Medical Returnees: Somali Canadians Seeking Psychosocial and Spiritual Healing in East Africa by Mohamed Ibrahim M.Sw, Washington University in St. Louis, 2009 Higher Diploma, Psychiatric Nursing, Kenya Medical Training College, 2006 Diploma Nursing, Kenya Medical Training College, 2004 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the Faculty of Health Sciences © Mohamed Ibrahim 2018 SIMON FRASER UNIVERSITY Summer 2018 Copyright in this work rests with the author. Please ensure that any reproduction or re-use is done in accordance with the relevant national copyright legislation. Approval Name: Mohamed Ibrahim Degree: Doctor of Philosophy Title: Medical Returnees: Somali Canadians Seeking Psychosocial and Spiritual Healing in East Africa. Examining Committee: Chair: Maya Gislason Assistant Professor Marina Morrow Senior Supervisor Professor David Ndetei Supervisor The University of Nairobi Professor Lorraine Halinka Malcoe Supervisor Associate Professor William Small Internal Examiner Associate Professor Kwame McKenzie External Examiner Professor of Psychiatry Center for Addiction and Mental Health & School of Medicine, University of Toronto Date Defended/Approved: 26th April, 2018 ii Ethics Statement iii Abstract Background: The refugee experience has been associated with increased rates of psychosocial challenges. At the same time, evidence suggests that those who resettle in Western countries underutilize Western mental health services. The reluctance of refugees to use mental health services has been attributed to barriers to accessing services such as language, complexity of the health system, and differing explanatory models of illness. The same is true for Somali refugees in Western countries. Studies suggest that Somali refugees prefer spiritual healing for psychosocial illness and that some return to East Africa for healing. However, little is known about the mental health of the Somali community in Canada and the services they utilize for psychosocial problems. Objectives: In conducting original ethnographic study, I aimed to understand the psychosocial challenges faced by Somali Canadians, their health seeking behaviors, and their access and barriers to psychosocial services in Canada. Because some have sought psychosocial services at international destinations, I conducted fieldwork in Kenya to provide new evidence on the little-known transnational spiritual healing systems popular among diasporic Somalis. Methods: Ethnographic fieldwork and in-depth interviews were utilized. Thirty-seven in-depth interviews of about an hour each were undertaken in Canada and Kenya. Fieldwork focused on visiting spiritual and cultural healing centers in Nairobi for three to four hours each. Results: The findings show that some families struggle with childhood autism and youth substance use, while others deal with psychosocial and spiritual distress such schizophrenia, depression, and Jinn. The preferred treatment approaches ranged from holistic biomedical treatments combined with spiritual healing to only cultural and spiritual healing. Discussion: This study reveals important findings regarding psychosocial and substance use problems among Somali Canadians. I discuss psychosocial illnesses, challenges with accessing iv Canadian healthcare services, the role of spiritual healers, and seeking culturally appropriate services in East Africa. I further discuss substance use problems among Somali Canadian youth, the lack of culturally appropriate services in Canada, and the emergence of transnational cultural recovery programs in Kenya. I also highlight challenges associated with transnational rehabilitation programs. Keywords: Somali Canadians, translational health practices, ethnography, psychosocial illness, Jinn, dhagan celis. v Dedication To my mother, Rahma Abdi, who enrolled me in primary school so that I would never need an interpreter for English and Swahili (Kenya’s official languages). To my father, Sheikh Abdullahi Ibrahim who embodied the value of education and hard work. To my dear uncle Eng. Dr. Alikheir, thank you for uplifting me and all family members through education. vi Acknowledgements This dissertation would have not been possible without the help, support, and guidance of so many people. Let me take this opportunity to express my deepest gratitude to all those who made this journey a success! I would like to pay tribute to my supervisory committee member, the late Dr. Elliot Goldner who passed on November 27, 2016. His support, kindness, thoughtful critique, and knowledge sharing will be missed, but his work is not in vain. I would like to express my deepest appreciation to my senior supervisor, Professor Marina Morrow. I have learned so much from you and am incredibly lucky to be mentored and taught by you. I cannot thank you enough. I am so very grateful to my committee members, Professor Lorraine Halinka Malcoe and Professor David Ndetei, for your teaching, coaching encouragement and support throughout. In addition, I thank the faculty and my fellow students at the faculty of health sciences for their support throughout this process. Thank you to colleagues and fellows at the Center for the Study of Gender, Social Inequities, and Mental Health. Special thanks go to the research participants, family members and my community—the Somali Canadians in Metro Vancouver and Kenya. This research is for you. I am fortunate to come from an incredible family. Heartfelt thanks to my siblings in North America and Kenya. Finally, my dear wife and friend, Rahma Maalim and our lovely children Hodhan, Fatuma Udgoon & Shaqlan. Your love and support are why this PhD come through. Shukran vii Table of Contents Ethics Statement ......................................................................................................................iii Abstract ....................................................................................................................................iv Dedication ................................................................................................................................vi Acknowledgements ................................................................................................................vii Table of Contents ................................................................................................................... viii List of Tables ............................................................................................................................xi List of Figures .........................................................................................................................xii List of Acronyms .................................................................................................................... xiii Chapter 1: Introduction ........................................................................................................... 1 Self-statement ................................................................................................................ 6 Purpose of Study ...........................................................................................................10 Layout of the Thesis ......................................................................................................11 Literature on Somali Psychosocial Illness: An Introduction ............................................14 Psychosocial Illnesses among Somalis .........................................................................16 i) Spiritual and Psychosocial Illness ........................................................................17 ii) Psychosocial Issues Associated with the Consequences of the Civil War...........18 iii) Psychosocial Issues during In-Transit and Post-Resettlement Periods ..............19 Chapter 2: Theoretical Frameworks ......................................................................................24 Colonial or Ethno-Psychiatry and its Contemporary Relevance in Mental Health Services ......................................................................................................................................25 Transcultural Psychiatric Framework .............................................................................31 Refugee Mental Health Framework ...............................................................................34 Transnational Framework ..............................................................................................38 viii Chapter 3: Study Methodology ..............................................................................................44 Research Methodology ..................................................................................................44 Research Methods ........................................................................................................45 Sampling Methods .........................................................................................................47 Data Collection Procedure .............................................................................................48 Qualitative Interviews .............................................................................................48 Field Study .............................................................................................................48 Research Settings ..................................................................................................49 Metro