Going 'walli' and having 'jinni': Exploring Somali expressions of psychological distress and approaches to treatment

Western researchers conducting studies with Somali refugee participants have identified Somali-specific idioms of psychological distress as well as high rates of Western psychological disorders such as depression and post-traumatic stress disorder (PTSD) in this refugee group. Methodological limitations of these previous studies, however, have limited the validity of the conclusions drawn. These limitations include the use of Western psychometric instruments and diagnostic nosologies, limited information about the methodological procedures undertaken, the apparently unqualified use of terms such as mental illness, madness and craziness in interview schedules, minimal exploration of psychosomatic idioms of distress, and limited applicability of some of the research findings to Somali women.. The current research primarily aimed to address these methodological short-comings and build on the findings of previous studies that have explored Somali conceptions of distress. Two additional objectives were to (i) identify protective and resilience factors which may decrease vulnerability to experiencing psychological distress in Somali women, (ii) gauge non-Somali health professionals' understanding of (a) the nature of distress and suffering experienced by Somali women, and (b) effective treatment modalities to ameliorate this distress. The analytical style employed in all three studies of this thesis was thematic. In the first study, ten Hamilton (New Zealand) based Somali women were interviewed. Particular areas of interest explored in the first study included psychological, physical and spiritual conceptions of distress, the symptoms of key idioms of distress, and the way in which these are managed/treated at the individual, community, and family levels. The findings of Study 1 identified spirit (jinn) possession as a form of distress known by at least some members of the local Somali community. Jinn appeared to be an explanation for both milder forms of distress akin to depression and anxiety, as well as more severe forms of distress similar to psychosis. Treatment for jinn possession tended to focus on Koran readings in conjunction with family and community-based support. Generally participants considered there was a very limited role for mental health professionals and Western psychiatric medication in the extraction of jinn. Faith was considered a key protective factor against experiencing non-spiritual forms of distress such as stress, worry, anxiety and depression. Although war trauma was acknowledged to have an adverse impact on the psychological functioning of Somali women it was not considered to impact on a woman's ability to manage her day-to-day responsibilities. The impact of having family in refugee camps in Africa was, however, identified as a common and very distressing issue impacting on many Somali women. The only way of alleviating the distress associated with this stressor, according to participants, was reunification. Interviewees stated that Western interventions for distress were rarely pursued by Somali as they were not considered efficacious. Given there is evidence that Somali communities residing in various cities in New Zealand are at various stages of acculturation, it was considered important to ascertain how valid the results from Study 1 were considered to be by women from other Somali communities. Six focus groups were conducted with a total of 27 Somali women recruited from three New Zealand cities. The findings of Study 2 identified numerous culturally specific forms of distress reported by participants. These states were qalbijab, boofis, murug, welwel and jinn. These Somali idioms of distress were akin to some Western psychological disorders, particularly the depression and anxiety spectrums. Treatment for Somali forms of suffering were reported to focus on Koran readings, in addition to family and community support. Generally, participants in Study 2 considered there was a very limited role for general practitioners (GPs) and mental health professionals in assisting Somali to deal with psychological and spiritual distress. Consistent with the findings of Study 1, faith was considered the most important protective factor, family separation was described as one of the most significant stressors, and war related trauma was suggested to cause significant distress only if the sufferer had family still in Africa. Study 3 explored non-Somali health practitioners' understanding of Somali idioms of distress, as well as their perspectives about how to best treat Somali presenting with psychological distress. A total of 18 mainstream mental health practitioners, general health practitioners (both GPs and primary care nurses), and specialist refugee mental health practitioners took part in this research. Few practitioners mentioned spirit possession as an aetiology for distress and none mentioned other Somali-specific forms of distress. The psychosocial stressors identified as contributing to the psychological distress of Somali women were relatively consistent across the three groups of practitioners and also consistent with the stressors identified by participants in Studies 1 and 2 (e.g., family separation, social isolation, financial concerns). Interviewees did not consider PTSD to be a common psychological disorder amongst Somali women living in New Zealand. Advocacy work and assistance with day-to-day concerns were suggested by many participants as more efficacious for the amelioration of psychosocial stressors than medication-based treatment. Generally, participants in Study 3 were supportive of traditional forms of healing being used as the treatment of choice by Somali clients. The findings of the current thesis suggest that there are clear parallels between Somali idioms of distress and those of Western cultures. However, the data indicate that equating Somali idioms with Western diagnostic labels would be rejected by Somali. Regardless of the similarity of symptom profile of some of the Somali states to Western states, the manner in which these states are conceptualised, understood and treated is markedly different. The findings of all three studies suggested that Somali tend to opt for their own traditional interventions to treat psychological and spiritual forms of distress rather than engage with Western mental health services. Numerous barriers including long waiting lists, mental health practitioners' apparent lack of knowledge/expertise working cross-culturally and poor treatment outcomes were provided for Somali not engaging with such services. The stigma attached to having a mental illness was also considered a barrier to engaging with mental health services. With respect to improving service provision for non-Western clients, an intermediate service that sits between primary and secondary health care agencies is recommended as an effective means of meeting the needs of non-Western clients experiencing psychosocial stressors and mild to moderate psychological distress. It is imperative, however, that any such service involves key stakeholders from the community groups it would serve, in the design, development, and implementation of interventions