Context and problem: In a mystico-religious environment, where traditional symbolism inherited from animist practices intermingles with so-called modern symbolism brought by Christianity, mental health sometimes appears more fantasized than real. In Cote d'Ivoire, the traditional practitioner and the religious guide enjoy a level of recognition that health professionals struggle to achieve. When a diagnosis is announced, the words “you say so, but God has not yet spoken His last word” set the tone for an atypical patient caregiver relationship. The defense mechanisms at work, from the announcement of the diagnosis through to acceptance of the therapeutic protocol, have already been studied in psychology. However, the context appears different when what is at stake is not the self as an individual but the child perceived as an extension of the self. The narcissistic wound and the feeling of helplessness break into the psyche and disorganize it. The mental health professional finds themselves at the heart of the ancient allegory of good and evil. This article attempts to analyze, among parents, the splitting of the representation of the health professional at the announcement of a diagnosis concerning their child, in Côte d'Ivoire.

Methods: This study uses an essentially qualitative method. Three clinical vignettes of parents of children with a neurodevelopmental disorder (ADHD, ASD, Rett syndrome) are briefly analyzed.

Results: Splitting, more than a defense mechanism becomes a regulator of emotions for coping with the stressful situation.

Discussion: Themes such as the controversy surrounding diagnosis, the right to know, and the difficulty of announcing a diagnosis are addressed here, in light of mental representations specific to the Ivorian context.

Conclusion: The analysis of defense mechanisms, particularly splitting, in a tradition modern context such as that of Côte d'Ivoire, highlights the cultural dimension and the importance of a specialized mental health care team in the announcement of a diagnosis and in family care.

In October 2024, together with a multidisciplinary team composed of a child psychiatrist, two special education teachers, and three assistants for students with disabilities, we undertook the care of neurodevelopmental disorders in children with learning difficulties. We were able to observe the defensive functioning of parents and its manifestations throughout the main stages of the therapeutic process, from the initial request, through assessments, the announcement of the diagnosis, and the implementation of the therapeutic protocol. However, the stage that most drew our attention was the announcement of the diagnosis. This is a particularly stressful situation for parents. They may undergo intense psychological work which, viewed from a defensive standpoint, allows them to withstand the overflow of affect and to cope with the trauma caused by the narcissistic wound. In the field of disability, much remains to be done to better understand the experience of mothers and fathers. In particular, the defense mechanisms that parent put in place once they learn that their child has a disability still “call out” to be studied. The singularity of the African context, its traditions, myths, and legends, gives an atypical orientation to the study of defense mechanisms. Indeed, Côte d'Ivoire is a country located in West Africa. Local religious traditions and those imported through colonization, along with rites, beliefs, and legends, nourish fantasy life. One legend, for example, tells of a queen named Abla Pokou. The Akan people, fleeing tribal wars, found themselves facing a river in flood. Confronted with this natural obstacle, the diviners were categorical: “the spirits are angry, a sacrifice is required.” The queen (then a princess) was the only one willing to sacrifice her only son to appease the river spirits. The sacrifice was accepted, the waters calmed, and the people henceforth named “Baoulé,” meaning “the child is dead” were able to cross. According to the legend, Abla Pokou was thereafter granted the status of queen, even of protective goddess, a symbol of strength and self-sacrifice for her people. Later, her brother incited a rebellion, arguing that “if she was able to sacrifice her only son, what will become of us if we cross her?” Fear then took hold of part of the people. The all-powerful mother figure became an object of terror, a symbol of malevolent power, leading to the division of the kingdom and even to the rejection of a matriarchal tradition. This is how, to this day, some Akan attribute to women the role of a power that is both protective and malevolent [1].

Beyond the myth (and the evident attempt by a threatened patriarchy to regain control), this symbolism of the maternal image as both benevolent and malevolent recalls the psychoanalytic object relation, and in particular the “good breast/bad breast” splitting [2]. The good and the bad are part of the same image. A parallel can quickly be drawn with the biblical allegory of a forbidden fruit, containing both good and evil, offered to Adam by Eve. Splitting of the object is described as a primitive defense mechanism against anxiety, within the interplay of introjection and projection. Faced with external reality, two attitudes coexist within the Ego: one that takes reality into account, and another that denies it. In the Ivorian context, cultural and religious beliefs play an important role in the general psychological functioning of individuals and ethnic groups. The psychologist (and health professionals more broadly) sometimes finds themselves projected into this metaphorical universe where mythology and the fantasies generated by animist and Judeo-Christian beliefs place us, at times, in the position of god, and at other times, of devil or spirit. The perception of the psychologist is itself sometimes fantasized, as one patient put it: “you psychologists play with people's minds.” The problem that arises, then, is to understand how splitting affects the relationship between parents and the psychologist in this mystico-religious environment. This issue has already been addressed in the scientific literature from several angles, notably within care teams: “the good/the bad nurse,” “the good/the bad doctor” (Malinowski, 2016), in relation to the patient's psychopathology [3]. Here, however, we aim to highlight, through a description of splitting linked to the Ivorian cultural context, what need splitting responds to at the moment a diagnosis is announced. It is therefore necessary to examine the atypical mechanisms that help us understand its existence and, moreover, to propose solutions for families and health professionals.

The search for causality first leads parents toward religious guides and traditional medicine. Mental health professionals are sometimes the last resort. We present three clinical vignettes, three families whose children present neurodevelopmental disorders, namely attention deficit hyperactivity disorder (ADHD), severe autism spectrum disorder (ASD), and Rett syndrome. We describe the journeys of these families and their religious beliefs and practices. The NVivo content-analysis software, together with clinical analysis of splitting, reveals patterns that shed light on the participants' inner functioning.

The B. family

The B. family consists of the father, the mother, and 4 children, including C.B., the youngest, aged 9 at the time of the first consultation. The family had been on a “medical” odyssey for 6 years. The first warning signs of a disorder in the child were raised by teachers from the first year of preschool onward. However, the mother “admits” having noticed unusual agitation in the child from the age of 18 months: “I told myself it would pass, not all children are calm,” she adds. Nevertheless, since starting school, behavioral, mood, and learning difficulties led the parents to seek consultation. The first consultations were carried out by the community pastor. “We are a Christian family, and we believe that nothing happens to us without our God being informed of it, so it is to Him that we turn.” Several prayer sessions and exorcism rites were thus performed. “The child was getting better, but this year, at school, things are not going well at all; he fights, gets angry, moves too much, and refuses to concentrate on studying, even at home,” says the father. It was therefore on the advice of the school principal that the parents sought our help. “You are our only hope of understanding what is really going on; it is God who has sent you across our path, doctor.” In the Ivorian context, it is common, after several years of wandering from one caregiver to another, for patients to address caregivers in such terms. But once the diagnosis was announced, following a series of assessments, the discourse of the B. family changed. “There's nothing wrong with my son, he's just boisterous; with prayer he will calm down. Doctor, are you a believer? I'm sure she isn't,” says the father, turning to his wife, “these people only believe in their science and give children strange illnesses.” The mother, for her part, asks, “Is it our fault that he is like this?” We let the parents express themselves, speak about their feelings, and ask questions. From that point on, the interactions become imbued with transference and countertransference, defense mechanisms, archaic beliefs, and mystical fantasies that must be understood and analyzed. Our words take on a symbolic connotation for the parents, tipping the balance now toward the forces of good, now toward those of evil, as though we were being put to the test.

The K. family

A.D., 8 years old, comes accompanied by his mother and stepfather. The parents state that they consulted 6 spiritual guides, the last of whom advised them to see a mental health specialist, so they made an appointment. The mother explains: “He's my son, not my husband's. His father abandoned me. Several marabouts told me that it was his biological father who cast a curse on us. We performed several rituals, but nothing changed. The child bites himself, hurts himself, is not autonomous and does not say a word; he screams and hurts himself all the time. The man who told us about you and your work is a good person; we believe you too are a good person you're a woman, do you have children?” During consultations, motherhood is often brought up, as though it grants us a particular status. Like the B. family, the K. family had been on a long, wandering search for answers. Here too, our meeting is initially perceived positively, before the diagnosis is announced. After the announcement, the mother breaks down; the diagnosis of severe ASD breaks into a psyche already fragile from a difficult life path. Her partner reassures her with these words: “the doctor has spoken, but God has not yet spoken His last word; I told you that at the hospital they never bring good news the doctors gave up on my brother, but he is still alive among us.” The partner then recounts the story of his brother, who defied medical prognoses, and confides that he does not believe the words of specialists, who only say “bad things.” Here again, we find ourselves in the camp of good before the diagnosis is announced, then in the camp of evil afterward.

The O. family

The patient S.O.,7 years old, is the eldest of 3 siblings and has Rett syndrome. At consultations, he is accompanied by both parents. The parents first consulted several traditional healers, then a general practitioner, who referred them to us. This family's case is particular in that, during the consultation, the father states that he does not believe in modern medicine, nor in psychology, nor in any other practice imported by the colonizer. It was, however, at his wife's insistence that they decided to begin the medical process. He also says that the fact that I am a woman reassures him, because “women hold the power of life.” When the diagnosis was announced, the parents asked many questions about the causes and the therapeutic protocol. They expressed themselves and listened to me attentively. At the end of the session, the father said he felt confident about what lies ahead: “I am very attached to tradition, and I remain convinced that a dark hand is behind all this, but I am also convinced that you will help us you are a good woman, the ancestors have sent you, thank you.” This time, the pattern is reversed: the psychologist moves from evil toward good.

Splitting as a regulator of affect

Analysis of the interview content reveals several patterns. The splitting of the object from good to bad, or in the reverse direction as in the case of the O. family, above all highlights the affect-regulating role of this defense mechanism. The announcement of the diagnosis produces a sudden disappointment that triggers an abrupt psychic collapse (Ciccone, 2013). This situation requires a cognitive, emotional, and relational reorganization. It is the mourning of the idealized child. There may be a disorganizing effect on the psyche that influences cognitive functioning. Splitting thus becomes a defense mechanism against anxiety linked to psychic ambivalence. Thought processes appear split in two: on one side, thought struggles against trauma; on the other, a struggle unfolds against anxieties (of death, of abandonment). Another effect of the encounter with disability is guilt.

Splitting as a defense mechanism against guilt

A feeling of guilt is sometimes observed the sense of having caused this situation, of having brought a different child into the world. Through projection, this guilt becomes the guilt of the health professional who “officially” announces the diagnosis. Paradoxically, “medical” attempts at reassurance such as “it's not your fault” can heighten the traumatic effect, because the parent is intent on finding someone to blame. This obviously does not mean that one should tell the patient that they are guilty. Rather, one must hear their guilt (here, our own, as it were), accompany it, and allow access to relief from guilt not through defensive denial of responsibility, but through acceptance of the disability situation. Living through one's guilt requires certain conditions, in particular the presence of another person capable of hearing, receiving, and accompanying this experience.

The idealized/demonized parent–psychologist relationship

Parents' state of mind oscillates between movements of life and survival, struggle, hope, and despair. Before the diagnosis is announced, the patient–psychologist relationship is often idealized through the illusion of a possible magical repair; once the diagnosis is announced, this relationship becomes disinvested, and disillusionment is abrupt. Conversely, among parents who do not trust the medical system, the announcement of the diagnosis sometimes initiates a process of idealization of the relationship. In the first case, for example, the mental health professional is invested with hope, and parents multiply appointments before the announcement; afterward, they withdraw this investment, experiencing the professional as hostile or incompetent. The professional becomes an object of anger. In the second case, the reverse occurs. In a cultural context steeped in myth, such as that of Côte d'Ivoire, the relationship is first demonized, then idealized, even deified.

Making sense of the experience

Splitting remains a way of giving meaning to the traumatic experience. Mythological perceptions of good versus evil have permeated Ivorian culture. This system of thought divides the psychologist and the parents into two opposing camps. This prevents the emergence of any internal psychic conflict and protects the individual from anxiety. The label of “good” or “bad” is attributed to the psychologist depending on whether their intervention is experienced as gratifying or frustrating. This makes it possible to give meaning to the unthinkable, to put words to the unspeakable during the announcement of the diagnosis.

Parenthood called into question

The image of the “damaged” child raises questions related to parenthood. Every child arouses ambivalent feelings in their parents (loved and hated), which take on an entirely different dimension in the context of disability. The child's disability intensifies threatening, potentially infanticidal parental imagos, as well as fantasies of repairing one's own childhood experience. The question “am I a good parent?” becomes, through projection, “is she a good doctor?” The psychologist not only “receives” the fantasy of punished guilt (as repeatedly appears in mythology) but also images of an incapacity to be a parent, which must be listened to.

Health professionals in Côte d'Ivoire are confronted with the fear of announcing a diagnosis, as attested by numerous news reports of physical and verbal assaults against caregivers. In mental health, the negative experiences of psychologists often reflect an internal struggle between reality and fantasy, between science and belief. Traditional and Judeo-Christian myths often seem unavoidable. Mourning the dreamed-of child requires difficult psychic work; the traumatic event is sometimes perceived as persecutory, with the psychologist as its instrument. How should one position oneself in the face of a parent's anxiety, when the response draws one into the mythical war between good and evil? Edelweiss (1958, p. 78) states that one of the greatest temptations facing the analyst is to disguise themselves as a kind of spiritual guide. This idea applies remarkably well to the context of the psychologist in Côte d'Ivoire, where one is tempted to be cast as an “envoy of the gods” before a parent unconvinced by scientific arguments. Beliefs are symbolically perceived as a wall against which scientific studies collide therapeutic plans meant to help the child adapt to the surrounding world, to help parents understand the difference, and to arrange a special school schedule for these children with specific needs. Yet the psychologist must maintain neutrality regardless of the context or the parent, and make their own way toward accepting their child's difference. The right to know frequently clashes with the difficulty of announcing a diagnosis. It is essential to establish teams trained in delivering diagnoses and in understanding defense mechanisms within the Ivorian context, in order to help families. A defense mechanism splitting, in this case can be understood and welcomed. Splitting of the object, as addressed in the literature in terms of good caregiver/bad caregiver, is described differently depending on the context, as illustrated by the parents' statements quoted above. The interplay of transference and countertransference takes an atypical direction when contact with reality is itself just as symbolic.

Being the parent of a different child constitutes an ordeal that disorganizes the usual points of reference one relies on. The announcement of the diagnosis causes a traumatic shock whose primitive response is splitting. The singularity of the Ivorian context, steeped in myths and legends, gives free rein to the fantasized imagination of a battle between god and the devil, in which the psychologist oscillates now to one side, now to the other. Welcoming and accompanying this experience underscores the importance of a care team adapted to the context of announcing a diagnosis in Côte d'Ivoire.

1. Mel MR. Anthropology of the dynamics of violence among the lagoon peoples of Côte d'Ivoire. African Sociological Review. 2009; 78-103.
2. Bouvet M. La relation d'objet. Paris: PUF. 1999.
3. Delion P. Splitting, psychopathology, and institutions. Le Carnet Psy. 2015; 190: 49-51.
4. Ciccone A. Encountering disability, a trauma? Enfance. 2013; 6: 91-96.
5. Edelweiss ML. Psychoanalytic neutrality. Bulletin de psychologie. 1958; 154: 78-81.
6. Korff-Sausse S. The impact of disability on parenting processes. Reliance. 2007; 4: 22-29.
7. Malinowski C. Etre soignant en psychiatrie. Chronique sociale. 2016.