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Somali Refugee Mental Health Cultural Profile

Author(s): Jacob A. Bentley; Christine Wilson Owens
Reviewer(s): Mohamed Ali Roble; Bria Chakofsky-Lewy; Lorin Boynton; Anab Abdullahi; Salma Musa
Contributor(s): Zeba Ahmad; Somali Community Services of Seattle
Date Authored: November 01, 2008

Methods

Medical interpreters, healthcare providers, and community respondents were recruited to offer information about depression, anxiety, and posttraumatic stress disorder (PTSD) within the Somali refugee community; and to share knowledge of common Somali beliefs about mental illness, traditional treatment approaches, and advice for healthcare providers working with this population.  Six interpreters and seven providers (including psychiatrists, counselor and primary care physicians) were interviewed individually, and two group discussions were held with elders from the Somali community in Seattle.  A review of the existing literature, and web search, were conducted.  In November 2008 a small group of Somali caseworkers, interpreters, health and mental health care providers gathered to discuss mental health care issues of concern for Somalis, including Somali youth.  Notes from that meeting are incorporated here as well.

Introduction

According to the United Nations Refugee Agency, Somali refugees and asylum seekers comprise one of the fastest growing populations seeking international amnesty. As of the end of 2006, approximately 460,000 Somali individuals were displaced into the international community, representing an 18% increase in prevalence from one year prior (UNHCR, 2007). Somali refugees represented the highest number of initial claims for asylum (about 45,600) with Yemen and Kenya among the foremost destinations for Somalis seeking refuge in 2006. Over the past decade and a half, about 2 million Somali refugees have fled the country to seek asylum elsewhere (Bhui et al., 2006). Given the rising prevalence of Somalis within the overall refugee population, health care providers need to become familiar with Somali perceptions and cultural understandings of both physical and mental health conditions.  Somalis need to understand the new system of health care and what services are provided in the United States. 

Brief Cultural Profile

For more information see Somali Cultural Profile.

Somali culture is comprised of a clan-based social system that places emphasis on family and communal bonds. Somali society is comprised of several major clans and multiple sub clans. Most Somali refugees living in the United States are documented as coming from either the Benadir or Barawan clans, minority clans in Somalia, with some individuals from others clans such as Hawiyo, Darood, Dir, Digil and Mirif.  The Benadir clan is primarily made up of merchants and artisans residing in southeast coastal regions of the country. The Barawan clan is mostly a fishing community living around Kismayu which practices small-scale artisanship in addition to prominent fish-trade. A lack of centralized government since 1991 has contributed to the proliferation of inter-clan conflict and ultimately the emergence of civil war. As a result, native Somalis may identify more with a particular clan or sub clan than with the broader Somali society.

Family structure in Somalia is organized within a patriarchal framework. The father is the head of the Somali household and is responsible for providing the family with steady and reliable income. Household responsibilities are maintained by women in the family. Women are also primarily in charge of taking care of the children, although this responsibility also rests with members of the extended family and close family friends. The female fertility rate, as of 2005, was listed at 6.2 by the United Nations Children Fund (UNICEF, 2007). Having several children per couple is highly valued in the community, thus large families are desirable. Extended family members are highly regarded and are kept in close contact with the core family unit. There is a strong, reciprocal relationship between the family unit and extended relatives wherein support is given from each to the other. Further, elders in the Somali community are held in high esteem and children typically assist their parents with any needs that emerge as they age.  The younger generation of Somalis who are growing up in the United States may express culture differently than previous generations.  They may be skeptical of traditional explanations of mental illness to which older generations subscribe.

Language in Somalia is characterized by the presence of several dialects.  Vocabularies may vary by geography.  However ‘Common Somali’ is the most widely spoken native language (Bhui et al., 2006). The second most common language is Arabic, due in part to the religious influence of Islam.

Almost all Somalis are Sunni Muslims.  For those who practice Islam, religion has a much more comprehensive role in life than is typical in the Americas or Western Europe.  It is a belief system, a culture, and a way of life. In Somalia, attitudes, social customs, and gender roles are primarily based on Islamic tradition and male-dominant society.   

Epidemiology and Research Literature Summary

In 2016, Lila Rice updated this section with new information added based on a review of research articles published 2004-2015. The updated section is presented separately as Somali Refugee Mental Health Cultural Profile - Literature Update - in order to maintain the structure and length of this original article. 

Limited research has been conducted examining the prevalence of mental illness among Somali refugees. Available research has suggested that refugees are at risk for the development of a variety of psychological disturbances including depression, anxiety and posttraumatic stress disorder (PTSD). However, inconsistent results have been reported regarding the prevalence and severity of psychopathology among Somali refugees. The discordant results within the literature may highlight the complexity of cross-cultural inquiry, interpersonal variability in psychological resiliency and the development of psychopathology, or result from methodological inconsistencies (Bhui et al, 2003)

Migration, Resettlement & Readjustment

Refugee migration, resettlement, and readjustment into a host country place refugees at risk for a number of physical health concerns and psychological difficulties (Palinkas et al., 2003). The act of migration poses psychosocial stressors by fragmenting social, vocational, and economic resources for refugees as they encounter this transitional period of their lives. The process of relocation may put refugees at risk for mental illness in relation to such mediating variables as level of stress, acculturation, employment status, individual personality characteristics, and experiences during the various stages of migration (Bhugra, 2004).  

Coming from a collectivistic society, Somali refugees may experience trouble adjusting within Western, traditionally individualistic societies. Perception of their native land and misconceptions of the prospective host country have been suggested to predict level of readjustment, particularly for young Somali refugees (Rousseau, Said, Gagne, & Bibeau, 1998). Upon entering a host country refugees may be subject to racism or discrimination (experiences likely at conflict with expectations of life in the host country) and may not have access to resources needed to construct a new life.

Level of adaptation is a key factor in the wellbeing of refugee patients. Political, social, physical, and psychological factors prevent many refugees from adequately adapting to life in their host country. Specifically, residential mobility in the host country has been highlighted as a significant mental health risk in the current literature on Somali refugees (Mohamud et al, 2004; Palmer, 2006; Warfa et al, 2006).  

Residential status in the host country is often in flux due to socioeconomic factors. Difficulty finding employment, for example, often leads to additional residential moves following expatriation. Recent research within samples of Somali refugees has provided preliminary evidence to suggest that frequency of change in residential status within the first five years in the host country is strongly related to depression even after controlling for age, gender, and area of residence (Mohamud et al., 2004).  Research examining mediating factors in the development of psychopathology within a sample of Somali expatriates found overall educational history and employment status in the host country to be related to lower risk for anxiety, depression, and PTSD (Bhui et al., 2006). Previous research has indicated that loss of social status, such as vocational status, may be linked to increased levels of depression in older Somali male refugees (Silveira & Allebeck, 2001).     

Depression and Anxiety

Due to their high prevalence and comorbidity, depression and anxiety have been studied in conjunction in the existing literature looking at Somali mental health. One study examining the prevalence of depression, anxiety and PTSD in 143 Somali refugees residing in the United Kingdom found depression and anxiety to be present in 33.8% of the sample (Bhui, 2006). Individuals at particular risk for psychological disorder included respondents recruited from primary care settings and users of a stimulant known as khat. Suicidality was reported in 9.1% of the sample. Further, risk of suicide was correlated with major depression and generalized anxiety within this sample. Consistent with these authors’ hypotheses, results indicated a high level of psychiatric comorbidity in that 80% of participants meeting diagnostic criteria for PTSD also met criteria for anxiety or depression.

A similar study of 180 Somali refugees found depression and anxiety to not be positively correlated with suicidal ideation (Bhui et al, 2003). Contrary to findings from previous research, this study found torture to have a non-significant relationship to psychological disorder. Further, individuals exposed to combat or imprisonment exhibited a lower risk for depression, anxiety and suicidal ideation. Suicidal ideas were most common in those with 7 or more years of expatriate residential status whereas depression and anxiety were more predominant among individuals with recent arrival status, potentially indicating the prevalence of a psychosocial adjustment component in those experiencing affective difficulties.

Stutters and Ligon (2001) found anxiety to be highest among 20 Somali refugees when compared to refugees from either the former Yugoslavia or Vietnam. Elevated anxiety was found to be particularly present in Somali males.  However, these differences failed to reach statistical significance in this small sample.

PTSD

Previous research has found intensity of experience and duration of trauma exposure to be related to increased levels of posttraumatic stress symptomatology (Buydens-Branchey, Noumiar, & Branchey, 1990). Gerritsen et al (2006) found Somali refugees to have experienced exposure to the highest number of traumatic events (M = 7.6 out of a possible 17; SD= 3.9) but among the lowest levels of depression, anxiety (16.7%) and PTSD (4%) when compared to refugees of other nationalities. Of the most endorsed traumatic events reported ‘forced separation from family members’ and ‘unnatural death of family or friend’ occurred with the greatest frequency. Recently, PTSD has been shown to correlate with current major depressive disorder and agoraphobia (Bhui et al, 2006). Somali refugees have also exhibited higher rates of PTSD-related psychoticism than other refugee groups; however no causal hypotheses have been offered in the existing literature for this finding (Bhui et al, 2003). 

The low association between combat experience and mental illness noted above is at odds with previous research conducted with East African community samples (Jaranson et al, 2004) as well as recent research conducted with Somali ex-combatants (Odenwald et al, 2007).  For example, Jaranson and colleagues (2004) found torture to be a significant risk factor for a variety of physical and mental health difficulties including PTSD in a sample of 1134 East African refugees (Somali N = 622). It is important to note the variability among refugees in the degree of traumatic exposure and posttraumatic stress in order to avoid culture-based overgeneralizations and type I error (false positive) as clinicians (Halcon et al, 2004). 

Comorbidity of depression and PTSD is common among Somali refugees thus suggesting the need for clinicians to assess for psychological loss at a number of different levels (e.g. interpersonal, social, economic) when working with members of this group. Unlike symptoms of depression which tend to fluctuate in response to recent stressors, PTSD symptomatology and diagnoses may be more persistent over time (Sack et al, 1993).

It is important for clinicians to develop long-term treatment strategies for posttraumatic stress symptoms while also assessing and reassessing for longitudinal changes in depression (related to concurrent readjustment issues). However, the use of exposure-based psychotherapies, a common evidence-based treatment approach for PTSD, may be an incomplete psychological treatment approach or even contra-indicated when working with refugee groups due to the multiple layers of trauma experienced in these populations (Guerin, Guerin, Diiriye, & Yates 2004).

Hypertension and Diabetes

Medical disorders potentially related to chronic stress or pervasive changes in diet and lifestyle have been observed in Somali refugees as evidenced by a high prevalence of hypertension and diabetes in this group (Kinzie, 2007). In one study preliminary results indicated that hypertension affects approximately 43% in a sample of refugees whereas diabetes can be seen in 12-18%. Similar rates of hypertension were observed across groups; however the highest rates of diabetes were seen in the Somali group with 48% of diabetic Somalis also presenting with hypertension. Studies examining health risks among American veterans has shown a relationship between chronic PTSD and hypertension/ diabetes, offering a potential explanation for similar results observed in Somali refugees (David, Woodward, Esquenazi, & Mellman, 2004; Kinzie, 2007).

The hypertension medicine prazosin (which affects the alpha 1 norepinephrine receptor) has been found to be effective in reducing PTSD re-experiencing symptoms, such as trauma-related nightmares (Bennett, Zatzick, & Roy-Byrne, 2007). Research is currently being conducted to evaluate its effectiveness in minimizing intrusive flashbacks during awake states.

Clinical Features

Nin madaxa laga haayo, meeli uma fiyooba”:  Somali idiom translated “If a person has a sickness or pain in their head, no other parts will work” (Palinkas et al., 2003)

Disease Recognition

Consistent with overall Somali perceptions of health and illness, psychological well-being is dichotomized into categories of mentally well and mentally ill (or “sane” and “insane”).  Mild forms of affective disorders are not readily recognized as being a problem requiring professional assistance.  Generalized worry and other types of anxiety such as paranoia or obsession/compulsion are not known as mental problems, but are considered personality characteristics.  Depression or anxiety at the level of disorder were not considered prominent in Somali culture prior to the emergence of civil war in the early 1990s and may not be recognized as a problem until seen as impeding with one’s daily functioning.  For a period of time before seeking treatment, Somalis may experience many of the symptoms associated with clinical depression such as emotional dyscontrol, problems with sleeping, concentration, attention, or difficulty initiating behavior. From the patient’s perspective, symptoms reflect daily stresses and difficulties of refugee resettlement.  Patients often seek treatment to help with sleep or appetite and consider these main symptoms from which other problems stem.  A patient may reject a diagnosis of depression, honestly believing that is not their problem, especially when other life stresses remain constant.

Stigma

Mental disorder carries stigma and for many people is associated with weak-mindedness, fear and hopelessness.  Words like “mental” and “depression” may shut communication down and bring to mind Somali institutions where mentally ill (“crazy”) patients are kept locked or chained up, often in unsanitary or unsafe conditions, without hope of treatment or recovery, and with few resources to care for basic survival. De-stigmatizing mental illness is a central clinical consideration when working with Somali refugees. Efforts to de-stigmatize mental illness might include explaining the prevalence of disorders in the larger population and framing psychiatric illness in general and PTSD or mood disorders in particular as a normal response to atypical biological, psychological and social stressors.  Patients may prefer to visit their primary care clinic for mental health care, in order to avoid the stigma of being seen entering a mental health clinic or building specifically designated for mental health care.

Trauma Experience

PTSD is common due to experiences of war and personal trauma.  With education and time, patients may learn symptoms of nightmares and flashbacks as ‘PTSD’ and know they can come to a doctor for help.  In general, there is recognition that previous experiences can affect current functioning but people do not know there is professional health care available to address this.   When asked, patients may or may not tell their providers that they are hearing voices or having nightmares.  Typically, patients are frightened and do not attribute the nightmares or hyper-vigilance to psychological factors, but more often to spiritual factors.  When awakened by nightmares, they read the Quran and may ask Allah for protection from an oppressive ‘jinn’ or evil spirit. They pray that they can sleep better.

Symptom Clusters and Psychosis

Somalis may exhibit higher rates of PTSD-related psychoticism than other refugee groups (Bhui et al, 2003) and may present with unusual symptom clusters not clearly fitting into DSM-IV diagnoses.  Questions can arise about how to classify and treat psychotic or outlier symptoms and patients may end up on an array of medications. Patients with unusual clusters of symptoms should be referred to a psychiatrist.  It is helpful if a family member or cultural mediator (if available) attends an appointment to give an indication to the provider whether something unfamiliar or seemingly unusual is within a cultural norm versus bordering on psychotic presentation.

Interpreters suggest providers and staff need more awareness to identify patients who are at risk of becoming “lost in the system” because they appear to function normally but may be expressing subtle signs of memory loss, confusion or bizarre behavior. Examples given are a patient who demonstrates a lack of engagement or mute acceptance of whatever he/she is told; a patient who normally dresses conservatively and neatly who arrives in clinic one day wearing excessive nail polish, bright colors, or tight clothes; a patient who consistently has missed appointments (even after being rescheduled), arrives days late, waits for hours in the waiting room without appointment, or is angry when he/she can’t be seen. In this last example, staff might conclude the patient is simply disorganized and acting that way on purpose and therefore could refuse to schedule more appointments, when the patient actually may be experiencing confusion.  Interpreters may be helpful in identifying marked patterns or changes in a patient’s appearance or behavior.  Providers and staff might look for patterns in how a patient accesses services, like trouble keeping appointments in clinic, and frequent visits to the ER.  Interpreters recommend calling social work for help assessing potential concerns, and that flexible appointment times be considered for patients who are unable to meet strict appointment schedules.

Medical interpreters emphasized that, in some cases, feelings of deep frustration and/or desperation with life circumstances or pain may be the factors underlying someone’s behavior.  (They described a person who was restrained and admitted to the psychiatric unit following an incident in which his speech became pressured and angry, his voice rose higher and he banged his head against a wall. This occurred after he had come repeatedly to the hospital to ask for help finding food and shelter, been hampered by limited communication skills and a language barrier, and was unable to obtain assistance.)  Interpreters recommend listening to the individual about their frustrations, to consider if social work or pain management is what’s needed.

Somatic complaints

Somalis are likely to report somatic symptoms or prominent complaints related to disrupted sleep, lack of energy, headaches, abdominal pain, gastrointestinal problems, gross body aches, arthritis and back pain. Patients may request imaging or other techniques that seem tangible or verifiable in assessing their problem.  Descriptions of pain may sound harsh, generalized or pervasive. Somali patients may use pressured speech and make physical gestures to communicate a sense of urgency and frustration, e.g. making cutting-like motions toward their arms as a means of communicating their experience of pain. A patient may use descriptive speech, e.g. "I can’t even touch my head" when referring to the experience of headaches.  Many Americans may have heard the expression “I feel like I’ve been run over by a train”.  Similarly, a Somali patient might state, "I’m hurting head to toe, in each and every vein and hair”; “A very hot wind is blowing through every nerve”; or, “A very cold wind is blowing through every nerve”.  If relying only on the modality of direct interpretation, a provider might misunderstand the patient's meaning.

Social Isolation

Social isolation is a major risk factor for Somalis.  Communities and services may be spread out geographically with transportation barriers.  Housing and financial assistance programs may have resources and rules limiting the number and relation of people in the family household and some people end up homeless, in shelters, and seeking other temporary housing solutions.   In the U.S., newcomers find less government support and time provided for settlement than was made available to refugees in the past. Many people are separated from family and are homesick.  Some desire to return to Somalia but cannot do so because it is unsafe for themselves or their family.  Many Somalis are worried about their families who are left behind in Somalia.  The continuation of the civil war there increases the mental health stresses experienced by Somalis living in the U.S.   People listen to the BBC and trauma is relived as long as the war continues.  Somali refugees who lived as nomads in Somalia may feel particularly isolated in Western culture.  The nomadic way of life was naturally communal, allowing time for people to be social and to be storytellers in between the work of raising animals and migrating.

Gender

Both men and women may resist discussing traumatic history, expressing a belief that “The past is in God’s hands.  Who am I to question?” Somali men may talk with providers about loss related to previous occupational status as compared to current status which is often lower; frustration with being ‘taken care of’ and the adjustment issues that go along with that; and in the older males, a sense of loss associated with farmlands, nomadic lifestyle, or connection with their sons.  Some male patients mention experiences of being beaten by soldiers.  Somali women refugees are often under chronic stress resulting from acculturation challenges, responsibilities as main caregiver to the family and household and being a primary income earner who may go to work outside the home.  In Seattle, Somali women are more socially isolated when compared to Somali men.  There are few community gathering places where Somali women are able to visit with each other, be active together and have access to childcare.  Somali men in the area have more opportunities to gather socially with their peers.  The men may go for coffee together after work, play cards or dominoes, and watch or play soccer with each other on the weekends.

Cultural norms centered on gender specificity or respect for elders may present obstacles in providing mental health services, and may be important to consider in some cases, e.g. when physical contact is involved, or a younger psychiatrist is treating an older patient.

Suicide Risk

Somalis may possibly be a low risk group for suicidality as a result of devout religious beliefs. Religion as a protective factor is worth considering when assessing for suicide risk in major depressive episodes. The Quran contains statements speaking against the taking of one’s own life prompting followers to avoid suicide and to search for alternate solutions to their distress. In general, Somalis have strong faith in Allah’s will. “He who brought it is He who relieves it, takes it from you.” There is belief in a judgment day and that anyone who commits suicide will enter hell in the next life. Being asked directly whether they have had thoughts of suicide is considered by many patients to be “the worst question”.  The trust between a provider and patient can weaken based on this question.  The patient may think the doctor doesn’t understand their perspective.  Patients may wonder whether their own faith is stronger than their doctor’s or whether their doctor believes in God at all.  Before asking Somali patients (especially elders) about suicide, health care providers need to first alert them to the question by saying something like, “As a professional I need to ask you what I know is a sensitive question.   I am not meaning to show disrespect.”

Treatment

Qalbiga caafimad qaba, cagli caafimad qaba ayuu leyahay”: Somali idiom translated “If your soul is healthy, your mind is healthy”

Treatment for mental disorders such as depression, anxiety, or PTSD in the general “sane” population is an unfamiliar concept for many Somalis, not something they have seen back home.  Patients and their families need education about the American healthcare system and roles of different providers.  For instance, explanation should be provided about different purposes of a crisis center versus a mental health center, or counselor vs. social worker.  Interpreters suggest that primary doctors clarify for patients the roles of the other professionals to whom they refer, and understand that some patients will not want to see a mental health specialist preferring their doctor consult with a psychiatrist and then administer a recommended treatment. Doctors are usually held in high esteem by Somalis and the primary care doctor would be considered the point person for health care, including mental health care.

Religion

Quran and Beads Image
Photo by: Ranoush. Licensed under Creative Commons Attribution-Share Alike 2.0 Generic license (http://creativecommons.org/licenses/by-sa/2.0/deed.en)

For many Somalis, the first line of healthcare treatment is reading the Quran (particularly for individuals raised in rural Somalia). Many Somali patients believe in beginning treatment this way.  Trust can be built around exploring traditional conceptions of illness and treatment.  Incorporating readings from the Quran into treatment planning/ case management may be helpful in eliciting the patient’s trust in the healthcare process. There are a number of commonalities present amongst the prominent world religions, for instance, the notions of forgiveness and mercy. Focusing on similarities when thinking of patient perspectives can promote dialogue and provide a fundamental place from which the patient-doctor relationship can proceed. Providing care that is consistent with how patients understand the world from a cultural standpoint can minimize psychological tension.  Many Somalis believe in religion as their medicine, more than interventions by a doctor or multidisciplinary team.  The Quran is believed to be a cure.  To assume or imply that the Quran is ineffective is insulting.

See also: A Tailored Approach to Trauma Intervention - Information about a Seattle-area pilot project "Islahul Qulub: Islamic Trauma Healing" that combines prayer, prophet narratives, and guided discussion in a six-week PTSD intervention program tailored for Somalis suffering in the aftermath of war-torn conflict.

Medication

Many Somalis are wary of pharmacologic treatments for fear of developing dependence on their prescription medications.  There is belief that psychiatric medication is very addictive and there is fear that a person will become hooked and need to take medication for the rest of their life. Some people, especially some women, are wary of the side effect of weight gain. There is a lack of understanding about how medicines work, especially medication that is not for acute symptoms or that takes time to begin working.  The perception is that medication should begin to work right away. Patients typically appreciate medications that help them sleep and take away nightmares, and may be receptive to medications described as “helping moods to get better”.  Unless explicitly told otherwise, patients may expect a cure for symptoms being treated, not realizing for instance that depression might fluctuate over time and trauma-related symptoms including altered sleep pattern may improve but never completely dissipate. Patients may struggle to understand why prescribed medication is unable to provide a full cure.  Somali culture places value on expressiveness so that reportedly even a violent or an explosive expression is preferable to a subdued affect.  Reflecting that notion, there is fear of getting “worse” with the use of anti-depressants.  There is a phrase used in the community to describe the “dulling” effect of psychiatric medication on a person’s expression.  It is said that that person “got injected”.

Initial Focus on Resettlement Stressors and Somatic Complaints

Health care providers’ initial focus on current resettlement stressors and somatic complaints rather than previous trauma exposure may help alleviate patient concerns about their healthcare and their worry about situational conditions.

Guerin and colleagues (2004) suggest spending time with Somali patients in discussion about their families, community bonds, living conditions, and economic situations. Referrals to social workers and other community counselors are helpful in situations where social and contextual aspects of the patients’ lives are out of balance. From the perspective of many Somali refugee patients, the focus is on current circumstances. Helping refugee patients improve their social situations, like obtaining affordable housing, may alleviate posttraumatic stress and depressive symptoms without or in combination with medication and other therapy.  Somali patients may benefit from a treatment approach that focuses on the function of the presenting problem, for example alleviating posttraumatic stress symptoms (e.g. increased startle; hyper vigilance) in order to aid the patient in returning to a functional state at work. Assessment of potential PTSD/ depression symptoms should occur over the course of treatment given the significant overlap in symptom presentation. Such an approach will assist providers in differentiating the influence of psychological factors in the physical/medical patient presentation.

Care should be taken in evaluating physical symptoms so as to not place immediate responsibility on the patient as somatisizing symptomatology. In treating potential somatic complaints, from the patient’s perspective it is important to empathize with the nature of the complaint and make a prudent assessment of it before attempting to describe the possible psychosocial underpinnings of the physical complaint (e.g. anxiety, stress). Patient input regarding how he or she copes with psychosocial distress may help facilitate patient self-efficacy while providing health care providers with a baseline for how to go about treatment planning. 

Somali patients may have experienced a great depth of trauma.  Treatment is aided by a connection of trust built with a patient over time, through listening and responding to how he/she presents the illness, especially somatic complaints.  Somalis may need to talk about headaches or other physical complaints at every appointment and allowing for that builds strength of rapport, which can then allow a provider to gently ask about more sensitive concerns.  Encouraging a patient to talk more about somatic symptoms can open communication about other problems: “When are you most affected by your headaches? Do they affect you at night or disrupt your sleep?  Are they associated with nightmares or thoughts about the past?”  It takes time and patience to help a patient connect somatic complaints with emotional or psychological problems. Some patients who bring up physical complaints with their psychiatric care providers feel shut down when they are told to talk to primary care providers about those issues.

Psychotherapy/Counseling

For Somalis, counseling from elders and family is the cultural norm back in Somalia as well as in the United States.  Some may consider it silly or odd to talk through their problems with a psychotherapist or counselor, when they already talk about their experiences and feelings with friends and family.  It is very important for patients to have an established primary care physician first, who can refer them to psychotherapy when necessary.  The patient might be more inclined to attend psychotherapy if several appointments are scheduled in advance. ‘No shows’ for psychotherapy are common. Some patients attend their counseling appointments only because they believe doing so will maintain their government benefits.  Patients do not know what to expect from therapy and are often surprised after they meet with a psychiatrist. It is important to give them an idea ahead of time about who the psychiatrist or counselor is and the role they will fulfill in patient care. Psychoeducation that takes into account culture-specific perspectives of mental health plays a critical role in the initial stages of psychiatric care of refugee populations. Patients from some cultural backgrounds may not want to be asked about what they think is going on with their symptoms or their perspective on treatment, wanting the doctor to fulfill the role of expert. Patients are often extremely afraid when experiencing symptoms such as hypervigilance, panic, nightmares and flashbacks.  They may appreciate a provider’s explanation to help ‘normalize’ why these occur.  Somali leaders suggest that counseling support groups are needed in their communities and could help reduce stigma of mental health problems.

Evidence-based practices for the treatment of PTSD typically occur within the context of a one-to-one professional psychotherapeutic relationship, a practice seemingly at odds with the collectivistic approach seen in Somali culture. A clinical relationship invested in developing rapport with a patient before providing psychological care may help bridge the gap between these perspectives. A recent study evaluating views of general practitioners and Somali refugee patients suggests that establishing rapport remains a relevant but difficult endeavor in treating Somali refugees (Feldmann, Bensing, & de Ruijter, 2007). Results from the study indicate that Somali refugees may be more likely to attribute psychological worry and their physical concomitants to displacement factors than other refugee groups that identify cultural heritage as a predisposing factor. Findings from this study suggest that engaging patients at a personal level, especially in the initial stages of treatment, may lead to more favorable treatment compliance and health outcome.

Relaxation

Hand massage
Image of women practicing hand massage.

Relaxation techniques familiar to Somalis such as reading the Quran at sunrise and sunset or before bed, deep breathing and touch massage may be effective complimentary treatments of anxiety disorders.  Massage is known to be used by Somali women in Seattle for relief of physical pain and stress. "Daryel" is an exercise, massage-therapy and social support group for Somali women in Seattle. Read more about this group in an article published in the Seattle Times.

Cultural Knowledge and Traditional Treatment

Mental Health Care in Somalia

As previously mentioned, mild forms of affective disorders are not readily recognized as being a problem requiring professional assistance.  Somalis typically seek to resolve these issues within the family and through spiritual healing. Consultation occurs with members of the family or with community leaders in order to preserve dignity and avoid the social stigma associated with psychopathology. Mental disorder carries stigma and may therefore go unaccepted or be denied. The Somali traditional healthcare system does not acknowledge or provide treatment for non-psychotic depression or anxiety disorders. Taken together, these factors suggest that psychological disorder may go underreported in Somali culture and that medical treatment may be sought out only after all other resources have been exhausted.

Medical and psychological hardships are viewed to occur as a test of one's faith under the will of God (Allah). As a result, the Quran is traditionally the first treatment tried when someone is mentally ill. People living in urban areas may be more inclined to seek treatment at hospitals whereas those in rural areas start with the Quran and then traditional healers who use herbal medicine.  Family and spiritual leaders in the community read passages of the Quran and pray with the person who is sick.  The individual might read the Quran often throughout a day, at night, or commonly at sunrise and sunset. Physicians are often consulted only after treatment from spiritual and traditional practitioners has proven ineffective for the presenting complaint leading to the exacerbation of symptoms in the interim

Hargeisa Mental Ward
Photo by Nimo Hussein. Picture of Hargeisa Mental Ward.

Institutionalized treatment of mentally ill people in Somalia includes isolation where the individual may be chained and locked up. Mental health institutions in urban Somalia have developed indigenous methods of evaluating one’s mental capabilities and diagnosing mental disorder. A group of Somali elders described a method of diagnosis in which hospital personnel pour water into a basin with a hole on the periphery so that as water is poured in it exits through the hole. Mentally capable individuals recognize the dilemma, that the container can not be filled due to the hole whereas the mentally compromised continue attempting to fill the basin in futility. 

In general, mental illness would be seen as incurable.  Some mentally ill people might have temporary periods of recovery/remission, but most would be expected eventually and inevitably to "crack" and experience further onset of symptoms.  Cases of recovery from mental disorder by traditional and spiritual healing may be known.

Ritual Ceremonies and Herbal Medicine

Traditional healing practices include Quranic readings done by sheikhs, ceremonial rituals performed by healers, and herbal remedies.  These modes of intervention often serve as the initial treatment approaches and one or more are likely to be in progress when patients first present in a clinical setting. Assessing for the type and duration of these treatments as well as consideration of how they can be integrated into patient care will help build rapport and may produce more favorable outcomes for patients. This approach allows providers the opportunity to monitor and be informed about the kinds of treatment sought by their patients and extends the possibility to reach out to healers in the community for the advancement of patient care.

Ceremonial rituals to expel spirits may last four to seven days and are centered on dance, song and eating special foods.  A type of coffee called Danguis, and food such as halwo, dates, coffee, ginger, sugar and popcorn that are specially prepared and served, are used in treatment.  The particular spirit within the afflicted person is what specifies which ceremony and kind of treatment is needed.  The ill person may lie down while others dance around. A group of scholars, or sheikhs, know the appropriate passages to read from the Quran for specific symptoms. Each patient has unique symptoms and there are corresponding readings as treatment. Some healers prepare and administer herbal remedies to treat the ailment, for example garlic honey and blackseed (habadsoda).

Translation and Language Equivalence

Typically, Somali patients understand and relate to words like “worry”, “sadness”, “feeling down in your heart”, “something weighing on your heart” more than words like “anxiety” and “depression”.

Buufis is a Somali word initially and commonly used in refugee camps in Kenya to describe a person's dream of or longing for resettlement, conveying the idea of comparison between one's life in the camp and others' lives elsewhere.  Other, closely related meanings of the word have come to be used: "resettlement itself, the people who long to go overseas, and the madness that at times occurs when the dream of going overseas is shattered." (Horst, 2006) One interpreter interviewed for this article had heard the word buufis used to convey the notion "they are wrong" in reference to someone who is suffering mentally or emotionally from the disappointments of the resettlement experience.

Shaki is a Somali word meaning “worrier”, in the sense of an obsessive, compulsive worry or doubting.  For example, the word might describe a person who needs to clean all the time because of great concern about getting sick.   The word can be used to describe personalities that tend to obsess or worry.  Mostly, people who are called this would not be thought of as mentally ill.  They would be able to live and work.  Others who are not able to function due to extreme obsessive/compulsive behavior could be seen as mentally ill.     

Carroll (2004) discussed the Somali concepts of psychological distress murug, waali, and gini. Each of these terms describes levels of psychological distress but each carries with it a cultural distinction as to the type of psychological hardship experienced. 

Murug/Murugo

Murug or murugo, is understood as a general sense of sadness or mild depressiveness.   Symptoms associated with murug include loss of appetite, disturbed sleep, crying, headache, and loss of interest in social activities. A person with murug has a harder time accommodating to life stresses.  Physical symptomatology, such as hypertension, may also be present particularly in more severe cases of murug. (Carroll 2004)  Interpreters iterated that there is always stress in the sense of the life that accompanies the refugee experience here, but not many patients would call that distress murug.  In Somali language, the word murugo is used two ways: less serious sadness due to life's disappointments, or being very sad, feeling “low” inside all the time.  People would say this latter murugo was rare and most patients will not say they have that sadness.  There is belief life is hard now, but can get better. 

Waali

When asked to describe waali Somalis often refer to it as being “crazy” or “mentally unfit” (Carroll 2004), although some suggest that waali may present very differently from person to person. Waali is characterized by disorganized personal appearance, nervousness, aimless wandering, unintelligible speech patterns and potential acts of random other- or self-directed aggression. In Somalia, people with waali are considered unable to function and are institutionalized (if in an urban area) or kept isolated at home by their family. 

Somali community members suggest that individuals suffering from waali might be considered psychotic in the United States, though the symptoms in the U.S. may actually be a more muted external expression than back home.  Extreme stress or trauma is thought to be an antecedent of a type of waali and like many mental illnesses may be viewed as emerging in relation to the rise in civil conflict in Somalia. Waali resulting from severe trauma is thought to have no cure. Quranic readings are even thought ineffective for individuals with this affliction.

Gini/Jinn (also seen spelled Gin/Geni)

What would likely be considered severe psychopathology in Western cultures may be described as a consequence of jinn from a traditional Somali perspective (Elmi, 1999). This is a particularly stigmatizing form of psychological disorder that does not have natural causes but is a condition that derives from the influence of spirits.  Jinn are spirits that possess supernatural powers capable of entirely controlling human processes, including psychological processes (Carroll, 2004).  Symptoms may include visual or auditory hallucinations, speaking in tongues, not eating or sleeping, and general lack of interest in life’s activities. It is considered that there are all varieties of jinn, just as there are of people.  For example, some jinn are short, some are tall, some Christian and some Muslim.  People cannot see the jinn, though jinn see and live alongside people. 

Two interpreters described how the condition of being afflicted by jinn is somewhat analogous to being in an abusive relationship, a vicious cycle in which the same symptoms will reappear again and again once a person is affected.  The afflicted person is compelled by the jinn to do what it wants, not curing it, but “feeding” it, making it “comfortable”.  The spirit may want sacrifice, and a person may need to promise to do certain rituals for the jinn, dress a certain way or wear a certain perfume, for example.   Some jinn may be tempered or moderated by Quran readings.   Jinn is mentioned many times in the Quran, and it is said that Allah created jinn out of fire (Surat al-Hijr, 27).  While recognizing and accepting the existence of Jinn, some Somalis may consider attempts to appease the jinn to be “sharika” (an Arab word roughly meaning “associating or comparing other things to Allah”), in the sense that the person attributes power to the spirit or worships the jinn.

Somali interpreters and community members identified other terms -mingis, saar, widaadu, borane, hayat and folkabralle – which, like jinn, describe conditions derived from the influence of spirits.  Different languages or tribes may use one term rather than, or in addition to, other terms to describe the same or similar condition.

Mingis

Mingis is a condition of spirit possession commonly seen in central Somalia.  Mingis is a spirit that comes to someone (more often a woman than a man) or to a family, unintentionally, from another person.  The cause may be positive or negative – for example, the mingis may come from someone who likes the other person very much (positive cause) or a mingis can come when someone unintentionally made the spirit mad (negative cause).  Most often, there is a positive cause.  The mingis itself is not violent, but reading from the Quran might incite verbal outbursts from a patient.  People with mingis who can afford it will go to an alaqad (also spelled alacot) to be treated.  An alaqad is the highest level of healer.  Treatment is expensive, and patients bring money, silk scarves, and special oils and perfumes as offerings to be used in the treatment which also involves slaughter of animals, chanting, eating sweet foods such as halwo and dates, and dancing for several days. 

Saar/Zar

The DSM-IV describes zar as “a general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran and other North African and Middle Eastern societies to the experience of spirits possessing an individual.  Persons possessed by a spirit may experience dissociative episodes that include shouting, laughing, hitting the head against a wall, singing, or weeping.  Individuals may show apathy and withdrawal, refusing to eat or carry out daily tasks, or may develop a long-term relationship with the possessing spirit. Such behavior is not considered pathological locally.” (American Psychiatric Association, 2000)

Saar is seen many places including in the U.S.  Interpreters described it as a condition almost the same as mingis (see above).   The saar is considered a spirit that came inside a person that needs/wants to be pleased in particular ways.  Appeasing the saar or mingis in the right way is important and a practiced healer leads a ceremony, asking questions to diagnose which spirit is involved and what that spirit specifically wants. There is a notion that feeding the spirit that is possessing, taking over the person, may help in healing, while some people think that approach just encourages the spirit to remain. Food is cooked for an altar offering and feast, and a celebration is held for the spirit. 

Wadaado

Wadaado is a condition with a spiritual cause characterized by symptoms of body ache, severe headaches, lack of sleep, word-salad, offensive language and inappropriate behavior. Medication is thought not to be helpful for treating wadaado.  Reportedly there are traditional healers who specialize in treating this particular condition.

The following two words were added by Lila Rice in 2016:

Niyadjab

A word used to describe mild long term sadness, disappointment and hopelessness related to external factors rather than individual emotions (Kuittinen et al, 2014).

Qalbijab

Another word used to describe depressive feelings, similar meaning to niyadjab (Kuittinen et al, 2014).

Other Considerations

Barriers to Service Utilization

A systematic study of service utilization by Somali refugees in the UK has shown that, although Somali refugees endorse a variety of physical and mental health needs, access to organized services to meet these needs remains relatively low (McCrone et al, 2005).  In Nashville, the Mental Health Access for Refugees and Immigrants (MHARI) project identified several needs in improving access to healthcare services among several refugee populations, Somalis included. Barriers to service utilization identified by MHARI include: (1) lack of community knowledge about the healthcare system, (2) stigma attached to mental health problems (particularly among Somali males), (3) discomfort discussing personal (sexual) information with providers of the opposite sex, (4) fear that treatments for PTSD will worsen symptoms, (5) difficulty differentiating disorders in need of professional care, (6) difficulty managing their children within the American social system and fear that DCS will take their children away for disciplining them the way they normally would, (7) economic and occupational difficulties, and (8) lack of transportation or childcare.

Head Injury

Significant overlap exists among the symptom presentations of PTSD, severe stress, depression, and traumatic brain injury (TBI) in trauma-exposed populations. Research with prisoners of war and victims of mass violence has highlighted the biological/neurological aspects of trauma exposure (e.g. reduction in hippocampal volume; effects of malnutrition) and its interaction with lower levels of psychological functioning (Weinstein, Fucetola, & Mollica, 2001). Torture, starvation, imprisonment, and acquired head injury can have chronic neuropsychological (neurobehavioral) effects which in turn impact the level of psychosocial adjustment/ resiliency for refugees. However, cultural variables hinder the assessment of neuropsychological disorder among refugee groups that may have experienced a multitude of physical insults including head injury (Weinstein, Fucetola, & Mollica, 2001). The development of culturally un-biased assessment tools will help providers differentiate the complex clinical picture of patients experiencing psychological and potential neurological trauma. Recent research with brain-injured American soldiers serving in Iraq and Afghanistan has suggested significant overlap between the neurocognitive/neurobehavioral deficits associated with neurologic insult and posttraumatic symptomatology. Likewise, the clinical profile of refugees with a history of torture may consist of physical impairments (e.g. pain, sleep disturbance, fatigue), behavioral disturbances (e.g. trouble initiating behavior, interpersonal changes, anger management difficulties), and impairments (e.g. short attention span, difficulty processing information, impaired memory) some of which are also associated with PTSD.

Mild TBI in particular is underreported within the larger American culture and may be even more so in refugee populations. Questions about history of head injury, without specifically asking about combat scenarios, may prompt stories about falling out of a tree as a child with loss of consciousness, for example.  Irritability and anger associated with head trauma and PTSD are usually more severe than when associated with PTSD alone.  In clinical encounters staff and providers may be confronted by patients, often males who had repeated head trauma and torture, presenting now with explosive emotion.  Sedating antipsychotic medication can be helpful treatment.  In clinic the patient may benefit from provider’s assurance that the medical team does all they can to help, while also setting very firm boundaries for what is acceptable behavior with staff.

Khat (Chat, Qat), Alcohol and Other Drugs

Use and abuse of alcohol and illicit drugs is rare among Somalis due to their fervent religious beliefs.  Somali men who do drink and are addicted to alcohol would likely try to hide it due to the taboo nature of alcohol use and fear of being outcast in the community.  Reportedly, some people don’t hide their alcohol use as much in the U.S. as they would have back home. 

Although substance abuse is uncommon within Somali society, use of an East African stimulant with amphetamine-like qualities called khat (pronounced cot, also spelled qat) has been associated with mental illness in Somali refugees (Bhui et al, 2006). Khat is typically chewed and has become increasingly available internationally in recent years. Historically, its use has been linked to the rise in civil conflict and economic struggle in Somalia (Randall, 1993). Increased international trade, capitalistic commerce, and urbanization have also increased the speed and availability of a host of African goods since the early 1980’s (Affinnih, 2002). Similarly, the international drug trade and national use of khat has increased across African communities since that time. Along with economic concerns, geographical factors may play a role in the rise in sub-Saharan drug trafficking with the location of many communities facilitating trade to not only neighboring communities but to Europe, Asia, and North America as well.

Although Khat is available in the United States in general and metropolitan Seattle in particular, it remains an illegal substance domestically and its high cost also prohibit many from using it. The prominence of khat use among Somali refugees has been highlighted in the international research literature (Salib & Ahmed, 1998; Al-Samarraie, Khiabani, & Opdal, 2007; Browne, 1990; Nencini, Grassi, Botan, Asseyr, & Paroli, 1989; Stefan & Mathew, 2005) and has been implicated in the development of psychotic, depressive, and anxiety disorders (Bhui et al, 2006; Critchlow & Siefert, 1987; Odenwald et al, 2005; Pantelis, Hindler, & Taylor, 1989). Bhui and colleagues (2006) found khat to be associated with psychological disturbance, although the use of other substances were not found to be significant predictors. Khat use appears to be more common among Somali males.

KhatCommunity respondents indicated that discussing khat is sensitive and guarded, especially since fourteen Somali residents of the Seattle area were arrested for crimes related to khat possession.  According to community members, khat addiction does exist as a problem for some people and some families have been disturbed and marriages have ended in separation and divorce due to this problem.  Over time, some people miss work due to illness stemming from their frequent and habitual khat use, or lose jobs after giving excuses why they cannot show up for work (after nights spent awake using khat).  Community elders identified negative effects of longterm, frequent use, including stress placed on families when attention and money is spent on Khat.  They knew of people who experienced irritability, confusion and visual hallucinations after using khat regularly over time with repeated episodes of lack of sleep and reduced food intake.  Other health problems experienced by people who used a lot of khat included gum erosion, broken and discolored teeth, swollen cheek muscles, and tongue and throat problems.  Community members suggested diabetes was an issue of concern as healthful diet and exercise are not a priority for many frequent khat users.  Additionally, while chewing khat, people will often drink large amounts of tea strongly sweetened with sugar (others may drink soda).  

Speaking to the Seattle Times in 2006, Caleb Banta-Green, a research scientist at the Alcohol and Drug Abuse Institute at the University of Washington, reported khat isn't a major problem in Seattle and that in 2005, there were no emergency-room admissions in King or Snohomish counties for khat abuse.  Banta-Green said people are motivated to use khat for the same reasons many Americans drink coffee — to keep themselves energized throughout the day. It is however doubtful whether patients would have admitted to khat use.

According to a community respondent who works in Seattle schools, some of the younger generation of Somalis growing up in the United States are using drugs similar to those used by their non-Somali peers, such as marijuana, pills and cocaine.  Parents may not understand the effects of drug use on the mental health of their children.  Conflict can arise when young people, aware of the treatment process, are encouraged by parents to seek healing through reading the Quran.

Youth

Interpreters reported that Somali parents worry about their children, and fear youth getting into trouble. In Seattle, a community leader reported that parents sometimes worry more than is warranted, simply because they are not aware or do not participate in their children’s activities outside the home.  A study in Minnesota surveyed 338 Somali and Oromo refugees aged 18–25 years, and concluded that “many young Somali and Oromo immigrants to the United States experience life problems associated with war trauma and torture, but many others are coping well. The findings suggest a need to develop age-appropriate strategies to promote the health of refugee youth to facilitate their successful adaptation to adult life in the United States.” (Halcon J., 2004)

Providers and educators need to learn about Somali culture, including norms of parenting and expectations of the emotional development of youth, along with understanding students’ emotional needs and their histories.  Teachers may be more inclined to see problems children of color have in school as being discipline-related issues.  Somali children may be at greater risk, then, of being misperceived as having behavioral or discipline problems, when they may in fact be struggling with adjustment issues or frustrated with school work or activities.  One reviewer of this article suggested that educators who are concerned about a child's development or behavior be in touch with parents as early as possible to make an intervention; and, cautioned against making assumptions about a family's interest in or care of their child.

According to one Seattle pediatrician who sees low-income and diverse patients, including Somalis and other immigrants, ADD and ADHD conditions are seen to be increasing among Somalis as a function of acculturation challenges and feelings of being caught between two worlds.

In cases when a Somali youth is admitted to the hospital’s psychiatric ward, it is a norm for parents, often the mother, to expect to also stay in the ward with the admitted patient the entire time.  Parents may have trouble accepting a mental health diagnosis for their child, perhaps saying “but my child is smart”.  The experience of seeing mentally ill people back home who were “crazy” and non-functioning in society would be hard to reconcile with a child being called mentally ill, especially when the child still seems to function intelligently in some ways - like being savvy with computers or doing well with subjects in school.

See also the 2010 article by Ellis et al in the Journal of Orthopsychiatry: Discrimination and Mental Health Among Somali Refugee Adolescents: The Role of Acculturation and Gender

INS/Homeland Security Pressures

Trauma survivors and other patients may be dealing with an immigration system which can feel unwelcoming and further traumatize.  Patients may worry about immigration policy compromising eligibility for social services.  Since September 11, 2001, the Department of Homeland Security has restricted procedures governing legal aliens. Before, test waivers were granted more often to excuse older adults, living more than five years in the U.S. who never learned to read or write their own first language, from taking the written English citizenship test about US civics history and government. Now, fewer exemptions are granted and achieving a waiver may require three appeals and hiring a lawyer.  In some cases, patients have learned about the possibility of waivers being granted on the basis of mental impairment and may actively seek a diagnosis of psychological disorder, even when symptoms were never previously reported or observed by their provider. 

Some patients are concerned that the medical system is in some way connected to the immigration system and so they may sensor information they share with medical providers in an attempt to avoid problems.

Recommendations for Providers

  • It is ideal for clinician, patient and trained medical interpreter to be the same gender, if possible. This is especially important when there is physical contact or exam.  Some patients feel bad and won’t tell the provider about their discomfort with his/her gender for worry about hurting the provider’s feelings.  The patient may tell the interpreter.  It is up to the provider to ask the patient about this concern.  
  • Recognize that Somalis are storytellers. Somali culture is highly conversational with poets and storytellers holding high status in their native society.  Rural and traditional care providers in Somalia listen to the patient’s stories.  They sit with the person seeking healing, for whatever time is needed to listen.  They also get to know the patient in a sincerely familiar way, greeting them personally with their first name after a time of knowing them.  Getting the whole story may yield helpful information from the patient, or maybe it is only a story for story’s sake and useful for getting to know the patient.  The interpreter may be helpful in suggesting to the patient a balance in “summarizing” and being aware of time, and to not forget to tell the doctor about a main concern. Because memory may be an issue for some patients, a provider can ask “did I address all your issues?”
  • Be humble, attentive and aware of power differences.  Be aware of physical gestures of respect, disrespect. For example, it isn’t appropriate from a Somali perspective to wave a patient in. Talk to the patient, not to the interpreter.  Show interest in the person’s background (e.g. where they are from geographically).Avoid assumptions or generalizations, such as “patients are uneducated”.  Listen and give the patient time to talk about the problem she thinks she has.
  • Be sensitive to the fact that patients may not want to share trauma history in detail or at all until they trust the provider.
  • Provide clear responses to patient questions. Don’t simply respond with a “no”.  That can be perceived as shutting down communication and the patient might not share any more information.
  • Explaining unclear information, like the rationale for certain lines of inquiry (e.g. about suicidal ideation) and that confidentiality and privacy are protected can ease concerns or misconceptions. Diagnoses and treatment plans should be explained carefully with openness to Somali views of mental illness. It is helpful for the patient to know what an additional provider is for, such as psychologists or other specialists.
  • Interpreters recommend inquiring indirectly about suicidal ideation, when possible.  One person suggested questions like “do you take care of yourself?” or “do you love yourself?”
  • Some primary care providers may wonder when to refer a patient out for psychiatric care, and when to diagnose and continue treating a patient. If primary care doctors can pick up on decrease in functionality sooner before the patient is out of the workplace for too long, there is more chance for patients to successfully use medication to stabilize and return to work and a healthier life. Looking at level of functioning can help determine who to refer to psychiatry or for more aggressive medication management, psychotherapy, social work, etc.  
  • When asked about use of traditional or other medicine, some patients assume that a Western care provider may recommend against other methods of healing and won’t tell about other healing approaches.
  • Ask questions to learn how the patient’s faith may be a protective factor.  How do you take care of yourself? Do you have a strong faith that protects you? How are you able to deal with life stressors, sadness, isolation?
  • Partnering with the patient on the idea of hope is useful.  “I am hopeful this medicine will help you relax and sleep better.  I think this medicine will be helpful.  But, you need to work with me on this to tell me if this medicine is helpful.”
  • Incorporate indigenous religious views into treatment when appropriate, e.g.:

Allah may have brought this pain upon you as you believe for some reason, but he may also be providing you with some avenues to get you relief from the pain.  I believe Allah will still lead you and help you survive; that Allah’s presence with you gives you strength. Maybe you coming into the clinic today is a way he is providing for you and maybe we can try to work on that pain inside of you, because Allah would not want you suffering like that.”

  • When using a word that does not exist in the Somali language, such as a diagnostic term, explain in detail what it means.
  • Explaining PTSD in reference to bodily phenomena or by using metaphor can help avoid stigma of mental disorder:

“It’s like when you are about to cross the street and you look both ways and you don’t see any cars coming.  And you step off the curb and you suddenly see a car coming, and you jump backwards.  And your whole body feels stressed, your heart is pumping and hormones called adrenaline and cortisol are naturally racing around your body.  The hormones are what helped you jump back.  When you experience or witness trauma, your body’s hormones work overtime to help you survive.  Later, the hormones start working overtime automatically because the body remembers the trauma, and you have that feeling of jumping in front of a car again.  Only you don’t know why it is happening now because you haven’t stepped in front of a car and aren’t currently experiencing or witnessing great trauma like you did before. It is your body that remembers that feeling and may be why you are having the nightmares.  Things are stirred up in your body and you are feeling fearful even though there isn’t a reason you can see that you would be fearful now.”

Further Reading

Boynton L, Bentley J, Jackson JC, Gibbs TA. (2010).  The role of stigma and state in the mental health of Somalis. Journal of Psychiatric Practice, 16(4):265-8.  "This case report describes the presentation of a 55-year-old Somali refugee suffering from depression and posttraumatic stress disorder, in the context of his culture. The discussion suggests ways in which clinicians may respond to and work with Somali patients, in order to promote their well-being in a culturally competent manner."

Boynton L, Bentley J, Hussein N, Jackson JC. (2010). Images in psychiatry. Hargeisa Group Hospital psychiatric ward. American Journal of Psychiatry, 167(7):762.

Del Loewenthal, Ahmed Mohamed, Samyukta Mukhopadhyay, Kalai Ganesh & Rhiannon Thomas. (2011). Reducing the barriers to accessing psychological therapies for Bengali, Urdu, Tamil and Somali communities in the UK: some implications for training, policy and practice. British Journal of Guidance & Counselling.

Mölsä ME, Hjelde KH, Tiilikainen M. (2010) Changing Conceptions of Mental Distress Among Somalis in Finland. Transcult Psychiatry. 47(2):276-300.

Patient Education Materials

  • Caafimaadka Maskaxda (Mental Health) from Healthy Roads Media, this information is available in several formats, including multimedia with pictures and sound; sound-only; and written text.  Several topics related to mental health and illness: Stories of Depression - The Basics; Stories of Depression - Getting Help; PTSD - A Real Illness; Anxiety; Autism; Bipolar Disorder; Mental Health; Obsessive Compulsive Disorder (OCD); Panic Disorder; Schizophrenia; Suicide; Postpartum Depression
  • Egal Shidad: Stories of Somali Health  is a program about mental health which aired multiple times in the Twin Cities on both radio and television and which is available for viewing online and to order on DVD.  This program was created for members of the Somali community, using Somali language and aspects of Somali culture to relay information and reduce barriers associated with mental health.  Somali producer Mukhtar Gaaddasaar takes the audience on a journey to learn about mental health that includes storytelling, personal opinions, historical accounts of traditional ceremonies, guidance from an Imam, and valuable insight from two mental health professionals experienced in working with Somalis.
  • Feeling Sad - Dareemidda Murugo (Somali/English) PDF from Health Information Translations.
  • Emotional Changes After Giving Birth - Isbeddellada Dareen ahaaneed Dhalidda ka Dib (Somali/English) PDF about Postpartum depression from Health Information Translations. 
  • What is Mental Illness English | Somali Overview of mental illness, including common forms and causes, translated for EthnoMed from a brochure titled “What is Mental Illness” produced by ADEC (Action on Disability within Ethnic Communities), Victoria, Australia. 
  • PDF Factsheets from Center for Addiction and Mental Health in Canada Note: the following factsheets contain specific information about where to get help in Canada which may not apply outside of Canada. About mental health (factsheet): What is mental health; What contributes to mental health problems; Types of mental health problems. Asking for help when things are not right (factsheet): What is part of the normal reaction to living in a new country; When it is a good idea to ask for help. Understanding Addiction (factsheet): What is addiction; What are the signs and symptoms of an addiction; How are family members affected; Will treatment help; When is it necessary to get help. Coping with Stress (factsheet): Tips on dealing with stress.

Related Information on the Internet

Mental Health Access for Refugees and Immigrants (MHARI) - Nashville, 2004-2007

In Nashville, the Mental Health Access for Refugees and Immigrants (MHARI) project has targeted improving community relations and promoting community knowledge about psychological disturbance by offering education on the various levels of the healthcare system, the roles of different providers, as well as the clinical presentation of a variety of mental illnesses. Through a series of community presentations and focus groups over a two year span, MHARI nested education about mental health issues within the broader context of social service needs and medical care. This approach helps relieve the stigma associated with mental illness by representing it within the larger context of general community needs. Focus groups are beneficial in facilitating discourse within the community about healthcare concerns while allowing refugees to learn from the experiences of others. In addition, education was also provided to healthcare practitioners to increase understanding about the various barriers to treating African refugees.

Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth

Recognizing the unique mental health challenges facing growing numbers of immigrant and refugee children, in March 2007 the Robert Wood Johnson Foundation (RWJF) announced a new national program to reduce emotional and behavioral health problems among school children in low-income, immigrant and refugee families. The program, Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth, has awarded $4.5 million in grants to 15 projects in communities across the country that will work to bring school-connected mental health services to children in need, particularly those from immigrant and refugee families.”

Somali Mental Health Project – UK

In the UK, the Somali Mental Health Project was organized to bridge a gap existing between providers and Somalis suffering from mental illness. Through this project mental health care workers work in the community through a house call program to assess needs and relay relevant information to health care providers. These individuals also provide the community with information about community resources and available mental health services. When inpatient care is required “link workers” serve as mediators between providers and patients by translating patient-provider interactions while navigating cultural nuances.

Information from Canada’s Center for Addiction and Mental Health

Report: Culture Counts: Best Practices in Community Education in Mental Health and Addiction with Ethnoracial/Ethnocultural Communities. Includes key findings about alcohol use from Somali community in Ottowa.

Information from Academy for Peace and Development, Hargeysa, Somaliland

Draft: The Impact of the War and on the Family - Principal Researcher: Sucaad Ibraahim Cabdi. This paper describes the traditional northern Somali pastoralist family and the impact on the family of socio-economic and cultural changes brought by colonisation, urbanisation and pre-war government policies. It continues with an overview of the impact of civil war on the family and the associated increase in the incidence of qaad (Khat) consumption. The paper describes existing and recommended structures of support for the family and disadvantaged members of society.

Is it possible to ethically research the mental health needs of the Somali communities in the UK?

This article summarizes ethical issues that arise when researching common mental disorders within the Somali communities in the UK. It addresses the danger of researching these disorders from a Eurocentric perspective which risks overlooking the difference in conceptualization of mental illness between diff erent cultures in the West and Somalia. Written by A.D. Mohamed and D. Loewenthal, 2009, published as an Editorial Committee Reviewed Selection, Research Reflection, by the Journal of Ethics in Mental Health.

References

Affinnih, Y. H. (2002). Revisiting sub-Saharan African countries' drug problems: health, social, economic costs, and drug control policy. Subst Use Misuse, 37 (3), 265-290.

Allden, K. (1998). The Indochinese Psychiatry Clinic: trauma and refugee mental health treatment in the 1990s. J Ambul Care Manage, 21(2), 30-38; discussion 43-55.

Al-Samarraie, M., Khiabani, H. Z., & Opdal, M. S. (2007). [Khat--a new drug of abuse in Norway]. Tidsskr Nor Laegeforen, 127(5), 574-576.

American Psychiatric Association. (2000). The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, DSM-IV-TR. 903.

Bennett, W. R. M., Zatzixk, D., Roy-Byrne, P. (2007). Can medications prevent PTSD in trauma victims? The Journal of Family Practice, 6(5). Retrieved November 30, 2010 from http://www.jfponline.com/Pages.asp?AID=5342.

Bhugra, D. (2004). Migration and mental health. Acta Psychiatrica Scandinavica, 109(4), 243-258.

Bhui, K., Abdi, A., Abdi, M., Pereira, S., Dualeh, M., Robertson, D., et al. (2003). Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees--preliminary communication. Soc Psychiatry Psychiatr Epidemiol, 38(1), 35-43.

Bhui, K., Craig, T., Mohamud, S., Warfa, N., Stansfeld, S. A., Thornicroft, G., et al. (2006). Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors. Soc Psychiatry Psychiatr Epidemiol, 41(5), 400-408.

Browne, D. L. (1990). Qat use in New York City. NIDA Res Monogr, 105, 464-465.

Buydens-Branchey, L., Noumair, D., & Branchey, M. (1990). Duration and intensity of combat exposure and posttraumatic stress disorder in Vietnam veterans. Journal of Nervous and Mental Disease, 178(9), 582-587.

Carroll, J.K. (2004). Murug, Waali, and Gini: Expressions of distress among Somali refugees. Primary Care Companion to the Journal of Clinical Psychiatry, 6, 119-125.

Critchlow, S., & Seifert, R. (1987). Khat-induced paranoid psychosis. British Journal of Psychiatry Vol 150 Feb 1987, 247-249 Royal College of Psychiatrists.

David, D., Woodward, C., Esquenazi, J., & Mellman, T. A. (2004). Comparison of comorbid physical illnesses among veterans with PTSD and veterans with alcohol dependence. Psychiatric Services, 55(1), 82-85.

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