Mental Health Problems and Healing among Somalis in Sweden* Johan Wedel I. Introduction Refugees are particularly at risk of mental health problems and they often have special needs that must be met if integration into the new country is to succeed.1 However, there is a lack of research that focuses on the refugees’ own perceptions and ideas about mental health.2 One of the largest refugee populations worldwide is the Somalis. It is esti- mated that more than a million have fled their country because of the civil war.3 Many Somalis in the diaspora experience anxiety, marginal- ization, and mental health problems. At the same time, few make use of biomedical health services when suffering. Moreover, there exists a certain mistrust of the biomedical health sector.4 In addition, many Somalis turn to non-Western healing practices when suffering from episodes of ill health.5 Somalis in the diaspora have depression and anxiety related to war, the loss of family members, and afflicting spirits known as jinni or jinn.6 This essay examines ideas and experiences of mental health prob- lems among Somali refugees in Sweden. It explores these issues from an anthropological perspective by emphasizing people’s own words about illness, healing, and well-being. In so doing, the article adds to the knowledge about how Somalis in the diaspora conceptualize and respond to mental illness. 73 Bildhaan Vol. 11 II. Somali-Swedes and Medical Health Care Services About 30,000 Somalis reside in Sweden today.7 Many suffer from health problems. The probability of becoming hospitalized is high among Somalis, both compared to native Swedes and to other immigrants.8 Many also feel discriminated against, stigmatized, and unwanted in Swedish society; a situation that tends to lead to isolation and segrega- tion. At the same time, the role of religion as a source of comfort has become more important.9 A. Swedish Medical Health Care Personnel and their Encounters with Somali Patients When interviewing Swedish biomedical health care personnel about their encounters with Somali patients, it was generally agreed that Somalis seldom sought help for mental health problems and that med- ical doctors hardly ever recommended or referred patients to psychia- trists or psychologists or prescribed antidepressants. A physician said that, “many Somali patients suffer from depression but few will admit it and very few consult a health care unit [for mental health problems]. If I tell someone that he has a psychological problem, he will deny it.” Another physician claimed that Somali patients generally made a sharp distinction between body and soul, and that “the soul is very rarely discussed.” He also felt that he was expected to present a diag- nosis almost without asking the patient anything: “If I ask a patient what he thinks about his problem, I will appear very strange. A doctor is supposed to know the problem.” Somalis often expressed psychological problems as “headaches, chest pain, and forgetfulness,” according to McGraw Schuchman and McDonald.10 Medical personnel in Sweden claimed that Somali patients often had diffuse pain in the whole body or in a certain body part, such as the head or the back. This could move around and after some time cause pain in another part of the body. In many cases, according to the biomedical practitioners, the physical symptoms could be related to stress and feelings of worry. A physician explained that, “Many women are single and they have between three and eight children. This often causes a lot of stress.” The physicians and nurses reported that Somali patients often exaggerated their symptoms in order to get the physician’s attention, but also that they were very stoic and seldom showed any signs of pain in their faces when they were examined. This, in turn, often made it difficult to give a diagnosis. On the whole, 74 Johan Wedel Somali patients were considered to be “difficult to deal with” and sometimes hard to understand. B. Somali-Swedes’ Experiences with Biomedicine and Biomedical Personnel Many Somali-Swedes have experienced prejudice, discrimination, and even racism in Swedish society.11 Prejudicial treatment was also common when meeting with physicians and nurses. Several people recounted that there was little understanding for Somali forms of heal- ing in hospitals, such as reading the Qur’an. On occasion, the reading was interrupted because visiting time was over, which, in turn, could complicate and delay the healing process. A woman in her thirties retold a story about a very sick young Somali girl in a Swedish hos- pital. The physicians had first opposed the Qur’an reading but later gave in when they could do no more for the girl. In the narrative, the girl became well after an imam had read the Qur’an and the physicians were very surprised. A Somali woman in her early thirties gave her view of the problems that Somali people encountered: There are a lot of prejudices against Somalis. People have heard that Somalis are difficult, complicated and strange. If I am mentally ill and behave completely crazy, they will say it’s a ‘Somali thing’ or a ‘Somali woman.’ I went with a friend to the Health Unit. She suspected that she had sinus- itis. She had been sick for several days and had a lot of pain. The physi- cian asked her how many children she had. She said eight. Then he said, ‘You are not sick, you are worn out, that’s why you feel like this.’ She had to leave without treatment. I have heard several mothers saying that they never reveal how many children they have so that the doctor won’t think they are sick because of their children. They are told to do gym- nastics, drink water, meet people and that they have too many children. Swedes see children as a problem. We see children as resource, richness and an obligation. III. Somali Concepts of Mental Ill-Health Mental illness is generally denied and stigmatized by Somalis.12 Hospi- talization because of mental illness is also highly stigmatized in Somali culture.13 It is usually not until someone becomes severely ill and, for 75 Bildhaan Vol. 11 example, is struck by a psychosis and cannot take care of himself/ herself that psychiatric or biomedical health care is considered. Inter- viewees commonly expressed a fear that there would be rumors about madness or spirit possession if it became known that one sought help for depression or other mental health problems from biomedical health care services. It was also considered improper to recommend that someone seek psychiatric care or psychological help as this could eas- ily cause feelings of shame, frighten the person, and affirm that he/she actually had become “crazy.” Moreover, to take antidepressants also “confirmed” a state of madness. A middle-aged man said that he did not expect the psychologist to understand him or his culture. In fact, he expressed fear that the psychologist’s questions “could make it worse.” He also expressed worry about possible side effects of antidepressants and fear that psychiatric treatment could lead to being locked up in a mental institution for years. Overall, Somali-Swedes seldom contact psychologists.14 Many are inclined to avoid psychological treatment as psychologists tend to be associated with mental illness.15 When talking to an academically edu- cated Somali woman in her thirties about why so few people sought psychological help for their mental health problems, she said: The problem is that we Somalis don’t believe in psychologists. That is especially true when one, for example, hears voices [which is a sign of possession by spirits, or jinn]. Many suffer from post-traumatic stress disorder. They go around with neurotic symptoms for years and nothing happens. Then they get a psychosis. She added that it should be possible for physicians to refer Somali patients to someone who had psychological knowledge but who did not openly carry the “epithet” psychologist. In this way, patients with mental health problems would get a collocutor and could discuss their problems without being viewed as “mad” by others or by themselves. A man in his early forties reported that some Somali men were depressed because they lived alone and felt lonely, and that this had to do with gender relations in Sweden: “If you are a real Muslim, you should not live alone. You have to get married to avoid problems. The problem is that here in Sweden the women have a higher status and importance. They sometimes kick out the men.” The Somali language contains several words for describing various stages and forms of mental ill-health. “Welwel” was described by the 76 Johan Wedel Somali-Swedes as a form of general stress, worry, or depression, to some extent caused by the Swedish winter weather. The term “murug” also refers to feelings of severe stress and anxiety, frequently due to worry about unemployment or family problems or constantly thinking of relatives in war-torn Somalia. A woman in her thirties explained: “You could have problems in your marriage and no one to talk to because you don’t trust anyone or you could hear bad news from your hometown where you have family. Then you sit and think about that constantly, until you are completely overwhelmed and obsessed by worry.” Another concept is “buufis,” which indicates severe depression or near insanity. The malady may strike Somalis in Sweden but it mainly affects men in Somalia and in refugee camps in neighboring countries, commonly those who have strived to migrate to the West for a long period of time.16 A 25-year-old woman explained: “You have this long- ing which is never realized and you become like crazy.