Mektab and Sabr: Cultural and Societal Factors Affecting Mental Health Treatment for Moroccan Adolescents

“To be sick is mektab, it is my fate. I must be sabr, have patience and wait for God to solve my problems.” As Zohra Ajaarouj – a social psychiatric nurse for Mentrum, a mental health organization with 15 centers all over the city – notes, this is a common sentiment expressed towards mental illness in Moroccan communities. Such an attitude regarding mental health is only one example of the differences between Dutch society and Moroccan immigrant communities – but this difference can have significant implications for the sufferer. Adolescents are especially prone to these issues, due to the combined and often conflicting demands of home and school. Could it be that they face yet a third challenge when it comes to accessing mental health services? The stigma attached to mental health issues within their own communities, the clash of Dutch and Moroccan values, and a failure to properly identify problem behaviors in schools can all contribute to a decline in mental health among these youths. The results can be disastrous. Take, for example, the October 2007 case of Bilal B., a 22 year old male of Moroccan descent who was killed during an attack on two police officers in the western Amsterdam neighborhood of Slotervaart. In the controversy that followed the attack, his family complained that they had tried to find him adequate psychiatric care for years, but found no effective options. Although his case was complicated by many other factors, it had the effect of pushing the issue of mental health in immigrant communities to the forefront of public consciousness. Specifically, it raises two questions: what are the barriers preventing access to mental health services for immigrants; and, if services are found, are there factors that hinder quality care?

Many studies show that Moroccan youths are more susceptible to mental illness than Turkish adolescents. At first glance, the difference between Moroccan and Turkish communities in the Netherlands may seem minimal. These communities are the largest minority groups in country, with more than 250,000 Moroccan and over 300,000 Turkish individuals. They have similar migration histories, having arrived in the 1960s to supplement the Dutch labor market. Lastly, many Moroccan and Turkish peoples are Muslim by religion, and the children of these families tend to be bilingual, speaking their cultural language at home and Dutch at school and with peers. However, there are some glaring differences between their home countries that highlight these groups’ struggles within the Netherlands. In Morocco, church and state are less separated, and industrialization occurred later than Turkey (which is also more secular). Education levels in Morocco lag behind those in Turkey; whereas 70% of women and 43% of men in the former are illiterate, in the latter, this is true for only 28% of women and 8% of men. In general, these differences mean that Moroccan communities have a wider cultural gap to bridge in a highly secularized, educated country like the Netherlands. Such a drastic process of acculturation among Moroccan immigrants, whether successful or not, can involve stressors that influence mental health.

According to an opinion article that appeared in the Dutch newspaper De Volkskrant in reaction to the Bilal B. incident, immigrants face a higher risk of developing schizophrenia than non-immigrant Dutch. Schizophrenia, as a mental illness, has both “nature” and “nurture” components to its etiology. People with a genetic tendency do not necessarily have to develop the condition. This can also happen when there are factors in that person’s environment that trigger it; for example, using drugs. Other factors that could lead to schizophrenia are: lack of oxygen during birth, sexual abuse, deafness, and migration. Statistics concerning the chance of developing schizophrenia differ among ethnic groups, but generally speaking, they seem to be the highest for the ethnic group that is least successful, and most excluded, in the host society. For instance, Moroccans are arguably one of the most excluded ethnic groups in the Netherlands. First-generation Moroccan men have five times the risk of developing schizophrenia as ‘native’ Dutch. Second-generation Moroccans face an even greater chance of being stricken: seven times the risk. Yet in immigrants' own home countries, the rates of illness are not significantly different from those of other countries – including the Netherlands. It seems, therefore, that migration has a dramatic impact on this disparity.

The progression of schizophrenia is associated with dopamine production, and emotional stressors such as humiliation can increase dopamine production in the brain. Second-generation Moroccan immigrants face more ‘humiliation’ issues since they tend to compare themselves to native peers of their own age, whereas first-generation men often see themselves as “better off” than fellow citizens who remained in their home country. It is also humiliating not to be accepted by people of the country you were born in; this further contributes to humiliation issues for second generation men. Dutch natives, on average, have a 0.8 percent chance of developing schizophrenia. The five to seven-fold elevated risk among Moroccan youth is a significant issue that affects both Moroccan communities, and the Netherlands as a whole.

How does this translate to the classroom, where adolescents are expected to be productive with their peers and in society? A 2003 study by Stevens, Pels, and Bengi-Arslan found that teachers reported more problems for Moroccan adolescents than for Dutch and Turkish adolescents between the ages of eleven and eighteen. This took the form of externalizing, outwardly aggressive behaviors. These researchers theorize that the teachers’ perception of behavioral problems can be based on prejudices they hold regarding the behavior of those adolescents. Moroccan people, and Moroccan youth in particular, are seen as a threat to Dutch society; this was illustrated by the dramatic rise of Geert Wilders’ anti-Muslim party in Parliament, whose platform included a great deal of anti-Moroccan rhetoric. As a result, teachers may watch the behavior of these Moroccan adolescents more closely, and be more apt to report problem behaviors. Alternatively, in this same study, the adolescents and their parents did not themselves report a higher level of perceived problems in the classroom and at home, when compared to Dutch and Turkish adolescents. This gap in perception can lead to further complications when it comes to determining mental health issues such as schizophrenia. Teachers will have a difficult time discussing problem behaviors with the student and family, if in their view no problem exists. This, in turn, can lead to lowered expectations for these students, and results in a self-fulfilling prophecy whereby students perform according to the challenges and expectations assigned to them by their instructors. This negative spiral is not only detrimental to the academic careers of many Moroccan students, but means that even when they referred to mental health services, they may not receive adequate care as a result since there is no clear problem in their perceptions.

Teachers play an important role in the development of children. Complications that might not appear in a safe” home environment could surface in the classroom. It is not only a right, but an obligation on the part of teachers, to report issues whenever they suspect them. In most schools, special care teams exist to monitor the physical, social and mental well being of the children, and these should be properly utilized.

Stigmas concerning mental illness also exist outside of the school. In most societies, it is harder to tell someone that you have a mental health disorder, like schizophrenia, than to explain diabetes or another physical disease. Mental health problems are stigmatized all over the world; in some cultures more than others. In Dutch society people refrain from “airing their dirty laundry”, especially in the case of mental llness. But compared to 30 years ago, it is relatively normal to see a psychologist or be treated at the Geestelijke Gezondheids,- en verslavingszorg (GGZ), the government mental health institution. In Moroccan society, it is commonly believed that people suffering from mental disorders are being punished by God, possessed or ‘touched by the devil’. In general, many psychological and social issues are explained from a religious point of view. This is also the case among young people who grew up with stories about the devil, the evil eye, and other ‘horror’ stories. Such negative connotations of mental illness create a situation in which the stigma becomes harder to overcome.

According to Ajaarouj and child psychologist Sarah Huber, it seems that so-called ‘we’ cultures have more problems discussing and addressing mental health issues than ‘I’ cultures. The Dutch system emphasizes individuality, a straightforward approach, the direct assertion of problems, and asking directly to have needs met. In short, it is your personal responsibility, and much less related to what is important for one’s family or community. In contrast, the Moroccan culture generally operates on the concept of “we”, meaning what’s best for the family, community, etc. Within this cultural paradigm there are other significant issues, which many scholars have recognized. The first issue is the language gap. Some of the first-generation Moroccan families did not have a proper language education. These immigrants worked in professions where learning Dutch was not necessary, and was not encouraged by their employer. Nor was it encouraged by the government, which expected Moroccan immigrants to return home eventually. When wives started to join their husbands in the Netherlands, they mostly stayed at home and did not learn Dutch either. Second and third generations usually speak Dutch better, since they go to school in the Netherlands. But an issue arises when parents of adolescents have to access services in Dutch, but do not understand the treatment offered. In the mental health field, language barriers are an obvious obstacle to quality treatment. But Hubert mentions that there is another issue of interpretation within the Dutch language. Mental health professionals must be able to identify the subtleties in language; at times, what a client says is not what he/she really means. This is a problem that professionals encounter with many Dutch patients, but it is especially difficult with a patient of another culture whose subtleties you are especially likely not to understand.

A second big problem is cultural differences; again, not only in terms of the obvious clashes between cultures, but in more in-depth fashion, especially with respect to autonomy and self-determination of the individual. In ‘we’ cultures, where responsibility falls on every member of the community, the authority figure, such as a doctor or school, is expected to solve a problem or give instructions. Meanwhile, in the Netherlands, an individual is expected to take the responsibility of seeing a doctor and choosing his/her treatment, or to solve school-related problems within his/her own personal sphere. Furthermore, doctors do not want to impose certain treatments for fear of being sued by the patient later. Therefore, there is a mismatch between the expectations and duties of Dutch systems, and Moroccan communities. Dutch society expects these immigrant communities to fend for themselves, and to treasure the individuality that Dutch values hold so highly; whereas Moroccan communities wish for a connection to others in their communities, and rely on systems like schools and healthcare for guidance. So, both sides are disappointed and frustrated when their expectations are not met. Yet another cultural difference can be found within mental health organizations. These institutes have predominantly white, autochtoon (native non-immigrant) staffs. They are not only “white” in terms of ethnicity, but with regard to their cultural knowledge, meaning that they do not, or are unwilling to understand, complexities of other cultures.

Third, recent changes in the social security system have complicated access to different types of doctors, and the public’s understanding of benefits. Five years ago, free access to basic mental health was standard across the board; a family could see any mental health professional and send the bill to their insurance company to cover the costs. Now, families must buy health insurance packages above the basic, standard level of care, depending on what services they need. Basically, comprehensive mental health coverage needs to be bought. Furthermore, certain healthcare companies only work with certain doctors, so depending on one’s insurance, that person can only see a certain set of doctors; not necessarily the best one for his/her situation or needs. Moreover, navigating this system is difficult and the terminology complicated even for Dutch speakers, not to mention those who cannot speak Dutch.

Fourth, the significant barrier of shame and guilt within Moroccan communities prevents people from accessing health care. Ajaarouj and Huber state this is especially problematic for youths, because it comes up against the “we” culture in dating and marriage. The woman/mother is the core of this “we” culture, and while this it is an esteemed role, it is one that carries great burdens. The woman is seen as the center of the family; if she has a problem, the structure will fall apart. Therefore, she must be strong at all times; so strong, in fact, that taking time for herself to resolve mental health issues would be seen as a sign of weakness. For a young girl, being associated with mental illness can separate her from her community, and result in her being considered unsuitable for marriage, which then brings shame to both her and her family. Meanwhile, culturally, men/fathers are also often seen as strong, and less emotional. For a male to reveal feelings that suggest mental illness is seen as shameful, and can cause him to be ostracized from the community. Another issue arises when a family visits their home country for an extended period of time to visit family, and sometimes, to see a ritual healer or religious leader about their child’s psychiatric illness. Ajaarouj reports that some cases, adolescents will stop taking their medication during trips to avoid the need for explanations to their communities and the shame that will result. This reverses the progress made in therapy, and often sets the adolescent back to where he/she had been pre-treatment. Thus, the entire recovery process needs to be repeated upon return to the Netherlands.

Lastly, the concepts of mektab and sabr are important when understanding choices made within the mental health system regarding therapies and medications. Mektab means destiny, or God’s will. Sabr, one of the great virtues of believers in Islam, means the capacity to endure hardships, firm loyalty and reliability, endurance, and self-control from various urges. Some Moroccan adolescents and their parents see mental illness as something given to them by God, and to challenge their illness with treatment or search for solutions means questioning God’s will, which is forbidden. So, accepting one’s illness with endurance and steadfastness is following God’s plan; there must be a reason for their affliction. Although mektab and sabr have positive connotations, mental health practitioners often perceive them as expressions of passivity. Ajaarouj notes that this is partly an issue of education. For families who are more educated about mental illness and/or have a higher educational level, one can follow mektab and still be proactive about treatment. To those people, it means that mental illness is a challenge to be overcome. Meanwhile, they use sabr for strength to control their symptoms and remain steadfast through treatment.

So, what can be done to counteract these negative and distorted perceptions of mental illness among Moroccan youth? Some answers come from Anne-Marie van Bergen, a psychologist, policymaker, and senior consultant at MOVISIE, a prominent center for social development. First, she would like to remove the stigma associated with mental health problems in certain cultures. She notes that adolescents everywhere are more likely to be underdiagnosed, because they try to avoid doctors. However, if these adolescents also live in households that have a lower socioeconomic status and lack knowledge of mental illness and how to get help, then their level of risk increases further. To remedy this, she argues, these families must be informed of a way to access healthcare, and how to recognize signs and symptoms. Mentrum offers a preventative program led by Ajaarouj for Moroccan families to recognize behavioral problems and psychiatric issues, taught in their mother language. Another program Mentrum offers is Pijn aan het gevoel, which literally translates to “pain at the feeling.” This program is specifically for immigrant communities and has an anonymous hotline and walk-in counseling hours, once again offered in their native language. Once families receive this information, however, the task is up to the parents. They must be willing to talk to their children candidly about psychiatric issues, and should not feel shame in looking for help. If such help is found, the parent and family must trust the caretaker, and keep their child motivated. Nevertheless, Mentrum does note that psychotherapy is not necessarily always the solution with problem behavior; sometimes, there are specifically cultural and personal explanations for “different” behaviors.

Ahmed Marcouch, a well known politician who was district mayor of Slotervaart during the Bilal B. case, and currently a politician in the Second Chamber for the Partij van de Arbeid, the Labor Party, believes that it is important to show success stories to the community in order to increase awareness of mental health issues. He claims that there are many more Bilals, and that more attention is needed for such people. In Bilal‘s case, his sister was a medical school student and knew where to go, and what to ask for. But even in this case, where a family member knew the problem and tried to address it with the caregivers, they were not taken seriously. Marcouch believes that a special law must be created that addresses these issues. But this is problematic for politicians. They do not want to create ‘special’ rules for this group because creating such laws is expensive, and they are also afraid of being accused of targeting particular groups.

In the Netherlands, support groups exist for a wide range of issues; yet, a support group for Moroccan or Turkish parents of children with mental health problems does not seem to exist. This could be partly as a result of the culture of shame and ignorance of mental health problems among these immigrant populations. But, according to Marcouch, a group like this could be useful in encouraging parents to help each other deal with issues related to their children’s problems, and to seek emotional support. Ajaarouj had cases in her clinic where mothers started to have problems themselves, due to the mental health problems of their children. They were looking for support in their own language, and could not find it. To prevent situations like this, it would be beneficial to have support groups where parents and children can talk to each other, share and learn.

As we have seen, the concepts of mektab and Sabr can be used to make Moroccan adolescents more proactive about mental health issues. There are several cultural and religious barriers that need to be challenged if we are to prevent more Bilal B.’s in the future. Recently, politicians as well as health care providers have started new programs designed to create awareness and provide easier access to psychiatric services. Organizations like Mentrum, GGZ and MOVISIE have begun offering intercultural facilitation on behalf of migrants, often in their native language. Positive changes are taking place concerning how society addresses mental health problems among immigrant, and immigrant adolescents in particular. Hopefully, these trends will lead to a situation in which access to care is available to everyone, at all times.

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HIA Program:

Netherlands Netherlands 2010

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