Dr. Dasherline Cox Johnson presented her dissertation research on Culturally-Sensitive Diagnostic Interviewing Protocol for Somali Immigrants and Refugees at the Minnesota Psychological Association’s 80th Annual Convention on April 16, 2016 and at the 2^nd Annual Mental Health Summit on June 17 in Minneapolis and St. Paul respectively, with the following objectives: 1. Demonstrate cultural-specific understanding of Somali mental health, 2. Recognize relevant issues related to Somali mental health, and 3. Apply cultural competent practice to mental health assessment of Somali clients.

Methodology: The researcher conducted semi-structured, in-depth interviews with eight mental health providers from five local agencies with at least two years of experience working with Somalis. A qualitative method of snowball sampling was conducted to identify research participants. Questions addressed challenges of working with Somalis within the current mental health system and how clinicians handle or resolve them. An inductive content analysis was used to analyze the interviews and to inform the development of a culturally sensitive diagnostic interviewing protocol.

Results: Conducting culturally sensitive interviews with Somali clients would ideally involve both pre-assessment and formal assessment phases. Three major themes became apparent: (a) clinician education about the Somali conceptualization of mental illness and mental health treatment, (b) education of Somali clients about mental illness and mental health treatment, and (c) a culturally sensitive information gathering approach.

Education of Clinicians

Clinicians would benefit from knowledge about the Somali perspective on mental illness, which they tend to reserve for the most extreme psychological cases. From their perspective, a person is either crazy or not crazy. Thus, a theme of denial emerges with respect to milder mental health conditions, which Somalis do not see as conditions that require treatment. It is beneficial to reframe the definition of mental illness for Somalis to capture a continuum of severity, which includes gray areas of human functioning. The results also show that religion plays a fundamental role in the conceptualization of mental illness and mental health treatment. This study reiterates that Somalis believe mental illness is caused by demon possession or evil spirits (Bentley & Owens, 2008; Guerin et al., 2004). Furthermore, findings support education aimed at dispelling stigma related to seeking mental health services. The stigma associated with mental illness results from Somali beliefs about the nature of mental illness and, to some extent, spiritual failings. To some degree, religion also dictates which norms and practices related to assessment and therapy are effective with Somali clients. Results of this study suggest clinicians ought to avoid initiating a handshake with a Somali client due to the client’s need to maintain the cleanliness required for prayer. It is recommended that female clients be assigned to female therapists and males be assigned to a male therapist. Current mental service providers need to be aware of culturally sensitive norms and practices and adjust their practice to accommodate such needs.

A pre-assessment stage could provide the opportunity for clinicians to acquire culturally specific knowledge and skills and establish rapport with the interpreter and the client. Contact with clients aimed at helping to develop rapport and create the atmosphere needed to facilitate communication during the formal assessment is crucial. Moreover, a pre-assessment meeting allows clinicians to develop rapport with interpreters as well as establish effective ways to utilize an interpreter’s service. Meeting with providers and interpreters provide an opportunity to preempt sensitive issues that might arise and/or develop strategies to handle them. Results suggest a solid triadic relationship between the clinician, client, and interpreter helps with avoiding situations that may arise due to a translator’s uncertainty about the translation or the age difference between the client and the translator. It is beneficial, too, for the clinician to initiate discussion of Somali culture and possess an understanding of their mannerisms, cultural beliefs and practices as well as to point out commonalities between the client and the clinician.

Education of Clients

A pre-assessment meeting would ideally provide education and additional assurance with respect to confidentiality in order to encourage clients to consider treatment.  Clinicians ought to explain that therapy can improve mental health symptoms and that psychotropic medication can help alleviate symptoms. Effort to help dispel stigma about mental illness and mental health treatment is imperative. Somali concerns may be conveyed through questions like, ‘Am I going to be chained?’ or ‘Are they going to lock me up?’ or ‘Am I going to be put away where I’m not going to be heard from anymore or will lose my senses?’

In addition, results also suggest that mental illness can be associated with the perceived failure of family members to properly care for an individual. Relatives of the mentally ill may blame themselves and feel shameful, which leads to a tendency for Somalis to hide mental health needs. Thus, endorsing the label of mental illness may lead to rejection and loss of connections within the Somali community. Clinicians should address the stigma and loss of connections to family and friends as well as seek to coordinate treatment with identified family, friends, and community members, thereby gaining support from the client’s support system and educating them when appropriate.

Culturally-sensitive information gathering

Strong evidence suggests a benefit to slow-engagement practices and the use of indirect open-ended questions. This involves beginning with culturally less intrusive topics and gradually moving toward sensitive topics, as well as moving from general to specific inquiries. Diving into a sensitive issue too quickly, before trust has been established, could easily cause the Somali client to deny problems, become defensive, shut down or leave the session. Culturally sensitive assessment involves exploring sensitive issues slowly and gently and/or asking about them indirectly. It also helps to use open-ended questions, preface sensitive questions with a warning, include a third-person example, and normalize thoughts and feelings the client may be tempted to cover up.  

Recommendations for policymakers, agencies, and individuals providing mental health services to Somalis are as follows: Invest in conducting specialized training in relationship-building with Somali clients, interpreters, families, and perhaps the community at large. Such an investment in time and training is an important part of the delivery of mental health service to the Somali population.  Policy makers/agencies should allocate additional resources for training and culturally competent service delivery. Service providers need to be aware of the importance of establishing a trusting relationship, the pace with which Somali clients are comfortable, and the topics they consider sensitive.  Well-trained providers can provide holistic mental health assessment and subsequent treatment based on relevant cultural values. Such service delivery includes important aspects of Somalis’ values such as relationship and religion.  

Dasherline Johnson, Psy.D., is a psychologist at NorthPoint Health and Wellness Center in North Minneapolis. She is embedded in Franklin Middle School, providing school-based therapy to adolescents. She is also the Owner/Founder of Victor Counseling and Consultant Services LLC, and Contracted Multi-Systemic therapist through Washington County Community Corrections.

Questions may be emailed to [email protected] 

References

Bentley, J. A., & Owens, C.W. (2008). Somali refugee mental health cultural profile. Retrieved from https://ethnomed.org/clinical/mental-health/somali-refugee-mental-health-cultural-profile

Guerin, B., Guerin, P., Diiriye, R. O. & Yates, S. (2004). Somali conceptions and expectations concerning mental health: Some guidelines for mental health professionals. New Zealand Journal of Psychology, 33(2), 59-67.

Johnson, D. C., (2015). Culturally-Sensitive Diagnostic Interviewing Protocol for Somali Immigrants and Refugees. http://pqdtopen.proquest.com/pubnum/3739831.html?FMT=AI