By Edwin N. Swaray, MA. LADC, CBIS Lead Case Manager, Vinland National Center

1. A Holistic Treatment Approach for African Immigrants and Refugee Populations with Co-Occurring Disorders By Edwin N. Swaray, MA. LADC, CBIS Lead Case Manager, Vinland National Center

2. Objectives • Understand the benefits of creating a holistic treatment strategy when working with African immigrants and refugees • Gain an understanding of the migration and immigration processes, acculturation stressors, and the mental health implications for African immigrants and refugee communities • Increase awareness on the importance of utilizing culturally sensitive approach when working with African immigrants and refugees

3. Holistic Wellness • ‘Parts of a whole’ are intimately interconnected. Therefore, they cannot exist independently of the whole, or cannot be understood without reference to the whole. The whole is regarded as greater than the sum of its parts. • Every part of us, our minds (mental), bodies (physical), emotions (emotional) and spirits (spiritual) are interconnected and have an effect on each other, as well as an effect on each of the major areas of life; health, career & finances, family & relationships, spirituality & self-development.

4. Holistic Wellness • Exercise and unhealthy diet • Sleep/memory • Planning/organization in a time-oriented society • Therapeutic process – time, topics and results

5. African Immigrants and Refugee Populations • Pre-immigration Challenges: • We migrate differently. The migration process is multifaceted and entails components of stress, physical or psychological trauma, violence, war, torture, robbery, rape, murder, diseases etc.

6. Post-migration Challenges–Acculturation Stress • Language barriers • Academic struggles • Employment problems • Financial stress • Credit and Credit Cards • Housing • Homesickness

7. Post-Migration Challenges–Acculturation Stress • Lack of social support • Cultural adaptation • Discrimination • Police/Law enforcement • Changes in gender roles • Inter-generational conflict

8. African Cultural Understanding of Mental Illness • Mental illness is seen as a spiritual problem, a result of evil spirits and/or demon possession(Somalis call it “Jinn”) • Spiritual problems require spiritual solutions: Imam uses verses from the Koran to chase the demons away, or to cleanse one of the evil spirit • In most African cultures, people will go to their pastors, priests or traditional healers to pray the demons away • In Liberia, Molleyman (traditional healer) uses African science (traditional medicine) to heal or cleanse people

9. Etiology of Mental Illness • Researcher (Arboleda-Flórez) asked Nigerians about the cause/causes of mental illness • 34% respondents cited drug misuse  • 19% said “Divine Wrath” and the “Will of God” • 12% reported witchcraft and spiritual possession  • Some cited other causes including genetics, socioeconomic status, war, conflict or the loss of a loved one • African men and mental illness

10. Mental Health Treatment • In a survey based out of Nigeria, only 8% of people reporting Serious and Persistent Mental Illness (SPMI), had received treatment in the preceding 12 months. • The same survey showed that in South Africa, 25% of people reporting SPMI, had received treatment in the preceding 12 months. • STIGMA • Mental illness is seen as a weakness • Seen as a sign of retribution for family wrongs • Most African countries do not prioritize mental health issues and therefore half of the countries on the continent do not have a mental health policy. • Mental illness is seen as weakness • See as a sign of retribution for family wron

11. Suggestions for working with African Immigrants • Focus on Collectivism vs Individualism • Confidentiality • Privacy - cameras • Learn about client’s country of origin. Do not mistake an Eritrean for an Ethiopian or an Ethiopian for a Somali. This could negatively impact the therapeutic relationship • Initiate discussions around cultural beliefs, practices, and mannerisms • Educate clients about mental illness – continuum of severity • Help dispel stigma about mental illness and treatment

12. Suggestions for working with African Immigrants Idioms of Distress: modes of expressing suffering which often reflect values and themes found in the societies in which they originate • Focus on symptoms NOT diagnosis • Example : Anxiety: “They’re just worried about things…they call it fekerayaa,”which means “just thinking about things.” • Depression: “They feel they’re just sad, don’t feel like eating, or don’t feel like sleeping.” • Make connections between tangible stressors (lack of money, employment issues, inability to take the bus) to mental health symptoms. • Normalize experiences • Build relationship, develop level of trust before engaging in difficult topics

13. Difficult Topics: Suicide Suicide is one of the most sensitive topics because “the act of suicide is taboo” according to Islamic teachings.

14. Difficult Topics: Sex and Sexuality • Sexuality is perceived as an inappropriate topic to assess, particularly when a male clinician asks a Somali woman • The interpreter may consider the question inappropriate and may not discuss it with the clients • Homosexuality is a taboo topic in most African Cultures

15. Difficult Topic – Substance Use Disorder (SUD) • Khat is a stimulant drug that comes from a shrub that grows in East Africa and southern Arabia. Like chewing tobacco, leaves of the khat shrub are chewed and held in the cheek to release their chemicals. Cathinone and cathine are the stimulants in khat that make a person feel high. • Khat is used among Somalis of all ages and should be assessed as a standard topic in the substance abuse category • Cane Juice, Palm Wine – Alcoholic drinks in Liberia • Alcohol is used as a means to connect socially • Men use alcohol to accentuate their masculinity • Functional Alcoholic

16. Religion: Islam supports Medication Assisted Treatment (MAT) Religion - Islam supports Medication Assisted Treatment (MAT • “The Qur'an frequently depicts unbelievers as having hearts which are diseased. This belief is in alignment with the medical model of addiction - for those who meet the criteria of dependence, it is a disease” • http://www.12wisdomsteps.com/islam/01_powerlessness.html

17. Working with Interpreters • Culturally Bound – Recurrent patterns of behaviors and experience that are specific to certain cultures • How Somalis greet non-Muslims • How members of opposite genders interact • Cultural mannerisms • Cultural beliefs • Cultural practices • Holidays/Celebrations– Fasting, country of origin independence day (Ex: Liberian Weekend off)

18. Working with Interpreters • Are client and interpreter from the same clan? • Are they the same gender? • Are they of the same faith? • Are they already acquainted/familiar? • Is the interpreter proficient in English? • Provide psycho-education on mental illness and Substance Use Disorder (SUD) • Provide psycho-education in clinical terms

19. Assess Client Social Support Structure • Social isolation may result from • Unemployment • Language barriers • Homesickness • Perception of racism • Discrimination • Affiliation with social groups – (Susu - informal loan club (Liberia) • Affiliation with spiritual or religious groups (Mosques or church)

20. Family Structure and Functioning • Assess overall nature and impact of disruption in family’s functioning • Legal prohibition of polygamy in the U.S. • Legal problems • Separation within the family • Separation or divorce after settling in the U.S. • Inter-generational conflicts

21. Lifestyle Issues • Exercise and unhealthy diet • Sleep • Planning/organization in a time-oriented society • Therapeutic process – time, topics and results

22. Achieving Holistic Wellness • Work with the WHOLE person (body, mind, spirit, health, career & finances, family & relationships, spirituality & self-development) • Have an open mind about different cultures and ethnic groups • Incorporate the use of interpreters to better understand your client (a complex area) • Provide therapy/counseling based on the client’s cultural needs. (at least learn the most basic practices of the client’s culture) • Allow the client to be the expert in their session (do not push your agenda) • Most of all, BE A GOOD MATCH!

23. REFERENCES http://www.12wisdomsteps.com/islam/01_powerlessness.html http://pqdtopen.proquest.com/pubnum/3739831.html?FMT=AI http://www.msktc.org/tbi/factsheets/Memory-And-Traumatic-Brain-Injury https://www.takingcharge.csh.umn.edu/what-spirituality https://rachelevaonline.com/living-a-holistic-life/ www.mentalhealthwales.net https://research.vu.nl/ws/portalfiles/portal/42204451/hoofdstuk+2.pdf Rev. Dr. Andrea Travers, Sacred Connections: Unifying Principles of the 12 Steps of A.A. in the Wisdom Traditions Dr. Vivian Swaray, VEEMAH Integrated Wellness & Consulting Services, LLC Dr. Dasherline Johnson, Victor Counseling and Consultant Services, LLC Questions? Contact me at edwins@vinlandcenter.orgor 763.479.3555