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The socio-demographic characteristics of the participants are presented in Table 1. A total of 77 individuals participated in the study. Three Arabic-speaking focus group discussions with 6 participants in each were conducted. Three Mandarin-speaking focus group discussions, with 6 participants, 7 participants, and 8 participants, respectively, were conducted. The majority of focus group discussion participants in the Arabic-speaking and Mandarin-speaking communities were female and fell within the 18 to ≥ 50 age range. Two Congolese focus group discussions with 4 participants and 8 participants, respectively, were conducted. Most focus group discussion participants in the Congolese community were male and most fell within the 30 years or younger age range. With regard to key informant interviews, all participants were aged 30 years or older.
Theme 1: mental illness terminology
There was considerable variation in mental illness related terminology used across all three communities in both the focus group discussions and key informant interviews. Participants utilised various terms to refer to ‘mental illness’ and used these interchangeably with no consistency. However, it was clear that all three communities generally distinguished between ‘mental illness’, a more severe condition and ‘mental health problems’ or ‘mental issues’, commonly considered to arise due to stressors.
“They are afraid that a mental health problem is a mental illness. In this case, Mandarin-speaking people try to protect themselves from others and try not to let other people know they have a mental illness.” (Mandarin FGD2, Female 60)
This distinction in the Arabic-speaking participants is important to note because there was a strong belief that mental illness was a hopeless, chronic and an incurable condition. One focus participant stated:
“In our society, the mentally ill is considered a hopeless condition and will never be treated or recovered. They will not accept it as a common disease, make it a shameful situation.” (Arabic FGD1, Female, 35)
By holding such views, individuals are less likely to see value in seeking help leading to possibility of a worsening in outcomes and prognosis over time and thus reinforcing perceptions of incurability.
“We do not think the mentally ill person will recover. But we trust that this person once mentally ill, will be forever ill!” (Arabic FGD2, Female, 47)
An interesting tension emerged in the views of the Congolese community with respect to mental illness. Both community leaders and focus group participants discussed the widespread traditional belief that mental illness is taboo and as such does not exist. and yet symptoms of mental illness were frequently described.
“There is this state of suspicion in my community that people first of all don’t recognise that mental health [illness] exists.” (Congolese Interview, Health Care Worker Male 44)
However, symptoms of mental illness, thought to be observable and usually not concealable to others were frequently described.
“They [people with mental illness] act different from normal people” (Congolese FGD1, Female, 19).
Overall this variation in terminology when discussing mental illness provides valuable insight into preferred expressions of mental distress. In particular, it is clear that there is a strong attachment of stigma to the label of ‘mental illness’ in all three communities. While greater contextualisation is required to identified preferred terms when working within communities, it would seem that ‘mental health problems’ was more digestible to participants.
Theme 2: cultural health beliefs
A notion that mental illness manifests when stress exceeds coping ability was discussed by all three communities, with resettlement challenges such as unemployment, loss of support structures, language barriers and so on consistently mentioned as either contributing to the development or worsening of mental illness.
“The experience in Australia, for instance, someone who’s driving and get a fine, they don’t know how to pay, or they lose their driving license, develop mental health because you lose employment, you don’t know how to cope, all those things are associated to mental health.” (Congolese Interview, Community Leader, Male, 50)
“Our supports are very limited. Not only do we need to support our children to go out and come back, but we also need to do chores and our work and everything for our career. We could easily get frustrated. But, then, what does it look like in China? There are many other supporting hands under the base hands, including relatives, parents, parents-in-law, and grandparents.” (Mandarin Interview, Mental Health Worker, Female, 30+)
“We are new here in Australia, and we get annoyed because we don’t know the language and people make fun of you because of it.” (Arabic FGD3, Female, 53)
Changes to the traditional family structure and distinct gender roles, which were clearly differentiated in Africa, following migration were described by some Congolese focus group participants as contributing to lowered self-esteem and loss of identity for males. As a result, a sentiment that mental illness disproportionally affect males more compared to females was expressed.
“When you get here in Australia, you have this thing where, I don’t think it necessary a bad thing women too can go and work. They can also go and do these things. This is well and good but then the fact that women can do these stuffs, the role of a men start to get degraded” (Congolese FGD2, Male, 21)
In addition to stressors associated with resettlement, the Congolese and Arabic-speaking participants discussed the additional unique challenges associated with being from a refugee and asylum-seeker background with the role of trauma featuring strongly as a contributing to mental illness.
“Congolese migrated to Australia, most of them came through offshore humanitarian settlement, they are refugees, they are already traumatized. And you can see that based on the trauma that they had in the refugee camp, there was not much support. So they carry the trauma and when they arrive to Australia, in a new country, they’re again traumatized by moving from Congo to the refugee camp, from the refugee camp to Australia, so there is that shock and trauma.” (Congolese Interview, Community Leader, Male, 50)
The impact of prolong trauma was also highlighted.
“I just want to point out that all the communities are affiliated, like the Iraqi communities, whether they are Muslims, Assyrian, Chaldean, Mandean etc, they live in the same community, the same shell, and almost have the same mental health status. All of such happens as a result of wars consequences, forced displacement effects, the effects of mental stress, and as a result of everything that happened before 2003 and after 2003. These are all accumulations of the difficult conditions that have been experienced by this region and its people.” (Arabic Interview, Community Worker & Religious Leader, Male, 59)
Beyond migration related stressors, the Congolese and Mandarin-speaking communities discussed the role of other factors in developing mental illness that had more culturally specific origins. Both focus group participants and leaders in the Congolese community acknowledged that when an individual is experiencing mental illness, some people may attribute it to supernatural causes. Words such as ‘mapepo’ (Swahili for demonic possession), witchcraft, and poison were used to refer to supernatural causes. The participants highlighted that such a belief is commonplace not only amongst some Pastors, but also family members and friends.
“Because when somebody is experiencing something like that, it means the family would start to think it witchcraft rather than thinking it mental illness. Which is a big problem.” (Congolese FGD1, Male, 59)
By contrast, supernatural or spiritual causes were rarely described in the Arabic-speaking focus group discussions, which is inconsistent with previous research that has demonstrated its prevalence in Arabic-speaking society [10]. However, disengagement from religion or absence of spiritual comfort was highlighted as contributing to the development or exacerbation of mental illness by some Arabic- speaking leaders.
“Whenever this person is distant from his spiritual and religion, the more he will suffer from mental problems” (Arabic Interview, Community Leader, Male, 56)
The importance of inter and intra personal harmony and disruptions to such were highlighted as causing mental illness amongst the Mandarin-speaking participants. Disharmony in the family unit, and in particular the parent–child relationship, was linked to cultural tensions that may arise due to cultural and generational differences. For example, how a child for example adheres to values such as filial piety. Participants noted that seniors especially will attribute their emotional distress to their children not adhering to cultural values rather than labelling their emotional distress as mental illness.
“I once have met a family, and I am very close to that family. The parents have always told me that their children were unfilial and asked them to do many things. Sometimes, they quarrel with each other badly…For young people, ” If I have a bad temper, I may have mental health problems”. The young people are willing to see a psychologist, but for the seniors, they won’t. The seniors always say, “I am this kind of person. My children are supposed to be kind to me. They are supposed to do this and that”. They blame a lot of the problems on their children and refuse to admit what problems they have. Maybe they are irritable, but they just won’t admit that they may have mental health issues.” (Mandarin Interview, Community & Organisation Leader, Male, 70+)
Other more culture-specific beliefs about mental illness were offered again emphasising the importance of harmony, this time within the individual.
“In Mandarin-speaking people’s concept, they always think I may be off-balance. They use ‘off balance’ to explain many symptoms, whether it’s physical or psychological.” (Mandarin Interview, Mental Health Worker, Female, 30+)
Other attributes applied to those with mental illness seemingly suggested unpredictability and personal responsibility.
“They want to do one thing, but they will change their mind in a minute. Or they’ve made a decision, but then they will overturn their decision quickly. This decision must be wrong. There are some new problems. In short, they blow hot and cold.” (Mandarin FGD1, Female, 60+)
Theme 3: stigma and its variations
The issue of stigma was commonly raised by participants in all three CaLD groups as a significant barrier to help-seeking. Common to all three communities was that openly speaking about or identifying mental illness was considered ‘taboo’.
“Our misunderstanding that mental health illness is a taboo topic or a secretive issue, no one should know about it or talk to anyone about it because we still consider mental health or psychological issues are madness.” (Arabic Interview, Community Leader, Male, 68)
“You are born you grow up you never hear about a certain something [mental illness], they start telling you about that thing you feel like “no,” they feel like it is something like kind of taboo.” (Congolese Interview, Community Leader, Female 41)
“In addition, it is not easy for people to speak up about their problems. It’s like a taboo for Chinese, right?” (Mandarin FGD2, Female, 69)
However, other more specific manifestation of stigma seemed to be influenced not only by the communities conceptualisation of mental illness but also by their traditional values. In this way the ‘what matters most’ theoretical framework [27] is useful to operationalise these more culture-specific aspects of stigma and their contextual environment effect.
The importance of family reputation and honour in the Arabic-speaking community is strongly upheld [43]. Consequently, mental illness is seen as leaving a ‘mark’ on one’s identity as well as their family’s identity and thus bringing dishonour and ‘Aár’ (Arabic word for shame related to mental illness)—to the individual and family. Consequently, participants reported families will hide the individual with mental illness or presence of mental illness in the family from the community to maintain reputation and status.
“His family tries to hide it from the community, they are aware of any rumours that could spread because of this and the reputation will be that this person in the family is mentally ill.” (Arabic FGD2, Female, 34)
Participants alluded to the strong presence of affiliate stigma in the Arabic-speaking community, that is, the extension of stigma to the family members of the person with mental illness, further motivating need for secrecy.
“The mentally ill person daughters or sisters will lose the opportunity in getting married even his relatives will lose a good chance in getting married” (Arabic Interview, Community Leader, Male, 56)
A view that disclosing mental illness is associated with losing ‘face’, and that such a ‘domestic shame’ should not be made public was reported by the Mandarin-speaking focus group participants and leaders.
“Maybe they are afraid of losing face. The traditional mindset is that domestic shame should not be made public.” (Mandarin FGD1, Female, 39)
Relatedly, was the belief that mental illness is associated with a loss of occupational or social functioning and therefore threatens social capital and reputation. Therefore, mental illness is often denied because it is associated with losing ‘face’ and reputation in the community.
“One important thing is that if someone has been diagnosed with mental illness, they will not tell us, and their children will not tell us either, as many Mandarin-speaking people care about their ‘face.’” (Mandarin Interview, Community Organisation Leader, Male, 70+)
Due to the general belief that religion and community leaders play an important role in addressing mental illness in the Congolese community, the importance of trust was highlighted. Some focus group participants who expressed a concern that when mental illness is addressed at this wider network level it may lead to gossip and invasion of privacy.
“You could be depressed but you will be wondering by yourself who can I talk to, who can I trust? To tell how I am feeling? You know, you are scared?” (Congolese FGD1, Female, 19)
Thus self-isolation and withdrawal was seen as a possible response to evade stigmatisation.
“That is why is so hard to identify people who are mentally ill in the Congolese community, because you won’t know if this person is staying home because they are depressed or because they’re running away from gossip.” (Congolese FGD1, Female, 19)
This strong adherence to religion to alleviate mental illness, was also seen by some of the younger focus group participants as minimising and dismissive.
“I think people come to you and tell you these things [mental health issues] straight out they don’t they don’t really hide it but I think – this might sound bad I like to be a rational person usually – I think that religion yeah kind of cloud our judgement. How does it cloud our judgement? I come to you and tell you aunty life, life is difficult I am going through all these stuffs and at school I am not doing well. You know our child, God is there go there and there. You know they start making it about prayers…we use religion to dismiss it.” (Congolese FGD2, Male, 21)
Finally, pride and the failure to espouse the traditional roles of African men as being the provider and ‘a strong person’ was highlighted by community leaders as having a significant impact on men not disclosing their mental illness.
“Like men, for example, with men feel proud of themselves rather than coming up and say I’m suffering from this, they would rather keep quiet, and the more they keep quiet, that particular mental health [illness] keeps eating them up.” (Congolese Interview, Health Care Worker, Male 44)
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