Reducing the Stigma Surrounding Mental Health in the Somali Community

Abstract

This paper focuses on mental health in the Somali community. Mental health has been considered a taboo topic within the Somali community for many years. In this paper we will discuss the importance of understanding mental health and the different health issues that are common amongst the community. With the stigma surrounding mental health individuals in the community to choose to ignore their mental health issues affecting their relationships with their families. In this paper we will also discuss the importance of bringing awareness into the community and the different resources that are available to the community in order for them to receive proper health care.  This paper also discusses the different programs that exist that have tried to help the community.

Introduction

Mental health does not exist on its own. It is an integral and essential part of overall health, which can be defined in at least three ways as the absence of disease, as a state of the organism that allows the full performance of all its functions or as a state of balance within oneself and between oneself and one’s physical and social environment (Bhugra, Till & Sartorius, 3). People in the community need to understand that even though they might think that they are healthy physically they also need to focus on their mental health as well. Mental health impacts other parts of their overall health as well. When mental health illnesses are ignored people tend to have a difficult time connecting with others forcing them to be isolated from their environment. Because of the traumatic experience that many Somalis’ in the community have experienced, they choose to ignore their illnesses since it isn’t visible to them.

Bringing the awareness of mental health issues into the Somali community allows people to discuss their mental health issues ending the stigma surrounding the issue, allowing people to receive proper health care services.

What is mental health

According to World Health Organization, Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to his or her community (World Health Organization, 2014). Mental health can affect a person’s daily life, relationships, and even their physical health. Mental health is away of describing how a person feels and how he or she manages to cope with their own emotions. Any severe illness of a family member creates stress for the rest of the family. The mental ill are unable to carry out a normal life pattern. Mental illness usually expresses its itself in a deviant behavior and in interpersonal difficulties causing family routines to be disrupted. Not only does mental illness remove a family member from the family it also causes change in family structure and function as a whole (John, C., Marian Y., 1955).

With many people in the community who have experienced the civil war they are prone to mental health issues. The civil war has had a huge impact on the community mentally and for some even physically.

There are two prevalent mental illnesses among the Somali refugees are Post Traumatic Stress Disorder and Depression (McCrone, P.,Stansfeld, S., Craig, T., Warfa, N., Curtis, S., Bhui, K., Mohamud, S., Thornicroft, G., 2006). A common illness that people who experience war go through is Post-traumatic stress disorder PTSD. . PTSD “is an anxiety disorder with exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following, directly experience the traumatic event, witnesses the traumatic event in person, learns that the traumatic event occurred to a close family member or close friend, or experiences first hand repeated or extreme exposure to aversive details about the traumatic event” (American Psychiatric Association, 2013). People with PTSD can experience flashbacks and exaggerated startled responses to normal stimuli (Warfa et al., 2006).

The second most prevalent mental illness in the Somali community is Depression. Depression is defined as having at least five of these nine symptoms: “irritable, decreased interest or pleasure, significant weight change, or change in appetite. Change in sleep, activity fatigue or loss of energy, guilt or worthlessness, lack of concentration, suicidality” (American Psychiatric Association, 2013).

The History of Somalia

The people of Somalia have traditionally been nomads, traveling between two main rivers as well as fishing around the coast (Warfa, et al., 2006). Around the mid-1800s, the country of Somalia has been colonized and divided by several foreign entities (Bhui et al., 2003). This included France, Great Britain, Italy, and Ethiopia. For generations, the people of Somalia have witnessed firsthand violence and wars. The violence lasted until 1991 then the civil war broke out. This civil war led to an estimated 400,000 deaths, as well as 45% of the population being displaced from their homes (Condon, 2006).

Since the civil war began, the United Nations has reported that more than one million Somalis have left their country as refugees or asylees. Many Somalis started arriving in Minnesota in 1992 and as of 2018, Minnesota hosts one of the largest Somali communities in the Somali diaspora. In 2015, the Census data offered an estimate of 57,000. The majority of Somalis in Minnesota live in the Twin Cities metropolitan area, while others have settled in smaller towns throughout the state (MNOPEDIA, 2018). Because of the civil war families had to witness their lives torn be apart, relocated and uprooted to a foreign country forcing people to learn new languages and adapt to new cultures. Whole the culture they were adapting to new very little about their cultural and religious background. 

Relocation

Even though Somali people experienced the civil war they had to deal with the stressors of relocating as well. For that reason there is a high prevalence of Post-Traumatic Stress Disorder, Depression, and Generalized Anxiety Disorder in the Minnesota Somali population (Kroll, Yusuf, & Fujiwara, 2010). With experiencing such high levels of trauma this shows that Somali families are more likely to experience higher rates of mental health symptoms. Although exposure to traumatic events increases the risk for PTSD and other mental health problems, also multiple social, cultural, and family-related resources can moderate the association ( Mulki M., Saija K. , Marja T. , Marja-Liisa., and Raija-Leena Punam P., 2017). Even though service utilization is low among children, those from refugee backgrounds may be at greater risk for mental health problems and have greater difficulty accessing services (Linda P., Hillary. B., Abdirahman Y., Francine M., & Anita R., 2014). With the difficulty of accessing services its easier for people to ignore their symptoms and minimize their mental health issues that they might experience.

Being in a foreign country stops people from receiving the proper treatment that they actually need in order to treat their mental health. People have this mindset that they are outsiders in society, so they tend to stick with the community only and with the community refusing to acknowledge mental health issues makes it difficult for people to openly discuss their mental issues. The community needs people who are trained in the health care system who also could connect with the community without feeling like an outsider who is forcing themselves into the community. The community needs someone that they could trust and rely on when it comes to their issues. With a middle-man people are more like to report their health issues and receive the proper treatments that they need.

Parenting in a foreign country

In addition, to relocating to foreign countries, parenting has changed a lot for parents after moving to a foreign country. Being that the Somali community is a collectivist society it was considered that all the adults in the community help raise a child. The adults in the community has as much say in the child’s life as much as the immediate family. Whereas in the western culture the parenting style was more focused on the immediate family raising their child. With the Somali parenting style, children are allowed to run freely since any adult of the community is a part of raising the child (Guerin et al., 2004). If an adult outside of the immediate family finds a child behaving poorly, it is not uncommon for that adult to discipline the child (Guerin et al., 2004). While in the United States of America, it would usually be considered taboo for anyone other than the immediate family to provide discipline (Warfa et al., 2006).

In Somali of the key leaders in the community were considered to be the elders. Elders were considered to be the head of the household followed by the fathers. Elders were held in high positions regarding the decision making as well as the culture keepers in the community. Whereas, today, the roles have shifted, and families don’t rely on the elders as much as people did in Somalia. Looking at my own family I could see the change in family structure compared to when my mother was younger. My grandmother would tell me stories on how family structure is different compared to today’s and how families raise their children. Ln my immediate family my father is considered to be the provider and head of the household, but nothing happens without my mother’s approval. She always has the final say but my father believes that he is in control because he was raised and taught with the idea of the man being the household leader.

Parent Child Communication

As a result of parenting in a foreign country, raising a child in the U.S. has been difficult for parents especially since the roles have shifted. Upon coming to Minnesota, the elders have been taken out of their role due to not being able to adapt to the new way of life (Jaranson, et al., 2004). Because of this, there has been a role reversal where the children are now the experts (Jaranson, et al., 2004). With children being the experts, they have used it to their advantage. Often, due to the language barrier between the adults and schools, the children will act as interpreters and withhold information, thereby leaving the parents uniformed (Ali, 2008; Jaranson, et al., 2004). With the lack of accountability and supervision, this has caused further distress in the parents as well as the children, increasing the likelihood of developing mental illness.  

Barriers to health treatment

In the Somali community there isn’t a grey area when it comes to mental health, you are either sane or insane. When people suffer from mental illness they go to elders or religious leaders in the community in order to be cured or cleansed. Even though there is a need for mental health services there is still the issue of the stigma of mental illness in the culture. The cause of mental illness to the Somali community is often believed to be associated with evil spirit (Warfa, et al., 2006; Guerin, 2004). Somalis, are a very closed net community, they do not want anyone seeing them associated with mental illness, fearing that they will be stigmatized (Warfa, et al., 2006; Guerin, 2004). Because of this strong stigma, it is very hard to reach out to this culture (Warfa, et al., 2006; Guerin, 2004). Some of the reasons that make it hard for providers to reach out is that Somali’s view on mental illness being a challenge that god gave them, and therefore being their burden to carry and pray about (Ellis et al., 2010). It is difficult for people to ask for help, asking for help can be felt as being shameful because of it being their burden to work through (Ellis et al., 2010). The last reason that makes it hard to reach out is because of the stigma and potentially being viewed by the community as insane (Guerin et al., 2004).

Support and awareness in the Community

Furthermore, some of the current supports that the Somali community are religion, family, and community-based supports. Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L., (2010) report that the Somali population will first look to religion for mental health support. Being that all of the Somali population is Muslim (Warfa, 2006). This proves that the mosques and other places of worship are major supports for the population. In the study by Ellis et al., they stated that families and family-based supports are considered supports, they reported that because of the stigma around mental illness, families have been shown to shun mentally ill members of the family even though they rely on family members for support.

Lastly, support is community- based, Somalis are unlikely to seek help from mental health clinics (Bentley, 2010). Medical clinics are more utilized because in the Somali culture it is not taboo to seek help for a physical symptom since the symptoms are visible (Ellis, et al., 2010). Even though there are not many, there are a few mental health clinics that specialize in work with the Somali population, such as the ‘Somali and East African Behavioral Health Services Program’ and ‘Somali Family and Youth Services Sabathani Center’, both located in Minneapolis, Minnesota (Volunteers of America Minnesota, 2014; Healing Resources for Refugees, 2014). The problem is these programs are being underutilized due to several barriers such as stigma and language difference between care providers and people in the community.

Places such as Summit Guidance in Saint Paul, MN provides a variety of services and programs including outpatient clinics, community-based support and rehabilitative programs, hospital liaison services, intensive family services, and long-term supports. Services are available to anyone. There specialty is caring for people with severe and persistent mental illness such as schizophrenia, major depression, post-traumatic stress disorder, and bipolar disorder and other severely disabling disorders requiring resolution long term or even ongoing treatment and support.

Additionally, there are programs such as Community University Health Care Center CUHCC in Minneapolis, who have been designed to help meet the needs of the Somali community. The clinic provides a wide range of outpatient’s services to the community. The different services include psychiatric assessment, medication management, individual and group therapy.

Even though there are programs designed to help people in the Somali community it will be difficult to connect with the community as long as they don’t feel any form of connection with the care provider. Providers need to find ways to establish trust with the community and that would allow providers to get their foot into the closed community. Before health care providers could start treatment they first need to establish connection with the community

A few of the different approaches and recommendations that studies have mention are having youth engagement, training programs, specific therapy, cultural sensitivity. Youth engagement programs allows health services to help the community in the long term. Engaging with the youth from a young age allows health services to train and teach the youth about the importance of mental health. Being taught at a young age changes how young adults view mental health and how it could help them in the future. The training program allows people in the community to be trained in order to help others in the community. Training a Somali person gives providers a better chance with having someone in the community work with them or even help interpret and be the middle person between the community and health services. These training programs would be helpful to the community leader such as Imams of the mosque. The Imams play a huge role in the community and building that connections between the health services and community leaders would be beneficial when it comes to connecting with the community.

Based on the research if health care providers were to connect with the Imams of the mosque then they would have a better chance of reaching out to the community. Being that religion is a big part of the culture I believe that health care providers would have a greater opportunity in spreading the importance and understanding of mental health issues and how to deal them. Other places that health care providers could visit in order to connect with the community is at the Somali malls. The Somali malls are usually packed every day and even more on the weekends. Health care providers could visit the community within their own space to help them feel more comfortable rather than attacked and defense. 

Other places that the community gathers is local coffee shops Cedar Riverside, where many Somali people reside. The elders in the community gather around these coffee shops and I believe that if health care providers and trained Somali individuals they could talk with the elders and change their mindset about mental health as well as break the cycle of minimizing mental health that has been passed on through the generations. Visiting the community in the space that if feels comfortable in would make the journey of connecting with the community much easier.

The most common mistake that health care providers make is that they send one of their own into a community and hope to get their message across. It is very rare for a community to greet that individual and accept them immediately. I believe that it is important to have an individual from the community who has the proper training to reach out to the community. In the Somali community it would be easier to send in a trained Somali person in to the community because the community is more likely to accept that person because of the similar background that they come from. They both share similar culture and traditions and above all they speak the same language.

Conclusion

Mental health illness is common within the Somali community because of the traumatic experiences that they have been through escaping the civil war and witnessing the violence that comes with it.  With mental illness being invisible to people, people in the Somali community choose to ignore their symptoms and hope that they are mentally stable. Building awareness in the community helps people to open about their health issues also allowing health care services to help people in the community. It is important for health care providers to understand the different barriers that the community experiences, without being culturally competent, the practitioner could do more harm than good in trying to reach out to Somalis. The community needs to feel understood and supported from health care practitioners because they already feel like outsiders living in a foreign country. With the help of practitioner and people in the community opening up about their mental health issues it allows to reduce the stigma surrounding mental health in the community. Training the youth and individuals in the community not only does it help the community in the present but it also benefits the community in the long term. Teaching the youth at a young age what mental health is and the importance of understanding mental health issues allows them to be aware of their own and others symptoms that they might encounter. Whereas to training individuals from the community such as the elders or leaders of the mosques gives providers a higher chance of connecting with the community and spreading the awareness.

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