in front of relatives; diaspora clients who feel cut off from home-community authority. It is working when the client describes their kin network, living and ancestral, and where their help comes from.

4.4 Explanatory-model inquiry (Kleinman)

Purpose: to learn the client's model of the illness and negotiate a shared plan. Use it after the core CFI, or whenever plans clash. [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: Cover the eight areas in your own words: what the client calls the problem; its cause; 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 the client thinks they should get; the main problems it has caused; and what they fear most. Then set your own model beside theirs and agree the overlap. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]
Example language (illustrative): "What do you think started this, and why now?" Then: "What would you most want help with, from me and from others?"
Watch for: a model in which an ancestor's request or a neglected family obligation explains the distress. Within Garifuna sources this is a recognised understanding of misfortune. [source: https://www.belize-glessimaresearch.org/?p=1673] Also watch for fear of being judged "crazy" for saying it. It is working when the client's explanation and the clinical plan sit side by side without either being discounted.

4.5 Asking about dreams, trance and ancestral communication without judgement

Purpose: to learn whether ancestral communication is part of the presenting picture. Community sources describe ancestors reaching the living through dreams and trance, with the buyei helping interpret them. [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/]
Steps: (1) Ask about dreams of deceased relatives in a neutral way. (2) Ask who in the family or community usually makes sense of such dreams. (3) Ask how the client feels about them: comforted, obliged, frightened. (4) Do not interpret them yourself in spiritual terms. Reflect their emotional and relational meaning only. [synthesis]
Example language (illustrative): "Have any relatives who've passed come to you in dreams? What did that mean to you and your family?"
Watch for: distress centred on obligation, cost or family conflict rather than on the experience itself; experiences happening outside any accepted context, which signals the need for 4.6. It is working when the client talks about these experiences openly and their meaning is clear.

4.6 Distinguishing normative ancestral experience from disorder

Purpose: to avoid both pathologising accepted spiritual experience and missing psychosis, dissociative, mood, substance-related, trauma or neurological conditions. [synthesis]
Steps: (1) Note the classification limits. In DSM-5, dissociative identity disorder may present as possession in some cultures, but it is excluded when the disturbance is a normal part of broadly accepted cultural or religious practice. DSM-5-TR keeps these points in substance, though whether it keeps the exact wording is [uncertain: not verified]. Dissociative trance under other specified dissociative disorder carries the same exclusion. ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] [source: https://www.findacode.com/icd-11/code-1807490186.html] (2) Ask whether the experience happens within an accepted setting and whether family or the buyei recognise it as such. (3) Ask whether it is wanted or unwanted, time-limited or persistent. (4) Ask about distress and impairment outside that context. (5) Screen for other psychotic features, mood change, substance use, sleep loss and medical causes. (6) With consent, get an informant or cultural-broker view of whether the experience is typical for the community. (7) Record your reasoning. The DSM-5-TR note on culturally sanctioned beliefs in psychosis assessment is [uncertain: not verified]. Apply the principle as [synthesis]. [synthesis]
Example language (illustrative): "Do others in your family or community see what's happening to you as part of the ancestral way, or as something different and worrying?"
Watch for: relatives saying "this is not like a gubida"; command hallucinations, disorganisation, functional decline, suicidality. Any of these call for psychiatric review whatever the cultural framing. It is working when the formulation explains both the cultural meaning and any clinical need.

4.7 Working with cultural concepts and idioms of distress

Purpose: to use the client's own idioms and recognise that DSM-5-TR's concept of "cultural concepts of distress" (idioms, explanations or perceived causes, and syndromes) applies even when no named entry fits. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: (1) Note that the DSM-5-TR examples listed in a university-hosted source (ataque de nervios, dhat, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto, taijin kyofusho) include no Garifuna-specific entry. The exact DSM-5-TR list is [uncertain: not verified]. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] (2) Record the client's own term, such as an ancestor's request, or Spanish-language idioms like nervios if the client uses them. Do not convert it into a DSM category. (3) Treat "ancestral cause" as an explanation or perceived cause, not a syndrome. (4) Then assess symptoms separately. [synthesis]
Example language (illustrative): "When you say the old people are asking for something, what does that feel like in your body and your days?"
Watch for: forcing a fit to a listed concept; ignoring a mood or anxiety disorder that sits underneath. It is working when the notes keep the client's idiom and also list symptoms and functioning.

4.8 Mapping kinship, reciprocity and ancestral obligation

Purpose: to understand distress that centres on family duty. Garifuna sources describe an obligatory cycle between parents and children that extends to the dead. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf]
Steps (adapted genogram, [synthesis]): (1) Draw a genogram that includes deceased relatives the client considers significant. (2) Mark who holds family authority, often older women, and who is in the diaspora. [source: https://www.press.uillinois.edu/books/?id=p066658] (3) Mark obligations the client feels are met or unmet, using their own words. (4) Mark conflicts, such as church versus ancestral views, cost, and who must travel. (5) Use the map to plan family sessions or problem-solving. Do not use it to judge whether an obligation is real; that judgement belongs to the family and the buyei.
Example language (illustrative): "Let's draw your family, including the people who have passed who matter to you. Where do you feel you owe something, and where do others owe you?"
Watch for: guilt or shame about neglected obligations; disputes over money or who leads; grief that was never resolved. It is working when the client can name the relational knots and choose next steps.

4.9 Asking about consultation with a buyei, church or other healers

Purpose: to learn about all the help-seeking in a non-judgemental way, so care is coordinated and nothing is hidden. Staiano's Belize ethnography describes competition, conflict, coexistence and some cooperation between biomedical, ethnomedical and sacred medical systems. [source: https://ehrafworldcultures.yale.edu/cultures/sa12/documents/005]
Steps: (1) Normalise the question. (2) Ask who has been consulted, including buyei, priest or pastor, herbalist, doctor, and what they advised. (3) Ask whether any advice conflicts with medical care. (4) For any herbal or other remedy, record it and pass it to the prescriber. Do not comment on whether to use it. (5) Ask whether the client wants you to know more about or coordinate with any of them. [synthesis]
Example language (illustrative): "Many people see several kinds of helpers. Who else has helped you with this? I ask so we don't work against each other."
Watch for: concealment because of past ridicule by clinicians; conflicting instructions. It is working when the client tells you about other help without hesitating.

4.10 Collaboration and referral with a buyei or elders, only if the client wishes

Purpose: to support coordinated care where the client wants it. Authority rests with the buyei and the family, so the therapist neither refers people into a ceremony nor stands in for the buyei's judgement. [source: https://amandala.com.bz/news/?p=269055]
Evidence context (from other countries, not Garifuna-specific): COSIMPO (Gureje et al., The Lancet, 2020) was a cluster randomised trial in Nigeria and Ghana. Collaborative shared care between traditional or faith healers and primary-care workers produced a greater reduction in psychosis symptoms, and harmful practices fell more with the intervention (57% to 9%) than in controls (42% to 10%). [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In the Ofori-Atta et al. prayer-camp trial in Ghana (Br J Psychiatry 212(1)), adding psychiatric medication lowered symptoms, but days in chains did not fall significantly. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] No published Belizean, Honduran, Guatemalan or Nicaraguan programme for formal buyei–clinician collaboration is documented in the sources cited [uncertain: not verified].
Steps: (1) Ask whether the client wants any contact. If not, stop there. (2) If yes, agree the purpose (e.g. sharing a safety plan or coordinating timing around a family ceremony), the scope of information shared, and who makes contact. Usually the client or a family elder makes it, not you. (3) Get written consent and limit what is shared. (4) In any conversation, ask what the buyei and family need from clinical care. Do not ask about ceremonial content. (5) Record agreements. Review risk independently. [synthesis]
Example language (illustrative): "If it would help, and only if you want it, we could let your family's buyei know what we're working on. You decide what's shared and who passes it on."
Watch for: you drifting into asking about ritual content; the family feeling pressured to choose between buyei and clinic; risk being handed over without review. It is working when everyone knows the plan and the client feels supported by both.

4.11 Interpreters and cultural brokers

Purpose: to make assessment accurate when the client's first language is Garifuna, or Spanish or Kriol, or when ancestral terms need context. UNESCO notes the Garifuna language is still widely spoken but almost absent from schools. [source: https://ich.unesco.org/en/RL/language-dance-and-music-of-the-garifuna-00001]
Steps: (1) Ask which language the client wants for emotional topics. (2) Use a trained interpreter. Avoid using children, and use relatives only by the client's informed choice. (3) Brief the interpreter on confidentiality and on not softening spiritual content. (4) Where a cultural broker such as a Garifuna community health worker is available, define their role and consent separately. (5) Debrief after the session. [synthesis]
Example language (illustrative): "Which language feels easiest for talking about family and things that matter most?"
Watch for: an interpreter who knows the family in a small community; terms translated as "spirits" or "witchcraft" in ways that distort meaning. It is working when the client's meaning comes through and confidentiality holds.

4.12 Supporting the client around a family ceremony

Purpose: to support a client whose family is preparing for or taking part in a dügü. Sources call it the most elaborate and time-consuming ancestral obligation. It can mean travel, money, time off work and intense family contact. [source: https://www.belize-glessimaresearch.org/wp-content/uploads/bsk-pdf-manager/2020/01/Rutgers-University-Presentation-Myrtle-Palacio-1.pdf]
Steps: (1) Ask what the client's role is and what support they want. Do not ask what happens in the ceremony. (2) Problem-solve the practical load: leave, travel, childcare, cost, medicine supplies and appointments while away. (3) Prepare for emotional intensity and family dynamics. (4) Make a safety plan if the client has risk issues, including contacts while away. (5) Agree when to resume sessions. (6) If the client is undecided about taking part, explore their values. Do not advise for or against. [synthesis]
Example language (illustrative): "You don't need to tell me anything about the ceremony itself. What would help you most in the weeks around it?"
Watch for: debt or family conflict; diaspora clients feeling torn between employers and kin; missed medication while away. It is working when the client goes in prepared and comes back with steady functioning.

4.13 Integration afterwards

Purpose: to help the client make sense of the experience in their own terms and carry any changes into daily life. [synthesis]
Steps: (1) Invite whatever the client chooses to share. Do not probe for ritual details. (2) Explore meaning: relief, reconciliation, renewed obligations, grief. (3) Link the experience to the client's therapy goals. (4) Check for unsettled sleep, mood or dissociation, and for family conflict. (5) Support new roles or commitments. [synthesis]
Example language (illustrative): "Without going into anything private, what has changed for you since the family came together?"
Watch for: persisting distress after the ceremony, which needs fresh assessment (4.6); feeling that it "didn't work" and the shame that can come with that; the client being used as a family scapegoat. It is working when the client describes the experience in a coherent way and their functioning is stable or better.

4.14 Grief work that respects continuing ancestral bonds

Purpose: to support bereavement where, in the client's tradition, the dead remain present and in relationship with the living. [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/]
Steps: (1) Do not frame "letting go" as the goal. (2) Explore the client's ongoing relationship with the deceased, including dreams and duties of remembrance. (3) Separate grief that is moving forward from complicated grief, depression or trauma symptoms. (4) Support memorial practices the client chooses, such as Mass and family gatherings, as their own. [synthesis]
Example language (illustrative): "How does your relationship with your grandmother continue now? What does she still ask of you, and what do you give?"
Watch for: guilt about unmet memorial duties; grief combined with migration losses. It is working when the bond comforts the client more than it burdens them.

4.15 Medical coordination and medicine safety

Purpose: to make sure physical illness is assessed and that no ceremony or remedy delays urgent care. No practice is presented here as a treatment for physical disease. [synthesis]
Steps: (1) Ask about physical symptoms and current medical care. (2) Encourage medical review of new or serious symptoms, alongside whatever the family is doing. (3) Pass any questions about starting, stopping or changing medicines, or about herbal remedies, to the prescriber. Do not advise on them. (4) Plan for medicines to be available during travel or a ceremony. [synthesis]
Example language (illustrative): "Your family's way and your doctor's care can run side by side. Can we make sure the doctor also looks at this?"
Watch for: a seriously ill person kept from care, which is a safeguarding concern (4.19); medication stopped because of conflicting advice. It is working when medical and family care are both in place.

4.16 Addressing discrimination, historical suppression and diaspora identity

Purpose: to name the effects of exile from Saint Vincent, discrimination and linguistic domination recorded by UNESCO, colonial and missionary suppression noted in Belizean commentary, and the identity shifts of diaspora that Johnson describes. Use it when mistrust, shame or identity conflict shows up. [source: https://ich.unesco.org/en/RL/language-dance-and-music-of-the-garifuna-00001] [source: https://amandala.com.bz/news/?p=269055] [source: https://muse.jhu.edu/book/25566]
Steps: (1) Ask about experiences of racism, including in health services (CFI domain 4). (2) Validate them, and name any power imbalance in the therapy room. (3) Explore the client's pride and ambivalence about Garifuna identity, language and spirituality. (4) Connect the client with Garifuna cultural organisations if they wish. (5) Treat racial trauma symptoms with your usual evidence-based methods, adapted to the client. [synthesis]
Example language (illustrative): "Have you or your family been treated badly by services because of being Garifuna or Black? How might that affect how you feel coming here?"
Watch for: the client hiding spiritual life to look "modern"; second-generation clients in the diaspora caught between family and peer expectations. It is working when the client brings their whole identity into the room.

4.17 Holding boundaries on privacy and appropriation

Purpose: to protect the privacy of a family rite. Community members have objected publicly to the dügü being marketed to tourists. [source: https://amandala.com.bz/news/?p=269055]
Steps: (1) Do not ask to attend, observe, photograph or record. (2) Do not write ceremonial details into reports or case presentations beyond what care requires. (3) If the client invites you, thank them, explore the meaning of the invitation, and decline unless the family and buyei have independently requested your presence for a clear care purpose. Even then, consult. (4) Do not recommend the dügü, or any "ancestral healing" offered outside Garifuna family and community pathways, to non-Garifuna clients. [synthesis]
Example language (illustrative): "I'm honoured you'd think of inviting me. I think this belongs to your family and your buyei, and my place is here, supporting you."
Watch for: your own curiosity; workshops or retreats that market Garifuna ceremony to outsiders. It is working when the client feels respected rather than studied.

4.18 Family sessions

Purpose: to work with the extended family as the unit of obligation and support, including the central role of older women described by Kerns and Quevedo. [source: https://www.press.uillinois.edu/books/?id=p066658] [source: https://revistas.una.ac.cr/index.php/tdna/article/view/17430/25910]
Steps: (1) Hold family sessions only with the client's consent. (2) Invite the family members the client names, possibly including diaspora relatives by video. (3) Agree confidentiality. (4) Focus on shared goals: the client's well-being, sharing practical burdens, communication. (5) Do not take sides on spiritual interpretation. [synthesis]
Example language (illustrative): "Everyone here cares about her. What does each of you hope for her, and how can we share the load?"
Watch for: elders speaking for the client; the client losing their voice; coercion. It is working when decisions are shared and the client agrees with them.

4.19 Safeguarding

Purpose: to act when any practice, from any source, harms someone. Examples include restraint, beating, deprivation of food or care, sexual abuse, accusations against children, or delay of urgent medical care. Nothing in the Garifuna community sources consulted describes such harms as part of the dügü. This intervention is general [synthesis]. Evidence from other countries shows such practices can be reduced through collaboration (COSIMPO). [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]
Steps: (1) Assess the risk directly. (2) Follow local safeguarding and mandatory reporting law for children and vulnerable adults in Belize, Honduras, Guatemala, Nicaragua or the diaspora country. (3) Separate cultural meaning from harm: the practice's meaning does not excuse harm, and a tradition is not itself evidence of harm. (4) Involve the client's trusted community figures where safe and consented. (5) Document. For suicide or self-harm risk, use standard risk assessment and safety planning. [synthesis]
Example language (illustrative): "I respect your family's beliefs. I also have to make sure you're safe. Has anyone hurt you, or kept you from a doctor, during this time?"
Watch for: fear of betraying the family; outsiders mislabelling ordinary practice as abuse. It is working when the person is safe and their cultural ties are kept wherever possible.

5. Handling problems

None of the Garifuna sources consulted addresses psychotherapy problems. Everything in this section is [synthesis] unless a source is cited.

The client won't talk about ancestors or spirituality. This may reflect stigma or past ridicule. Respond by explaining why you ask, saying you won't judge, and coming back to it later. Never push. Gentle question to use: "Some families have important traditions they don't usually share with doctors. You're welcome to bring yours in whenever you choose."
The client asks whether their ancestors are "really" causing this. Do not adjudicate. Say: "That's a question for you, your family and your buyei. What I can help with is how you're coping and what you need."
The family believes a dügü is needed and the client disagrees, or the reverse. Explore values and practical constraints. Use family sessions (4.18). Do not take a spiritual position. The decision belongs to the client, family and buyei.
Cost or travel overwhelms the client. Do practical problem-solving (4.12). Validate the strain of obligation without undermining it.
Symptoms continue or get worse after a ceremony. Reassess fully (4.6), including medical causes. Frame further help as "as well as", not "instead of". Address any shame about the ceremony "not working".
Possible psychosis inside a spiritual frame. Prioritise safety. Get psychiatric and medical review. Seek informant and cultural-broker views (4.6). Explain the plan in terms the family can accept, without dismissing their beliefs.
Medication is stopped in favour of a remedy, or a remedy is added. Do not advise on the medicine or the remedy. Pass it to the prescriber promptly and support an informed discussion.
Rupture after an early clinical remark that sounded dismissive. Acknowledge it plainly and repair: "I think I spoke as if your family's way didn't count. I'm sorry. Can you tell me how it came across?" Then use the CFI patient–clinician relationship questions.
Non-attendance around ceremonies, feasts or travel. Plan ahead (4.12). Agree flexible scheduling and telehealth. Don't treat it as resistance.
Interpreter or community confidentiality worries in small settlements. Offer interpreters from outside the community, or remote interpreting. Agree with the client what will and won't be said.
Conflict between church and ancestral views within the client or family. Many Garinagu blend both. [source: https://www.belize-glessimaresearch.org/garifuna-spirituality-celebrating-our-ancestral-spirits/] Explore the client's own synthesis. Do not set the two against each other.
The therapist is invited to attend, or feels pulled to learn the ceremony. Decline and consult (4.17). Explore what the invitation means within the therapy.
A non-Garifuna client wants "a dügü" or a buyei after reading about it. Explore the need underneath, such as grief, ancestry or belonging. Do not refer them into Garifuna ceremony. Community voices have objected to the dügü being taken out of its family context for outsiders. [source: https://amandala.com.bz/news/?p=269055]
Safeguarding concern framed as tradition. Follow 4.19. Name the harm, not the culture.

Sources

Garifuna community and Garifuna-authored sources

Official listing

UNESCO Intangible Cultural Heritage: Language, dance and music of the Garifuna

Scholarship (outsider accounts, attributed context)

Cultural assessment and classification

Collaboration evidence (other countries)

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