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First I will discuss the context of Somali Dutch people in the Netherlands. Then I will elaborate a theoretical framework where I will discuss how stigmatization and non-rational components structure Somali Dutch people’s vulnerability and limited psychological support. Following this, I discuss the shortcomings of the framework by elaborating a structural explanation about how demographical features influence the coping mechanisms of the Somali Dutch people. Finally, I will conceptualize the relevant concepts and discuss research ethics.
Introduction
There are 40.000 Somali Dutch people in the Netherlands, which makes them the second largest migrant group from Africa in the Netherlands (Andriessen et al., 2017). Many Somalis have fled the armed conflicts and ongoing unrest that plagued Somalia since the 1980s. The impact of collective violence and the destruction of social structures was further compounded by a severe drought in 2011, which led to an increase in refugees (Cavalera et al., 2016). The Somali Dutch people in the Netherlands are not doing well, according to a recent study by the Social and Cultural Planning Office (SCP). Language problems, poor school performance, poverty, and a low level of education make their position in Dutch society vulnerable.
Only a quarter of Somali Dutch people have paid work. Unemployment is more than twice as high as among the total group of non-Western migrants and almost six times as high as among native Dutch people (Andriessen et al., 2017). The majority (52 percent) of Somali Dutch people, therefore, depend on social assistance benefits. By comparison, for native Dutch, that is 2 percent (CBS, 2018). There is a lot of poverty among this group of migrants. More than two third of Somali Dutch live below the poverty threshold. Of the Somali Dutch children, 82 percent live in poor households (Andriessen et al., 2017).
Research have shown that the perceived health among refugee groups is generally less good than among people without a migration background (Hadgkiss and Renzaho, 2014). Refugees – in addition to the regular factors that influence health, such as socio-economic status, living environment and lifestyle – are faced with additional factors. This may include pre-flight factors (such as war and shocking events in the country of origin), but also events that occur during or after the flight (Andriessen et al., 2017). Several literatures discuss the interaction between social inequality and (mental) health problems (Ikram & Stronks, 2016, Lamkadden et al., 2013, Tuk, 2010). Social inequality both influences (mental) health problems and structures social participation.
There are many uncertainties regarding the perceived mental health of Somali Dutch citizens. Nijenhuis & van Liempt (2014) emphasize that most temporary research is distorted. They argue that traumas and psychological problems are relatively common in the Somali community, but because of the stigmatization on mental health problems, they are not reported. Andriessen et al. (2017) concluded that autochthonous Dutch people visit more often a psychologist than Somali Dutch people. They argue that stigmatization defines the help-seeking behavior of Somali Dutch people. Their research shows that only a small percentage of Somali Dutch seek psychological support.
However, stigmatization may not be the only explanation for the help-seeking behavior of Somali Dutch people. Tuk (2010) explains that the perception and processing of events can differ between cultures, which may lead Somali Dutch people to have a very different conception of psychological problems than what is customary within Dutch society. Health professionals frequently find it challenging to provide assistance to displaced Somalis with mental disorders or psychosocial problems due to distinct cultural and religious conceptualizations of mental health and psychosocial wellbeing (Cavalera et al., 2016).
Somali people have different embedded cultural explanatory models for coping with mental illnesses. Explanatory models refer to the way that people explain and make sense of their symptoms or illness, in particular how they view the causes, course and potential outcomes of their problem. This includes how their condition affects them and their social environment, and what they believe is appropriate treatment (Cavalera et al., 2016). Another possible explanation is the collectivist Somali culture, which offers a lot of mutual help within the community. This is usually regarded as a protective factor for mental health problems (Andriessen et al., 2017).
In order to adequately address the vulnerable position of Somali Dutch in the Netherlands, I propose to critically evaluate the mental health of Somali Dutch people and the obstacles in seeking psychological support. In order to do so I will elaborate a theoretical framework that focuses on stigma, explanatory models and structural forces which influence coping mechanisms and help-seeking behavior.
Theoretical framework
Stigma
Society establishes the means of categorizing people and the complement of attributes felt to be ordinary and natural for members of each of these categories (Goffman, 1963). Goffmans (1963) stigma is based on micro-level processes in which stigma occurs and are reproduced. Goffman (1963) argues that people value and devalue others within the process of categorization. People make assumptions as to what the individual before us ought to be. The character we impute to the individual is what Goffman (1963) conceptualizes as a virtual social identity. The category and attributes that the person could in fact prove to possess are the actual social identity. The discrepancy and attributes that make the individual different from others in the category make that the individual is reduced from a usual person to a tainted or discounted one. Such an attribute is a stigma. It constitutes a special discrepancy between virtual and actual social identity (Goffman, 1963).
Goffman (1963) identifies three types of stigma. The stigma of character is described as blemishes of individual character perceived as weak will, domineering, or unnatural passions, treacherous and rigid beliefs, and dishonesty, these being inferred from a known record of, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, and radical political behavior. (Goffman, 1963, p. 4). Physical stigma relates to various physical deformities. The third stigma, tribal stigma, relates to tribal identities such as race or ethnicity.
Sheehan et al. (2017) explain how the application of the social-cognitive model contributes to the understanding of stigma, and especially to explain the processes of stigma development for people with mental illness. According to the social-cognitive model stereotypes, prejudice and discrimination are components of stigma formation (Sheehan et al., 2017). Stereotypes can be described as public attitudes and prejudices as the emotional reaction resulting from the agreement with public attitudes. Discrimination is the behavior that results from stereotypes and prejudices (Sheehan et al., 2017). In the case of mental illness, social cues such as eccentric appearance or the presence of symptoms provide the foundation from which the process of stigmatization unfolds (Sheehan et al., 2017). Therefore, I will demarcate the analyses by focussing on Goffmans (1963) stigma of character and physical stigma.
Stigma and help-seeking
Corrigan (2004) discusses the link between stigma and help-seeking behavior. Corrigan (2004) argues that many people who would benefit from mental health services opt not to pursue them. One of the main reasons for this disconnect is stigma. In order to avoid the label of mental illness and the harm it brings, people decide not to seek mental support. Ikram & Stronks (2016) argue that the prevalence of mental health problems is higher among refugee groups than among native Dutch people. Lamkadden et al. (2013) substantiate this by showing that the prevalence of posttraumatic stress disorder, depression and anxiety symptoms are higher among refugee groups than among native Dutch.
However, temporary statistics show that there is no difference in the experienced physiological health of Somali Dutch and native Dutch. This earlier discussed distortion in temporary research is in line with Corrigans (2004) link between stigma and help-seeking behavior. Andriessen et al. (2017) emphasize that the frequency in which Somali Dutch and native Dutch seek psychological help differs. They argue that it is likely that the stigmatization of psychological problems in Somali Dutch culture influences help-seeking behavior. In all observed Somali Dutch groups, only a small percentage have had contact with a psychologist. Andriessen et al (2017) argue that this may indicate that the stigma on psychological problems applies throughout the entire group.
For several decades, the people of Somalia have been confronted with severe levels of armed conflict and forced displacement (Cavalera et al., 2016). Several literatures suggest that a large number of Somali Dutch people experience traumas and severe psychological health problems and it is argued that stigmatization influences the help-seeking behavior of Somali Dutch people (Andriessen et al., 2017; Kam & Stronks, 2016; Nijenhuis & van Liempt, 2014; Hadgkiss & Renzaho, 2014). In turn, mental health problems structure the social participation of Somali Dutch people and influence social inequality. However, stigmatization on psychological health problems are not the only obstacle for Somali Dutch people coping with psychological problems.
Explanatory models
The explanatory model is a term that denotes the ‘notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process’ (Patel, 1995 p. 1291). Explanatory models are formed from a variable cluster of cultural symbols, experiences and expectations associated with a particular category of illness (Patel, 1995). It relates to sickness labeling and cultural idioms for expressing the experiences of illness and have been shown to influence health-seeking behavior and health service utilization (Patel, 1995).
Explanatory models thus refer to the ways that people explain and make sense of their symptoms or illness, in particular how they view causes, course and potential outcomes of their problems. This includes how their condition affects them and their social environment, and what they believe is appropriate treatment (Cavalera et al., 2016). Explanatory models have potentially important implications for coping, help-seeking behavior, treatment expectations and worries about the long-term consequences of illness (Cavalera et al., 2016).
Cavalera et al. (2016) discuss the difficulties in western countries with providing assistance to displaced Somalis with psychological problems. Caused by distinct cultural and religious conceptualizations of mental health and psychological problems in Somalia. Also, Tuk (2010) argues that the perception and processing of psychological problems differ between cultures, which may lead Somalian Dutch people to have a completely different view on psychological problems common in Dutch society.
Somalian explanatory models of psychological health
In Somalia, the traditional concepts for mental distress are much more fluid than psychiatric, western categories. the description of distress may not fall into any specific western psychiatric category. However, these conditions may lead to serious suffering if the person is not able to recover from them (Cavalera et al., 2016). Mental health and treatment are relatively new concepts in Somali culture. For that reason, when talking about mental distress it is always important to remember that emotional states, by themselves, are not the central concern of the Somali population (Cavalera et al., 2016). In Somali culture, mind, body and spirit are seen as a whole, and for many Somalis, it may be odd and unusual to define their distress in psychological terms.
In Somalian culture spiritual factors play an important role in the explanation of mental disorders and psychological problems. The cause of illness if often captured in spiritual terms: Gods will and ones pre-determined fate (Cavalera et al., 2016). Western discourses are heard less among Somalis. When asked about the origin and cause of a disease the answer may simply be only God knows. Anything that comes to people in this life, good or bad, is seen as coming from God (Cavalera et al., 2016).
Mental illness is also thought to come from evil spirits. Evil spirits are generally known by the generic term Jinn. According to Islamic belief, Jinn are real creatures that form a world other than that of mankind, capable of causing physical and mental harm to human beings (Khalifa & Hardie, 2005). When a Jinn enters a human being, the person may hear voices or speak with an unfamiliar voice. Jinn are thought to cause a wide range of distress, including emotional states of fear, anxiety, apathy, general malaise, violent behaviors, hearing voices, shouting, crying, unhappiness and suicide attempts, but also somatic symptoms such as sleeplessness, tiredness, nausea and vomiting, fainting and persistent headache (Cavalera et al., 2016).
Other common explanations of metal health problems are Sar spirit possession, the Evil eye, curses and witchcraft. The psychiatric classification system DSM-IV describes Sar 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, 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 (Cavalera et al., 2016).
From a western view, explanatory models could be considered as non-rational components in order to manage vulnerability and mental illness. However, according to Bastide (2015), these forms of coping and managing trust are also found in western countries. Bastide (2015) emphasizes the role of faith or magic in modern society. Which highlights the presence and relevance of non-rational components when coping with illnesses and vulnerability. Several literatures suggest that explanatory models influence coping, help-seeking behavior and treatment expectations. It is plausible to suggest that spiritual factors influence the coping and help-seeking behavior of Somali Dutch people. In order to fully understand the coping of Somali Dutch people we must understand how the explanatory models influence the approach toward mental health problems.
A theoretical focus on stigma could potentially explain why few Somali Dutch people seek professional support for psychological problems. The focus on micro interaction and stigma partially explains the vulnerability of Somali Dutch people. However, it does not explain how cultural attributes influence coping of mental health problems. Explanatory models explain how non-rational components define the way that people make sense of their symptoms or illness and how to cope with them. Taken together, these theories offer a comprising theoretical lens to approach the difficulties of Somali Dutch people in the Netherlands. Nonetheless, this theoretical framework is neglecting a structural approach of the vulnerability of Somali Dutch people.
Structural approach
An alternative approach for coping with mental illness in Somalia is the collectivist Somali culture, which offers mutual help within the community. This is usually regarded as a protective factor when experiencing psychological complaints (Andriessen et al., 2017). Within the specific Somali context, having a strong social network reliant on extended family and community may be the primary factor contributing to resilience. For people with severe mental disorders, the extended family plays a key role in supporting patients, and it is considered the responsibility of the family to do so (Cavalera et al., 2016). People from collectivist cultures are more interdependent within their in-groups and are especially concerned with relationships (Finnström & Söderhamn, 2006) The needs of the group or family are given priority over the needs of the individual. The group is expected to help and support the individual that is in need (Finnström & Söderhamn, 2006).
In the Netherlands, a substantial part of Somali immigration consists of minor children. In the second half of the nineties, this group made up forty percent of Somalis’ total immigration (Andriessen et al., 2017). The Somali Dutch people can be considered as a young group. Somali Dutch households are more often single-parent households than other refugee groups in the Netherlands (Andriessen et al., 2017). The Somali community is also characterized by a relatively small percentage of couples, both with and without children (Andriessen et al., 2017).
It could be assumed that structural forces such as being a refugee and age influence coping and resilience with mental illness of Somali Dutch people. An intersectional approach of these categories could address important aspects of the vulnerability of the Somali Dutch people.
Intersectionality emphasizes how interlocking systems impact the most marginalized in society. Intersectionality addresses the effects of the intersection of structural forces and social categories (Mattis et al. 2008). In this specific context, the analysis is about the effects of being a Somali Dutch migrant in the Netherlands and the effects of age. Crenshaw (1989) argues that it is problematic to use exclusive categories in analysis. A single-axis analysis distorts multidimensional experiences as the intersectional experience is greater than the sum of the experiences of exclusive categories. Intersectionality is not about overlapping factors and categories, but about interwoven experiences that are far more nuanced than the sum of their constituent parts.
Being a young Somali Dutch migrant could potentially influence the coping and resilience mechanism based on collectivist community networks. Most Somali Dutch arrived in the Netherlands as minor migrants which possibly leads to an absence of a strong social network. This could negatively influence the required support with mental health problems as people from collectivist cultures are especially concerned with relationships, family and community (Cavalera et al., 2016). Therefore, it could be argued that the intersectional experience of young Somali Dutch migrants are greater than the sum of age and Somali Dutch (migrants). Young Somali Dutch migrants possibly could be multiply-burdened and their various forms of stratification therefore should be seen as interwoven together.
Operationalization
Stigma
Operationalization and data collecting focus on how stigma, explanatory models and structural forces influence coping with mental health problems. The dominant conceptualization of mental health stigma is composed of three interrelated constructs: stereotypes, prejudices and discrimination (Corrigan & Watson, 2002; Sheehan et al. 2017). Stereotypes can be understood as especially efficient, social knowledge structures that are learned by most members of a social group (Corrigan & Watson, 2002). Stereotypes are considered social because they represent collectively agreed-upon notions of groups of persons. Stereotypes are efficient because people are able to quickly generate expectations of individuals who belong to a certain group (Sheehan et al. 2017). Prejudices endorse these negative stereotypes and generate negative emotional reactions as a result. In contrast to stereotypes, which are beliefs, prejudicial attitudes involve an evaluative component. Prejudice also yields emotional responses to stigmatized groups (Corrigan & Watson, 2002). Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination or a behavioral reaction.
Explanatory models
Bhui & Bhugra (2002) argue that explanatory models should be researched with participant observation and open-ended conversation in order to embrace the authentic view of the participants world. Emphasizing certain aspects of the explanatory model leads to higher priority, leading to the neglect of the patient’s total experience of the illness (Bhui & Barga, 2002). The approach is to learn about indigenous systems of healing and explanatory models which are common to specific cultural groups so that an understanding of distress which is closer to the patients experience. However, as Bhui & Barga (2002) argue, it is important to conduct interviews openly without referring to specific aspects. Qualitative research must also provide insight in how the intersectional effects of age and Somali Dutch migrants influence the coping and resilience of psychological problems.
Data collection
The necessary data will be collected with qualitative interviews. In qualitative interviewing, there is great interest in the interviewees point of view. Qualitative interviewing tends to be flexible, responding to the direction in which interviewees take the interview and perhaps adjusting the emphases in the research as a result of significant issues that emerge in the course of interviews (Bryman, 2012). In order to adequately address the main concepts I will conduct semi-structured interviews. I will make use of an interview guide, but it also offers the interviewee a great deal of leeway in how to reply (Bryman, 2012). Questions that are not included in the guide may be asked as following the answers of the interviewee.
Ethics
Beauchamp & Childress (2001) describe four ethical research principles. The first is non-maleficence and concerns not doing harm to the research group. Bourdieu (1999) argues that the research relationship is primarily a social relationship. As such, it can have an effect on the results obtained. Researchers must be aware of the distortion in this relationship and potentially exerting any form of symbolic violence (Bourdieu, 1999). Therefore, Bourdieu (1999) argues for a relationship of active and methodological listening. In order to do so, the interview must meet certain criteria. Preferably, there is cultural proximity, understanding and submission of the subjects life history and knowledge of the context and structures in which the subject is embedded.
As the interviewer, I have a considerable social and cultural distance to the interviewees. The interview is set up to further understand the respondent’s worldviews. Hence, it is very likely that the interview is somehow distorted by the relationships of a different kind of capital and cultural asymmetry. I must be aware of reducing subjective reasoning to objective causes and possibly adjusting the level of language and status signs in the interview.
Constant labor of construction could potentially limit the effects of the research situation on the obtained answers (Bourdieu, 1999). When conducting interviews, there must be great emphasis on the understanding and submission of the subject’s life history and knowledge about the context and structures in which the respondent is embedded. Therefore, if possible, multiple interviews with the same respondent should be conducted. The second ethical principle that Beauchamp & Childress (2001) describe is beneficence. This is related to the question if the respondents benefit from being involved. Logically, the respondents will participate anonymously. As a group, the aim is to further understand the vulnerability of Somali Dutch people in the Netherlands. Results could be used for more appropriate support and policy. The third principle is respect for autonomy. It is important that is clear for respondents that they can quit and stop participating whenever they decide to do so. For the fourth ethical consideration, justice, we must question for what ends the research could be used. The research focuses on adequately addressing the vulnerable position of Somali Dutch and it implies the limited risk of harming this group.
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