A Literature Review of Mental Health Perceptions and Help-seeking Behavior in Somali Communities in Western Europe

A Literature Review of Mental Health Perceptions and Help-seeking Behavior in Somali Communities in Western Europe | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A Literature Review of Mental Health Perceptions and Help-seeking Behavior in Somali Communities in Western Europe Solin Colnadar, Aalaa Abdullahi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7716329/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Aim: This qualitative literature review examines Somali perceptions of mental health and illness in Western Europe, focusing on how cultural, religious, and biomedical frameworks intersect to shape experiences and help-seeking behaviors. Method: Using a narrative literature review, we analyzed 11 qualitative studies from Scandinavia and Western Europe. Results: Findings reveal that Somalis understand mental health from cultural and religious perspectives. The relationship with God is considered crucial, while recognizing external factors such as war and migration that can affect mental health. Somalis conceptualize mental health along a continuum, often using culturally specific idioms of distress rather than biomedical diagnoses. Shame, stigma, and fear of discrimination within and outside Somali communities present significant barriers to seeking mental health care. Additionally, the challenges of migration, acculturation, and cultural differences with healthcare systems further complicate access to support. Discussion: The discussion emphasizes the importance of cross-cultural competence in clinical care and identifies gaps in research, particularly regarding second-generation Somali immigrants and their evolving mental health narratives. Additionally, there is a need for qualitative data to better understand the perceptions and experiences of young second-generation Danish-Norwegian-Somali individuals regarding worries of the mind and their approaches to seeking help. Conclusion: Future studies should explore how generational differences influence mental health perceptions and help-seeking behaviors Future studies must address these gaps to inform culturally responsive interventions for Somali communities in Europe. Social science/Anthropology Health sciences/Health care Humanities/Health humanities Humanities/Medical humanities Biological sciences/Psychology Social science/Psychology Social science/Sociology Somali mental health Cultural perceptions of illness Help-seeking behavior Cross-cultural healthcare Stigma and mental health Qualitative research Religion Introduction What happens when distress must be translated? across cultures, across languages, across belief systems? What does it mean to suffer psychologically in a country where the very idea of mental illness may be understood in entirely different terms? In our clinical encounters with Somali individuals in Norway and Denmark, we have been repeatedly struck by the ways in which mental suffering is narrated, interpreted, and responded to in ways that challenge Western psychiatric standards. Here, mental illness is often not seen as a discrete, diagnosable condition, but as something more fluid, shaped by faith, family, displacement, and moral meaning. Many individuals from Somali backgrounds have expressed skepticism toward the concept of mental illness as it is framed within Western psychiatric paradigms. In our clinical practice, it is not uncommon to encounter patients who find the notion of being “mentally ill” unfamiliar or difficult to reconcile with their cultural understanding of distress (Fosse, 2011; Bhugra & Bhui, 2007). Some may seek clarification about how their experiences compare to those of others, particularly when observing behaviors such as speaking to oneself or displaying overt signs of mental disturbance. These questions often reflect more than clinical curiosity; they may indicate a deeper effort to make sense of personal suffering through a framework that feels foreign. Based on our clinical experiences, it suggests among Somali communities in Western Europe mental struggles are often conceptualized along a binary: either as spiritual or moral distress manageable through faith, or as extreme disruptions of the mind linked to madness. Mental illness is not typically recognized as a psychiatric condition but rather as a social, spiritual, or temporary state, fluid in meaning and embedded in a broader spiritual and cultural context (Bhugra & Bhui, 2007; Whitley & Berry, 2010; Fosse, 2011) Our curiosity and clinical experiences prompted this article’s central aim which is to explore the qualitative social science literature on Somali local communities’ conceptualizations of mental health and illness, as well as how these perceptions shape help-seeking behaviors. This article emphasizes qualitative research, shifting away from the quantitative or somatic-focused studies that dominate research on Somali communities in Western Europe and Scandinavia. While quantitative studies, such as those by WHO (2010) and Abebe, Lien, & Elstad ( 2017 ), provide data on the prevalence of mental health challenges among Somalis - estimating that one-third experience significant mental health difficulties - they often fail to capture the lived experiences and cultural narratives underlying these challenges. For example, quantitative studies have noted that Somalis are among the minority groups in Scandinavia least likely to access mental health care services (Abebe et al., 2017 ; Bhui et al., 2003a ; Bhui et al., 2003b ; Cinnirella & Loewenthal, 1999 ; Hjelde, 2008 ). Yet the reasons for that are not understood from quantitative studies. However, these studies do not fully explain the underlying reasons for this trend. To gain a deeper understanding, an idiographic research approach, as suggested by Molenaar ( 2004 ), is necessary; one that prioritizes qualitative methods to explore individual experiences, cultural idioms and contextual factors influencing mental health care access. Thus, this article underscores the value and importance of qualitative research in understanding the nuanced and culturally embedded ways Somali communities conceptualize mental health. Each person who might be in need for help to cope with mental health issues is a unique individual whom the clinician needs to understand in her or his terms. This article is thus guided by two central questions: How do Somali local communities in Western Europe conceptualize mental health and illness through culturally embedded narratives and expressions? In what ways do these cultural frameworks influence help-seeking behavior and perceptions of psychiatric care? This inquiry is particularly pressing in the context of Somali migration to Europe. The Somali diaspora, especially in Northern and Western Europe and Scandinavia, has been shaped by a history of extreme social upheaval. The civil war that erupted in 1991 displaced more than two million people (Næss, 2019 ; Cavallera et al., 2016 ), a crisis compounded by clan-based violence, systemic instability, and environmental disaster. Droughts, famine, and the failure of governing institutions forced many to flee not only due to violence but to survive basic human deprivation (Gundel, 2002; Abdullahi, 2020). The collapse of the Somali state led to mass displacement, trauma, and cultural fragmentation, all of which have profound psychological consequences. Studies estimate that more than a third of Somalia's population has experienced significant mental health challenges (WHO, 2010), and yet institutional support, both in Somalia and abroad, remains limited or culturally incongruent. Somali migrants often carry the psychological residue of trauma, dislocation, and loss. In host countries like Norway, Sweden, and Denmark, they encounter mental healthcare systems that are unfamiliar and frequently unresponsive to their cultural frameworks (Abebe et al., 2017 ; Bhui et al., 2003a ; Bhui et al., 2003b ; Cinnirella & Loewenthal, 1999 ; Hjelde, 2008 ), While Western health authorities define mental health as emotional regulation, productivity, and social functioning (APA, 2018; WHO, 2022), these definitions often fail to align with Somali conceptions of the self and suffering. As such definitions offer a broad framework for understanding mental health, they often obscure the lived realities of individuals whose experiences are shaped by cultural, spiritual, and historical factors. For Somali migrants, mental illness is not solely a biomedical condition, it is articulated through culturally embedded idioms of distress, shaped by the legacy of trauma, displacement, and collective memory. When clinicians rely exclusively on standardized diagnostic categories, they risk overlooking how individuals actually experience, express, and respond to suffering. Understanding the person behind the diagnosis is therefore not only a clinical necessity, but a moral and cultural imperative, especially in contexts where incongruent worldviews and systemic mistrust act as barriers to help-seeking. Without this understanding, well-intentioned care may be rendered inaccessible, ineffective, or even harmful. Concept Clarification and Language Challenges The American Psychological Association (APA, 2018) defines mental health as a state of well-being characterized by effective behavioral regulation, strong emotional relationships, and resilience in handling life's challenges. Similarly, the World Health Organization (WHO, 2022) views mental health as an individual's ability to realize their potential, work productively, and engage in society. Scandinavian health authorities echo these perspectives, emphasizing mental health as a dynamic process influenced by multiple factors, including social participation and functioning. In contrast, mental illness encompasses severe and enduring psychological conditions that impair emotional and cognitive functions, often meeting diagnostic criteria (APA, 2018; WHO, 2022). Distinctions are made between transient psychological challenges, such as stress or anxiety, and clinically significant disorders. These definitions largely reflect Western biomedical frameworks. However, Somali perspectives on mental health are better understood through culturally specific idioms of distress, as conceptualized by Nichter ( 1981 , 2010 ; Im et al., 2017 ). These idioms capture culturally grounded expressions of psychological suffering through metaphors, narratives, or behaviors, providing insight into how mental health challenges are framed and communicated. One of us, who is of Somali background and speaks Somali fluently (Abdullahi, A), encountered significant challenges in finding Somali literature to compare with the above definitions. Using a Danish-Somali dictionary (Hussein, Elmi, & Maacaani, 1998 ), we noted how direct translations often failed to capture the nuances of meaning. For example, the word "maskax," which directly translates to "head," is also used to mean "mental." Similarly, the term "psychiatry" in Somali is translated as "cilmiga dhaktarka silawa dakta waalan ama sikka ka jiiran," which literally means "the knowledge of medical treatment for crazy people or those struggling with something in the head." Anxiety is translated as "cabsi, naxsan, baqdin," which conveys fear, dread, or panic. These differences highlight the lack of specific terms for mental disorders in Somali, where symptoms rather than diagnoses are emphasized, and also illustrate a lack of direct equivalence between biomedical and Somali mental health vocabularies, and highlight the reliance on culturally specific expressions of distress. This reflects Nichter's (1981, 2010) concept of "distress expression," where idioms, metaphors, stories, and behaviors are used to convey psychological discomfort. The challenges of linguistic translation reveal how Somali culture communicates mental health concepts differently from Western frameworks. Samatar ( 2016 ) describes Somalis as a "nation of poets," emphasizing the use of metaphor and poetry to express social problems and personal experiences. This cultural emphasis on storytelling and metaphor suggests that Western technical definitions may not align with Somali modes of understanding. Instead of clinical diagnoses, Somalis often use a continuum of terms and symptoms to describe psychological conditions, further underscoring the cultural differences in conceptualizing mental health (Scuglik et al., 2007 ; Kaiser & Weaver, 2022 ; Gopalkrishnan, 2018 ). Understanding Somali mental health requires engaging with both continuity and rupture: with long-standing cultural traditions and the collective trauma of displacement. These dual forces, cultural resilience and historical fragmentation, shape how suffering is interpreted and managed. Mental illness, in this context, cannot be seen as an isolated pathology. It is embedded in migration histories, communal memory, and the navigation of healthcare systems that often misrecognize or marginalize non-Western expressions of distress. Accordingly, there is a critical need for research that elucidates how Somali local communities construct meanings around mental health and illness, and how these culturally embedded frameworks inform patterns of help-seeking within healthcare systems that frequently fail to accommodate non-Western epistemologies of distress. Methodology: A Narrative Literature Review Rationale for a Narrative Literature Review A literature review is an essential step in the research process, offering a systematic way to identify gaps in knowledge and critically evaluate existing studies (Sullivan & Forrester, Chap. 3–11, 2019; Shaw, Chap. 5, 2019; Frost & Bailey-Rodriguez, 2019; King, N, Chap. 3, 2019; Grant & Booth, 2009 ). By synthesizing and categorizing prior research, it provides a coherent understanding of the field and highlights areas for further research (Forrester, 2012; Baumeister & Leary, 1997 ). Among the diverse types of literature reviews, we opted for a narrative review, which is particularly suitable for examining qualitative studies and integrating cultural and contextual insights (Grant & Booth, 2009 ; Willig, 2013 ; Willig, Chap. 5 & 12, 2013; Halcomb et al. 2007 ; Bamberg, 2012 ; 2020 ). Given our focus on Somali perceptions of mental health in Europe, the narrative review approach allows us to explore how qualitative findings collectively construct a broader understanding. This method aligns with our qualitative focus, enabling an in-depth examination of perceptions, narratives, and cultural dimensions of mental health expressions and understandings within Somali local communities, making it particularly appropriate for our project. Search Strategy and Selection Process Scrutiny of analysis of the available literature in psychology and social sciences highlights a persistent lack of knowledge regarding Somali perceptions and experiences of mental health, illness, and care in Scandinavia and Western Europe. Searches in databases including Taylor & Francis, APA PsychNet, and Scopus generated only 212 results when searching for variations of "Somali," "Mental Health," and "Mental Illness." A total of 11 qualitative studies were included in this review. Articles were selected for inclusion based on their focus on Somalis, mental health, and help-seeking behavior, and their use of qualitative methods only. Inclusion and Exclusion Criteria Our inclusion criteria required that articles employ qualitative methods with a focus on Somali perceptions of mental health, illness, and help-seeking behaviors. We prioritized studies from Scandinavia, although research from Western Europe was also included. Articles primarily focusing on somatic illnesses were excluded, while studies on psychiatry and psychosis among Somalis in Europe (excluding khat-induced psychosis and addiction-related research) were deemed relevant. Only peer-reviewed literature about Somalis was included, with a particular emphasis on Somali communities in Scandinavia. However, the review was expanded to include studies from across Europe due to limited Scandinavian research. Literature from the United States was excluded, as adaptation tasks in America differ from those in European and Scandinavian context, making direct comparisons less relevant. Based on the findings from the included articles, the qualitative research on Somali perceptions of mental health predominantly consisted of interviews (n = 4), focus groups (n = 2), and a combination of interviews and focus groups (n = 5). The sample size of the studies ranged from n = 1 to n = 47, with a mean sample size of n = 17.8, indicating that the samples were generally small-scale. Analytical Framework and Thematic Synthesis Most studies analyzed their data using thematic analysis, including general thematic analysis, interpretative phenomenological analysis (IPA), narrative analysis, or anthropological analysis. Johnsdotter et al. ( 2011 ) applied Lincoln and Guba's framework for naturalistic inquiry, while Groen ( 2009 ), an anthropologist, conducted a clinical interview using the Cultural Formulation Interview (CFI). Most of the studies were interdisciplinary, with a primary focus on psychology, including clinical, pedagogical, and psychiatric aspects. A few studies combined anthropology with psychology and psychiatric research. The included studies were reviewed to identify core themes and narratives about how mental health and illness are conceptualized among Somalis in Europe and to synthesize what the research reveals about Somali help-seeking behaviors regarding mental health and illness. The following findings generated during the review of the literature relating to the conceptualization of mental health and illness were: Understanding mental illness and suffering caused by migration, the toll and challenges of acculturation, understanding mental suffering through physiological manifestations, spiritual and cultural perspectives on mental health and illness, and changing perceptions of mental health. Results: Thematic Synthesis of Somali Perceptions of Mental Health in Europe Migration, Trauma, and Mental Health in Context In 1991, a clan-based civil war in Somalia forced around 2 million Somalis to flee the country, with war, natural disasters, and resource scarcity driving migration (Næss, 2019 ; Cavallera et al., 2016 ). Migration processes, combined with the trauma of displacement, are recognized as significant risk factors for mental health issues among Somali migrants (Solberg et al., 2020 ; Zimbream & Dahal, 2020). For many, migration represents a forced journey toward safety and opportunities, but the realities of navigating asylum systems and settlement often exacerbate psychological stress. Palmer and Ward ( 2007 ) highlight how challenges in securing housing, work permits, and employment opportunities intensify migrants' stress, eroding their sense of hope and mastery. They describe how some participants used work as a coping mechanism, while others struggled with the mismatch between their skills and the available opportunities, which further diminished their sense of belonging and control. Groen ( 2009 ) examines the impact of migration on cultural identity, showing how the shift from a collectivist Somali context to the individualist Western environment can disrupt migrants’ sense of belonging. One Somali participant expressed their tribal identity as "the only thing that matters," (Groen, 2009 , p.457) emphasizing its central role in their self-concept. Groen notes that isolation from Somali communities in host countries often limits opportunities for cultural recognition, potentially exacerbating psychological distress. This raises broader questions about how Somali migrants adapt to new cultural contexts and how these shifts influence their mental health. The toll and challenges of acculturation Acculturation is another aspect that is equally important to mention when we look more closely at the common features shared by the study results. It is primarily a concept that aims to explain an adaptation process with cultural changes as a result of an encounter with a new cultural context (Berry & Sam, 1997 ). Acculturation can also be considered a factor in the influence of both somatic and mental health (Gupta, Leong, Valentine & Canada, 2013 ). One can distinguish between two types of acculturations, where acculturation itself as a concept takes its starting point from the change that occurs in a group. The second type of acculturation is that related to psychological changes that occur at an individual level (Berry & Sam, 1997 ). The study by Osman et al. ( 2020 ) focuses precisely on acculturation in the form of how Somalis in Sweden experience this process. They mention important points as the basis for their research questions, such as how some Somalis, despite their attempts to integrate into the society they live in, experience difficulties related to this (Osman et al., 2020 ). The main theme of their findings in this study was “longing for belonging”. They found that the experience of acculturation for these young Somalis was associated with a feeling of “outsiderness” in the form of social exclusion and lack of support when it comes to this adaptation process. Sub-themes that the studies found that were closely linked to the difficulties of acculturation included discrimination. Some of the participants reported perceived discrimination with experiences such as racism related to ethnicity, skin color and religion, among other things. Somalis migrate at different ages and in some cases, it may be the case that there are many young Somalis who migrate with their families. In the process of acculturation, we can imagine how these young Somalis are raised in and take part in the societies they settle in. E.g. their identity development becomes a mixture of their parents' culture and the culture they are raised in. Another example of this is how some of the participants in Osman et al. ( 2020 ) reported a feeling of being "between cultures". They explained a challenge such as not fully understanding where they belong. These were participants who were raised in Sweden, where they themselves feel different in terms of appearance and mannerisms that deviate from the typical Swedish. They express how they are not considered Somali if they were to have been in Somalia, nor are they considered Swedish, but feel that they fall into a "middle in between" category. This reminds us of the "third-culture kid" concept that aims to explain how children raised outside their parents' home country/culture struggle with the feeling of being in a "neither or" place. A place between their parents' culture, and the culture they themselves were raised in (Pollock, Van Reken, & Pollock, 2017 ). Understanding mental suffering through physiological manifestations Within the literature, Somalis in Europe's conceptualization of mental health and suffering is, among other things, based on physiological/somatic symptoms. Ex. all authors describe, that Somalis in Europe conceptualize mental health and suffering as physical manifestations and consequences of war and migration (Næss, 2019 ; Whittaker et al., 2005 ; Linney et al., 2020 ; Mölsa et al., 2011). Linney et al. ( 2020 ) describe that the majority of the focus group participants described a connection between mental and physical health (2020). The participants described mental illness as somatic or visible symptoms, e.g. such as physical pain to 'unusual behaviour' such as being "violent" or not dressing properly (Linney et al., 2020 ). In particular, the participants explained that mental illness and distress start with and are described to a general practitioner as a headache (Linney et al., 2020 ). Specific to this study, it is a new finding that Somali women explained that mental illness starts with the physical symptom of headache, as it has not been described in the other studies. Palmer & Ward also describe that the Somali participants described physical symptoms more prominently than the other ethnic groups, although the importance of headache was not mentioned (2007). In relation to this, the aticle's introduction elaborated on some Somali words that further support this, e.g. with the word Maskax which directly translated means head, but in the dictionary, it is translated to mental. If head and mental are linguistically the same in Somali, it is not a surprise if Somalis translate mental pain into headache. This illustrates the conceptualization of mental illness symptoms in Somali society, which may differ from conventional beliefs about illness. This is important clinically, as the presentation of headaches in women can be a description of distress or psychological problems The Spectrum of Suffering: Sane or Insane? It is clear that there are some contradictory features if we compare the traditional Somali perceptions of mental health and suffering with the Western psychiatric framework of understanding. Johnsdotter et al. ( 2011 ) and Wedel ( 2014 ) describe this contrast as, that Western doctors operate with specific categories e.g. illustrated by categorization in ICD-11 and in DSM-5, where the traditional concepts and categories for suffering in Somalia are much more fluid. In particular, Johnsdotter et al. ( 2011 ) illustrates how this can be understood along a continuum, which starts with mild suffering and challenges and ends with madness, where it is only at this stage when someone has become 'waali'/crazy, that it is classified as a medical problem. There are traditional Somali terms to denote different kinds of mental conditions, which are said to be about mental ill health, where in connection with this we have identified particularly prominent expressions, across the studies, which are commonly understood and used among Somalis in Europe to describe mental illness; Dhimir, Murug, Buufi, Waali and Jinn (Johnsdotter et al., 2011 ; Mölsa et al., 2010; Whittaker et al., 2005 ; Wedel, 2014 ). These terms, in the order written, describe the continuum. Some informants in Johnsdotter et al. used the term, Dhimir, which generally denotes poor mental health, however, all informants were not familiar with this term, which may be due to different local languages ​​(2011). The expression, murug , describes the state where you feel that you have many challenges, "feeling low", and when you are in a state of worry. This term refers to everyday situations, e.g. that one's financial condition can result in this (Johnsdotter et al., 2011 ). Further along the continuum, the term Buufi/Buufis , which translated means "to withhold breath" (Johnsdotter et al., 2011 p. 744) or "to be filled with air" (Mölsa et al., 2010, p, 286), characterizes a state where one is tense and paranoid. The informants in both Mölsa et al. (2010) and Johnsdotter et al. ( 2011 ) relate buufis to an anxiety-like condition, characterized by "sadness" and "distress", as a result of civil war and clan conflicts, which have destroyed social networks. Waali is at the extreme end of the continuum and is widely understood among Somali communities to mean “crazy”, “crazy person” or “mentally unfit,” and is perceived as significantly more stigmatizing than milder idioms like murug . As reported by all participants in Johnsdotter et al. ( 2011 ) and Carroll’s ( 2004 ) study, waali is used to describe individuals exhibiting behaviors such as talking incoherently, wandering aimlessly, dressing inappropriately, or showing signs of severe disconnection from reality. These behaviors are interpreted as symptoms of profound psychological disturbance, often following extreme trauma or shock. Importantly, waali also carries a high level of social stigma and is associated with unpredictability and potential violence, which contributes to the social distancing and exclusion of those labeled in this way. Informants in Johnsdotter et al. ( 2011 ) point out, that it is difficult as a local community to help and heal the illness that a Waali person suffers from. Here we understand that the limit to help from the local community is at waali/insanity. Several of the informants in particular attributed murug, buufis and waali mainly to traumatic refugee experiences, as described in the above section, the greater socio-political destruction of civil war and famine and in some cases post-migration stress factors (Johnsdotter et al., 2011 ; Mölsa et al., 2010; Carroll, 2004 ). The term Jiin , an evil spirit that can possess you, is often used across the studies, as a perception of, among other things, schizophrenia (Azaunce, 1995 ; Islam & Campell, 2014), this is further elaborated in the section below, on spiritual and religious perceptions of mental health and illness (Mölsa et al., 2010; Johnsdotter et al., 2011 ; Wedel, 2014 ; Loewenthal et al., 2012 ; Whittaker et al., 2020). To enhance understanding of culturally specific mental health expressions among Somalis in Europe, the following table (Table 1 ) summarizes key idioms of distress as documented in qualitative studies, along with their translations, contextual meanings, and associated clinical relevance. Table 1 overview of idioms of distress: Somali Idioms of distress Literal and conceptual translation Associated causes and cultural context Clinical Relevance Key Reference Dhimir General poor mental health / mental disturbance General psychological strain or distress; can be due to multiple life stressors May be under-recognized in Western diagnoses Johnsdotter et al. ( 2011 ); Mölsä et al. ( 2010 ) Murug Feeling low, sadness, worry Daily stressors such as financial problems, unemployment, loneliness, or unresolved worry Could resemble mild depressive or adjustment disorders Johnsdotter et al. ( 2011 ) Buufi/Buufis “To withhold breath” / be filled with air (anxiety-like state) Anxiety, sadness, distress related to traumatic displacement, social disconnection, civil war; anxiety and paranoia Comparable to anxiety or stress-related disorders, possibly PTSD Mölsa et al. (2010), p. 286; Johnsdotter et al. ( 2011 ) Waali Madness/Insanity Severe mental disturbance marked by erratic or socially inappropriate behavior (e.g., incoherent speech, wandering, disrobing), often seen as the result of extreme trauma; highly stigmatized and associated with unpredictability or violence Likely corresponds to psychosis or schizophrenia Johnsdotter et al. ( 2011 ); Mölsä et al. ( 2010 ); Carroll, 2004 . Jinn Spirit possession Attributed to supernatural possession by evil spirits in Islamic cosmology, often associated with psychosis Corresponds to psychosis. Jinn possession is believed to cause schizophrenia (Johnsdotter et al. 2011 ). Help is commonly sought through Islamic healing practices such as Quranic recitation Johnsdotter et al. ( 2011 ); Mölsa et al. (2010); Carroll, 2004 ; Azaunce, 1995 ; Wedel, 2014 ; Whittaker et al. ( 2005 ); Loewenthal et al. (2007) Spiritual and cultural perceptions of mental health In contrast to physiological manifestations of mental health, all articles in this review touch, to varying degrees, on the importance of spirituality and religion for Somalis in Europe's perception of mental health and suffering. Overall, there are two pervasive views of mental health and suffering, which touch on spirituality, the prevailing view, which focuses on Islamic cosmology and the other, which focuses on traditional Somali narratives. Both start from spirit possession and how this causes mental illness (Mölsa et al., 2010; Johnsdotter et al., 2011 ; Wedel, 2014 ; Loewenthal et al., 2012 ; Whittaker et al. 2005 ; Linney et al., 2020 ). Individuals can either be possessed by jinn, which are evil spirits in Islamic cosmology, or by traditional Somali zar/saar spirits, which many of the study's informants consider to be 'un-Islamic' (Mölsa et al., 2010; Johndotter et al., 2011; Wedel, 2014 ; Whittaker et al. 2005 ). Symptoms or behaviour, which are interpreted as mental disorder in a biomedical framework, e.g. schizophrenia, is considered by many Somalis in Europe to be caused by either supernatural forces, such as spirits, or by humans through mechanisms such as the 'evil eye' or a curse (Mölsa et al. 2010: Johnsdotter et al. 2011 ; Wedel 2014 ). Mölsa et al. (2010) point out, that according to Islamic theology there are jinn everywhere. Ex. describes an informant in Johnsdotter et al. ( 2011 ), how he developed schizophrenia: "Here is where the jinni hit me, you know of the jinn, right? (...) This vibration in my head, I was crying sometimes. At night when I was going to sleep, it was like … [makes a noise to show vibration], the vibration, from here, the side of my head. They said it was jinn. The sheikh [religious scholar] said it was jinn" (Johnsdotter, et al., 2011 , p. 744) The informant is medicated for schizophrenia, but his perception of the illness is based on a religious framework. The informants in Johnsdotter et al. ( 2011 ), who have developed schizophrenia described symptoms of jinn possession as anxiety, obsessive-compulsive symptoms, aggression attacks, nightmares, physical pain, sadness, headaches, insomnia and hallucinations. These symptoms are also described by the participants in Mölsa et al. (2010) which further includes symptoms such as nausea, vomiting, reduced appetite, apathy, aggressive behaviour, suicidal thoughts and behavior and violent bodily restlessness (2010). Both the participants in Johnsdotter et al. ( 2011 ), Mölsa et al. (2010) and Loewenthal et al. (2007) believed that within Islam one's belief in Jinn affects the perception of mental illness and how mental illness can be treated, but that Western health professionals do not understand this. This is pointed out by an informant from Mölsa et al. (2010); "But the jinn they [Finnish doctors] can't heal and can't understand the way we perceive it; they don't believe in the etiology. To us as Somalis and Muslims, it is a real thing that causes mental illnesses. (Individual interview, Somali healer)" (p.290). According to interviewees, Islamic knowledge and reading the Koran are necessary to fight and heal diseases caused by jinn. In these cases, biomedicine is considered insufficient (Mölsa et al. 2010; Johnsdotter et al. 2011 ). Among Somalis in Europe, spirits can also be understood within the framework of the possession cult, saar/zar, which is evoked in special ceremonies (Johnsdotter et al. 2011 ; Wedel, 2014 ). The traditional zar spirits are divided into subcategories, such as mingis, waddadu and borane, and are to be evoked by rituals involving song, dance, trance and speaking in tongues (Johnsdotter et al. 2011 ; Mölsa et al. 2010). The various spirits are loosely connected with the clan system, that a person is more likely to be possessed by a particular spirit depending on their class affiliation. Like Jinn, these zars are generally malevolent and are associated with dirt and unhygiene (Johnsdotter et al. 2011 ; Mölsa et al. 2010). The informants in Johnsdotter et al. ( 2011 )d lsa et al. (2010) maintained that Somalis generally trust the Finnish and Swedish health services when it comes to somatic, non-chronic diseases, where diagnosis and treatments are easily available. According to Somali tradition, mental health and suffering are also largely related to the social world and especially to the transcendental world. In that sense, mental illness is in a certain sense located outside the individual: It is about one's relationship with God, and with jinn and other spirits (Johnsdotter et al. 2011 ; Mölsa et al. 2010; Wedel, 2014 ). For example, this understanding of illness becomes clear when informants there suffer from schizophrenia in Johnsdotter et al. describes that this disease is 'placed' in them, and is not part of them (2011) Particularly in this study, a schizophrenic Somali woman pointed out that she is hesitant to accept antipsychotics from her Swedish doctor, where she says; " In our country, people may be mentally ill, but they get well again with the Koran and medication, and when they have recovered, nobody will notice that they've been ill. But here they make you take medicine until the day you die. Here you can see who is on medication for mental problems, their faces are hanging, they gain weight, they walk differently " (Johnsdotter et al. 2011 , p.749). This quote illustrates the above point about the Somali perception of mental health and health being closely connected with the social and spiritual spheres. Mental disorders are often seen as related to one's connection with God, spirits and community, rather than solely as individual somatic or medical issues. Evolving narratives and Changing Perceptions in the Diaspora However, there is a big difference between whether one believes in jinn or zar spirits. Overall, there is a general consensus in the literature that the prevailing perception of mental health and illness among Somalis in Europe is based on an Islamic framework of understanding. It also appears that zaar possession is to a large extent a stigmatized practice, with the study's informants pointing out that it is Somalis in Somalia in particular who are more likely to believe in zaar than those in Europe. Ex. tells a religious healer, as Mölsa et al. (2010) have interviewed that the zaar possession culture is defined as non-Islamic by the Somali Islamic religious community, where the other informants, in the same study, reveal that there are actually only a handful of people who practice zaar, secretly in Finland. Similarly, Johnsdotter et al. ( 2011 ) and Wedel ( 2014 ), that in Sweden this is a stigmatized practice, which is carried out by a small group of individuals. This makes us wonder about the change of the spiritual in Somalis' perception of mental health and suffering and what factors play a role in the change? Based on the literature reviewed, we identify a tendency among Somalis, which indicates that traditional perceptions of mental health, mental illness and help-seeking behavior are challenged and changed due to the encounter with the new culture, to which one has fled or migrated. We can build this argument on the basis of research, which has looked at the meeting with e.g. the Finnish and British biomedical system and due to new religious interpretations supported by the Islamic faith community (Mölsa et al. 2010; Whittaker et al., 2005 ). As described in the above section, acculturation refers to the process through which individuals or groups from one culture come into contact with and adopt elements of another culture, which leads to cultural changes in behavior and perceptions (Berry & Sam, 1997 ). In the context of understanding changing perceptions of mental health and suffering among Somalis in Europe, we consider the concept of acculturation to be a valuable frame of reference for understanding how the process of adaptation and integration affects their perception of mental health. Both informants in Mölsa et al. (2010) and Whittaker et al. ( 2005 ) study describes their perceptions of mental health and illness to have changed since they fled Somalia. Newly arrived young Somali female asylum seekers, who had more traditional beliefs and familial experiences of zar possession in Somalia, expressed concern and fear that the zar would control them (Whittaker et al. 2005 ). Whereas the women who had been in the UK for a longer time were very skeptical of the existence of zars and were more likely to perceive them as weak-minded and describe it as "Nonsense" and "it was a way that older Somalis tried to hold onto cultural beliefs in the UK" (2005, p.186). We understand this to mean that spirit possession can function as a way of concretizing and externalizing psychological difficulties for refugees and newcomers. This can further support our point, from the acculturation section, that a higher degree of acculturation results in increased integration of western understanding of illness, and the distancing from traditional understanding based on saar possession. Of this, the informants point out in both Whittaker et al. ( 2005 )d lsa et al. (2010), that through migration their faith in Islam has been strengthened. In addition to the fact that migration and acculturation lead to an increased integration of Western understanding of illness, we consider that this also leads to an increased integration of an Islamic-based understanding of illness, which results in a further distance from zar spirits and thus a further change in the perception of mental illness Table 2 below summarizes the main thematic findings from the reviewed qualitative literature, offering a structured overview of how Somali communities in Western Europe understand, experience, and articulate mental distress. While not intended to provide a fully tailored diagnostic framework, the synthesis highlights the importance of clinical curiosity and cultural humility in exploring spiritual, religious, and cultural idioms of distress. Attending to these perspectives can foster trust, improve therapeutic engagement, and support more context-sensitive mental health care. Table 2 Summary of Thematic Findings on Somali Perceptions of Mental Health in Western Europe Theme Summary Key findings: Illustrative insight Citied studies Clinical or Policy Relevance Migration, trauma, and mental health Migration and displacement increase psychological vulnerability; barriers in host countries exacerbate distress. "The only thing that matters is your tribe." (Groen, 2009 ) - loss of identity and belonging post-migration. Næss, 2019 ; Groen, 2009 ; Palmer & Ward, 2007 Highlight need for trauma-informed care and culturally sensitive psychosocial support. Acculturation and belonging Young Somalis face identity conflicts and social exclusion during acculturation, experiencing a sense of being 'between cultures' (Osman et al., 2020 ). "Between cultures" - young Somalis raised in Europe often feel neither Somali nor European (Osman et al., 2020 ). Osman et al., 2020 ; Pollock et al., 2017 Encourage youth-specific services that addresses bicultural identity and belonging. Physiological manifestations of mental distress Mental distress is often described somatically (e.g., headaches, pain), highlighting a linguistic and cultural conceptualization of suffering. Mental illness first reported as headache or physical pain; 'maskax' links head/body and mind linguistically (Linney et al., 2020 ). Linney et al., 2020 ; Palmer & Ward, 2007 ; Whittaker et al., 2005 Healthcare providers should explore somatic symptoms as potential signs of psychological distress. Cultural Idioms and Continuum of Suffering Somali idioms (Dhimir, murug, buufis, waali) describe a continuum from mild distress to madness; terms are tied to trauma, stigma, and social implications Terms like 'murug' and 'buufis' describe worry and anxiety; 'waali' indicates psychosis and social exclusion (Johnsdotter et al., 2011 ). Johnsdotter et al., 2011 ; Mölsa et al., 2010; Carroll, 2004 Avoid misdiagnosis by recognizing culturally specific idioms to build culture-sensitive frameworks. Spiritual and Religious Understandings Spiritual and religious frameworks (jinn, zar) shape understanding of mental illness; treatment often sought through Islamic or traditional healing. In particular is Jinn believed to cause mental illness; healing sought through Quran and religious scholars. Mölsa et al., 2010; Johnsdotter et al., 2011 ; Wedel, 2014 While biomedical systems cannot fully adopt spiritual etiologies, providers should remain open and curious about patients’ cultural, spiritual, and religious explanations of illness, not to confirm these understandings, but to validate lived experiences and foster trust, thereby enabling culturally sensitive and safer therapeutic relationships. Changing Perceptions and narratives around mental illness Migration and acculturation lead to re-evaluation of traditional beliefs, greater integration of Islamic frameworks and biomedical frameworks, and distancing from zar practices. Zar beliefs diminish in diaspora; younger Somalis describe traditional views as 'nonsense' (Whittaker et al., 2005 ). Whittaker et al., 2005 ; Mölsa et al., 2010 Understanding evolving perceptions can help tailor interventions for second-generation migrants and inform long-term mental health strategies. Building on the findings of how Somali communities in Europe perceive mental health and suffering through religious and spiritual lenses, the following discussion explores how these perceptions may influence their expression of distress and help-seeking behaviors. This is examined in the context of discriminatory attitudes, both within and outside their communities, which shape and potentially hinder their access to mental health care. Discussion From Stigma to Discrimination: Reframing Barriers to Somali Mental Health? In examining Somali perceptions of mental illness and their interaction with mental health systems in Western Europe, it is crucial to distinguish between the concepts of stigma and discrimination. Stigma, as a sociological concept, provides a critical lens for understanding how individuals are marginalized and discredited within societal structures and as Goffman ( 2009 , p.8) famously defined stigma as “a characteristic that is deeply discrediting,” emphasizing how it marks individuals as deviating from the “normal” behavior expected within society. He conceptualizes stigma as something a person is perceived to "carry," which sets them apart. Similarly, Arboleda-Flòrez and Sartorius (2008, p.5) describe stigma as a prejudiced and negative attitude, suggesting that those subjected to it are pushed to the margins and kept at a distance. While Goffman’s definition offers valuable insights, we approach it with caution when interpreting the experiences of participants in the selected studies. Scholars such as Tyler ( 2018 ) critique Goffman’s focus on individualistic experiences, arguing that it neglects essential dimensions such as racial stigma, historical context, and the influence of power dynamics on the formation and perpetuation of stigma. This is because Goffman’s framework tends to frame the problem in psychological or interpersonal terms. In contrast, discrimination emphasizes structural, institutional, and externally imposed forms of exclusion. This distinction is particularly relevant in the context of Somali experiences, where community-based stigma (e.g., shame or fear of being labeled waali ) functions differently from racialized or cultural discrimination encountered in the broader societal context (e.g., Islamophobia, xenophobia, or institutional mistrust). Idioms of distress such as murug or buufis often reflect internal struggles that remain hidden due to communal stigma, whereas reluctance to seek formal help can be tied to broader systemic discrimination. Maintaining this distinction is essential not only for theoretical precision, but also for understanding the complex barriers to help-seeking behavior. Where stigma may produce silence and shame within the Somali community, discrimination, experienced through exclusion, marginalization, or mistrust in services, can create profound structural barriers to accessing care. Recognizing how these forces operate differently, yet interactively, allows for a more nuanced and clinically relevant analysis. It helps avoid over-psychologizing what are often sociopolitical constraints and directs attention to both culturally informed mental health interventions and the need for systemic reform. We therefore apply Goffman’s concept of stigma to understand how individuals with mental illnesses are perceived and treated within Somali society. However, when examining discrimination experienced outside Somali local communities, we frame it as prejudice and discriminatory attitudes rather than "stigma," recognizing that its meaning shifts in the context of being outsiders in a society and culture different from their own. An example of this is how the participants in Osman et al. ( 2020 ) discuss the experience of discrimination as part of their acculturation process in Sweden. They explain an experience of exclusion and being an outsider in school situations that they describe as related to their skin color, ethnicity and religion. In such cases, the term "stigma" fails to fully capture or account for the participants’ experiences. We find it more appropriate to use terms like "racism" and "discrimination," which more accurately reflect the nature of what they are encountering. As mentioned, Goffman ( 2009 ) describes stigma as something that one “carries”. While this definition emphasizes the burden on the individuals, we argue that it risks portraying those who experience discriminiation as inherently flawed or unchangeable. This perspective fails to consider that stigma is shaped by social and individual interactions, as well as structural discrimination. Therefore, we argue that the participants' experiences of negative attitudes and exclusion, which primarily stem from outside their Somali communities, are better explained using terms such as discrimination and racism. Furthermore, it is noteworthy that most participants in the selected studies do not commonly use the term stigma to describe their experiences. Instead, they refer to the concepts like "shame" and "discrimination", "racism", "exclusion" and "labelling". Accordingly, we will adopt this term to more accurately reflect their lived experiences. Experiences with discrimination Discrimination linked to the acculturation process can also originate within Somali communities themselves. Bowie, Wojnar, and Isaak ( 2017 ) highlight how Somali families fear their children adopting "American bad traditions," such as involvement in drugs or gangs, as they prioritize preserving Somali cultural traditions. Several studies also discuss this in the context of intra-community discrimination, where acting differently in Somali society, such as being perceived as "too Western," often leads to judgment and labeling as "crazy." This fear of deviating from traditional norms stems not only from concerns about cultural preservation but also from stigmatizing attitudes towards transparency about mental health struggles. For instance, Whittaker et al. ( 2005 ) explain that participants feared being labeled as "mad" or "obsessed" if they were perceived as overly "Westernized" or as challenging their religious beliefs. This fear is particularly pronounced in Somali communities in the UK. While studies highlight this negative perception of "Westernization," they do not provide definitive explanations for why it exists. However, factors such as religion and the loss of cultural identity appear to contribute to this stigma. Many participants in the reviewed studies reported hiding their struggles from close family and the broader Somali community due to fears of being branded or judged. This recurring theme of "keeping hidden" underscores the role of discrimination in discouraging openness about mental health. Associating mental illness with stigma and discrimination creates significant barriers, preventing individuals from seeking help. Additionally, societal gender roles and expectations further influence help-seeking behavior. Most individuals tend to first turn to their families for support, as families are often seen as the primary source of help in times of difficulty (Whittaker et al., 2005 ; Næss, 2019 ) Suffering in silence A Somali woman's role in her family is an important role and if she shows her weakness, her conduct can reflect negatively on the family. We understand the recurring theme of having to "keep it hidden" as primarily associated with this role and the desire not to appear weak or "sick" within their local community. The latter reason is also linked to the previously mentioned point about how it is also the fear of being labeled "crazy" or "spirit possessed". This is also explained by Næss ( 2019 ), where he elaborates on the same point where he says that a Somali woman's domestic role limits her in seeking help, as disclosure of her mental state can, among other things, reflect negatively on Somali men in their roles as head of the household. This is why we assume that the need to keep "hidden" is primarily due to this role. In addition, we will also point out how the barrier to help-seeking behavior also revolves around the expectation that the family is the one they must rely on for help and if the condition cannot be handled by the family alone, then outside help must be assessed. In Whittaker et al. ( 2005 ) the participants explain precisely this, where they say that if one seeks help from outside, this could result in criticism and dissatisfaction from Somali society. Specifically, the participants in Whittaker et al. ( 2005 ) who were all young Somali women, also about the vulnerability associated with sharing personal difficulties. Something that gives us an understanding of why the tendency to want to "keep hidden" is central among Somalis, since the reality is that you risk being socially ostracized or looked down upon. The role of shame and stigma in social ostracism As described earlier, Somalis refer to mental illness as a continuum ranging from sane to insane (Johnsdotter et al., 2011 ; Selman et al., 2018 ; Linney et al., 2020 ; Palmer & Ward, 2007 ). Based on how this particular perception is repeated among the Somalis in all the selected studies, we gain a unique glimpse into why stigma is strongly associated with mental disorders and suffering. Interestingly, as the continuum ranges from sane to insane, the study participants' statements show that a reality also exists where one is quickly categorized into a dichotomy of either being sane or insane. If categorized based on two categories like "crazy" or "sane/normal," it is not strange how one can fear being labeled "crazy" at the first sign of mental difficulties. Therefore, it is understandable how one has a "suffer in silence" mentality where one is both expected to keep the suffering hidden, but also knows and fears the consequences of being transparent about one's difficulties can lead to social ostracism. Participants in Johnsdotter et al. ( 2011 ) highlight how "shame" strongly relates to psychological difficulties. Similarly, Palmer and Ward ( 2007 ) describe how shame prevents individuals from seeking help due to fears of breaching confidentiality and their condition becoming known within the Somali community. This reveals two key factors: 1) the reluctance to disclose mental health difficulties and 2) the fear of seeking help. Stigma and social ostracization are not limited to individuals with mental health challenges; having a family member with such difficulties can also lead to discrimination and exclusion. Selman et al. ( 2018 ) discuss how parents of children with autism face stigmatization, often through derogatory language used by others in the Somali community. Phrases like "your sick son" or "she with the sick child" are common, reflecting a lack of a Somali equivalent word for autism, and the use of terms such as "Doqon" (retarded) to describe mentally disabled children. This stigma often extends to parents, who are associated with their child's condition and subjected to judgment and social exclusion. Goffman ( 2009 ) describes how stigma can spread within families, with examples of parents being socially excluded and judged for their child's behavior. Although the stigma initially targets the child, parents also lose community support and understanding upon the disclosure of their child's challenges and illness. Barriers to help-seeking We believe that stigma and discriminatory attitudes associated with the understanding of mental disorders are not only challenging for those it affects, but can also act as a barrier in seeking help for those who need it most. This argues where we refer to our previously mentioned point about how the participants in our selected studies themselves report perceived discrimination and stigma associated with mental difficulties and disorders. This is based on how mental disorders are perceived within their society and then why one does not seek help. Another important factor that we consider to be a barrier is also an opinion expressed by the participants in the selected studies which indicates that it is a lack of cultural understanding on the part of healthcare personnel. Seeking help from outside is considered a "last resort" as they feel that the Western aid service does not have knowledge or understanding of the cultural and religious treatment methods (Johnsdotter et al., 2011 ; Loewenthal et al., 2011). We estimate that this may also have a connection with a fear of xenophobia towards Western aid services which inhibits help-seeking behavior, as it may also be a lack of information Somalis have about aid services in general. Another aspect of this that we have experienced ourselves is how a number of Somalis may fear the involvement of the child protection services if they should have sought help for their mental difficulties. This is something Næss ( 2019 ) also punctuates by saying that news among Somalis in Norway travels quickly and that if some Somalis should have had a bad experience with the Norwegian system such as child protection, this will help to influence other Somalis to fear the system as it can also happen to them. Something we then realize can reinforce the avoidance of seeking help. However, what we believe can also play a role in the two-sided opinion about lack of understanding is language. Language barrier, in line with the other barriers mentioned, is mainly also a factor in help-seeking behavior. Palmer and Ward ( 2007 ), Loewenthal et al. ( 2012 ) and Linney et al. ( 2020 ) all point out how the language barrier can be a barrier in help-seeking behavior where Somalis can be discouraged from seeking help. We believe that the importance of language is an important reason why Somalis report a feeling of lack of understanding by healthcare professionals. This can make it difficult to express yourself the way you want, and it can also be difficult for healthcare personnel to pick up concretely what it is that Somali patients need. Of course, this also depends on having a cross-cultural understanding and sensitivity. At the same time, we can see that it is perhaps the fear of involving a Somali interpreter which can also be an influencing factor in the already sensitive fear of confidentiality and that information may get out. In particular, we can imagine that it is the fear of xenophobia where you cannot fully trust health personnel who are different from your own to have your best interests at heart. Ex. explain the participants in Linney et al. ( 2020 ) that they experience a great deal of mistrust with regard to institutionalization or confiscation of their driver's license if they express themselves about their mental state. To conclude, we understand that perceptions of mental health and suffering are leading in how Somalis choose to act and how they seek help. We also see how perceived discrimination can originate both from within and from outside their local community, where they experience stigmatization within their culture and discrimination outside. There is a lot of shame they relate to that is linked to suffering psychologically, at the same time it is also the act of "leaving" one's cultural way of being and integrating into society which is also looked down upon as it is perceived as a negative thing. We would say that it is fear of xenophobia, language barrier and mistrust of services that are and affect the help-seeking barrier. Conclusion In light of the above findings, it is evident that Islam, culture, and the biomedical framework form the foundation for how Somalis in Europe perceive mental health and suffering. Our literature review highlights how the conceptualization of symptoms shapes the frameworks through which suffering is understood, as well as the interplay between physiological and psychological symptoms in the perception of mental health. Among Somalis, mental difficulties and suffering are often placed along a continuum ranging from "normal" to "waali," which contrasts with the categorical approach of ICD-10, widely used in Western Europe. The literature further reveals that Somalis perceive somatic illness as a test from God, while mental illness is often viewed as self-inflicted, resulting from a strained relationship with God. This perception ties closely to the concept of shame, which is a significant barrier to seeking help for psychological difficulties. Just as Somalis are selective in the frameworks, they use to understand illness, they are equally selective in their help-seeking behaviors, where shame often determines their choices. Additionally, fear of discrimination serves as another major obstacle, as many Somali informants in the reviewed studies highlight the lack of cultural insight and acceptance among healthcare personnel as a barrier to accessing effective care. Acculturation to Western European societies has influenced the perception of mental health and suffering among Somalis, alongside the inclusion of cultural factors in frameworks like DSM-5 and ICD-11. Lewis-Fernández and Kirmayer ( 2019 ) explore this cultural interplay by distinguishing between psychiatric disorders and cultural concepts of distress (CCD). CCDs encompass a broader spectrum of culturally specific symptoms, which, unlike standardized diagnoses, reflect varying levels of severity and meanings rooted in culture. For Somalis, terms like "waali," "buufis," and "murug" are not merely symptoms but culturally embedded conditions, underscoring that mental health perceptions are not universal but culturally situated. Groen ( 2009 ) emphasizes the importance of culturally enriched interviews, suggesting that healthcare professionals must validate and respect Somali patients' cultural perspectives. For example, a Somali patient's belief that schizophrenia is caused by Jinn underscores the need for empathy and curiosity in clinical encounters. This aligns with Kirmayer and Ryder's (2016) discussion of "culture and psychopathology," which emphasizes the need to integrate cultural concepts of distress into psychiatric care. Similarly, Kirmayer (1992) highlights how metaphors and narratives shape illness experiences, underscoring the importance of understanding patients lived experiences within their cultural contexts The findings also reveal significant research gaps, particularly regarding young second-generation Somali immigrants. Future studies should explore how generational differences influence mental health perceptions and help-seeking behaviors. Additionally, a focus on young Somali men, who are often underrepresented in the literature, would provide valuable insights into the evolving narratives of mental health within Somali communities. Reflecting on these insights, it becomes clear that the Western biomedical model alone is insufficient to address the complexities of Somali perceptions of mental health. Instead, a cross-cultural approach that incorporates cultural idioms, religious frameworks, and metaphors is essential. This integration not only enhances patient care but also fosters trust and understanding between healthcare providers and Somali patients. Declarations Funding No funding was received for this study. Conflicts of interest/Competing interests The authors declare no conflicts of interest. Availability of data and material Not applicable. Code availability Not applicable. Authors’ contributions Both authors contributed equally to the study conception, literature review, analysis, and writing. Both authors approved the final manuscript. Ethics approval Approved by the Ethics Committee of Aalborg University and supervisor Jaan Valsiner. Consent to participate Not applicable. 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Wardheer News. https://wardheernews.com/wp-content/uploads/2016/11/Sarbeeb-Prof-Said-S-Samatar-1.p df Scuglik, D. L., Alarcón, R. D., Lapeyre III, A. C., Williams, M. D., & Logan, K. M. (2007). When the poetry no longer rhymes: Mental health issues among Somali immigrants in the USA. Transcultural psychiatry, 44(4), 581-595. Selman, L. E., Fox, F., Aabe, N., Turner, K., Rai, D., & Redwood, S. (2018). ‘You are labelled by your children’s disability’—A community-based, participatory study of stigma among Somali parents of children with autism living in the United Kingdom. Ethnicity & Health, 23(7), 781–796 DOI https://doi.org/10.1080/13557858.2017.1294663 Solberg, Ø., Vaez, M., Johnson-Singh, C. M., & Saboonchi, F. (2020). Asylum-seekers' psychosocial situation: A diathesis for post-migratory stress and mental health disorders?. Journal of Psychosomatic Research, 130, 109914 Sullivan, C., & Forrester, M. (2019). Doing Qualitative Research in Psychology: A Practical Guide. 2nd edition. Chapter 3, 4, 5 & 11, London: Sage Chapter 3: King, N (2019) Research Ethics in qualitative research . In: C. Sullivan & M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 35- 60, London: Sage Chapter 4: Frost, N & Bailey-Rodriguez, D (2019) Quality in qualitative research reviews. In: C. Sullivan & M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 60- 78, London: Sage Chapter 5 Shaw, R. (2019) Conducting literature reviews. In: C. Sullivan & M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 78- 96, London: Sage Chapter 11: Bailey-Rodriguez, D., Forst, N. & Eliechoaff, F (2019) Narrative analysis. In: C. Sullivan & M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 209-233 , London: Sage Tyler, I. (2018). Resituating Erving Goffman: From stigma power to black power. The Sociological Review, 66(4), 744-765. Wedel, J. (2014). Religion and healing among Somalis in Sweden when experiencing illness and suffering. In African Dynamics in a Multipolar World: 5th European Conference on African Studies—Conference Proceedings (pp. 2346-2358). Centro de Estudos Internacionais do Instituto Universitário de Lisboa (ISCTE-IUL) DOI: 10.13140/2.1.4576.5767 Whittaker, S., Hardy, G., Lewis, K., & Buchan, L. (2005). An exploration of psychological well-being with young Somali refugee and asylum-seeker women. Clinical Child Psychology and Psychiatry, 10(2), 177-196. DOI https://doi.org/10.1177/1359104505051210 Willig, C. (2013). Introducing Qualitative Research in Psychology (3rd ed.). Open University Press, McGraw-Hill Education. Chapter 5 Willig, C.(2013). Putting together a research proposal.. In Introducing Qualitative Research in Psychology (3rd ed., pp.47-54). Open University Press, McGraw-Hill Education. Chapter12: Willig, C. (2013). Narrative Psychology.. In Introducing Qualitative Research in Psychology (3rd ed., pp.143-154). Open University Press, McGraw-Hill Education. World Health Organization. (2010). A Situation Analysis of Mental Health in Somalia. [https://applications.emro.who.int/dsaf/EMROPUB_2010_EN_736.pdf?ua=1 World Health Organization. (2022). Concepts in mental health. Hentet fra https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-respo nse Zimbrean, P. C., & Dahal, R. (2020). Risk Factors and Prevalence of Mental Illness. I Refugee Health Care, An Essential Medical Guide. Department of Psychiatry, Yale University, New Haven (s. 195-214) DOI: https://doi.org/10.1007/978-3-030-47668-7_13 Additional Declarations No competing interests reported. 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What does it mean to suffer psychologically in a country where the very idea of mental illness may be understood in entirely different terms? In our clinical encounters with Somali individuals in Norway and Denmark, we have been repeatedly struck by the ways in which mental suffering is narrated, interpreted, and responded to in ways that challenge Western psychiatric standards. Here, mental illness is often not seen as a discrete, diagnosable condition, but as something more fluid, shaped by faith, family, displacement, and moral meaning.\u003c/p\u003e \u003cp\u003eMany individuals from Somali backgrounds have expressed skepticism toward the concept of mental illness as it is framed within Western psychiatric paradigms. In our clinical practice, it is not uncommon to encounter patients who find the notion of being \u0026ldquo;mentally ill\u0026rdquo; unfamiliar or difficult to reconcile with their cultural understanding of distress (Fosse, 2011; Bhugra \u0026amp; Bhui, 2007). Some may seek clarification about how their experiences compare to those of others, particularly when observing behaviors such as speaking to oneself or displaying overt signs of mental disturbance. These questions often reflect more than clinical curiosity; they may indicate a deeper effort to make sense of personal suffering through a framework that feels foreign. Based on our clinical experiences, it suggests among Somali communities in Western Europe mental struggles are often conceptualized along a binary: either as spiritual or moral distress manageable through faith, or as extreme disruptions of the mind linked to madness. Mental illness is not typically recognized as a psychiatric condition but rather as a social, spiritual, or temporary state, fluid in meaning and embedded in a broader spiritual and cultural context (Bhugra \u0026amp; Bhui, 2007; Whitley \u0026amp; Berry, 2010; Fosse, 2011)\u003c/p\u003e \u003cp\u003eOur curiosity and clinical experiences prompted this article\u0026rsquo;s central aim which is to explore the qualitative social science literature on Somali local communities\u0026rsquo; conceptualizations of mental health and illness, as well as how these perceptions shape help-seeking behaviors. This article emphasizes qualitative research, shifting away from the quantitative or somatic-focused studies that dominate research on Somali communities in Western Europe and Scandinavia. While quantitative studies, such as those by WHO (2010) and Abebe, Lien, \u0026amp; Elstad (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), provide data on the prevalence of mental health challenges among Somalis - estimating that one-third experience significant mental health difficulties - they often fail to capture the lived experiences and cultural narratives underlying these challenges. For example, quantitative studies have noted that Somalis are among the minority groups in Scandinavia least likely to access mental health care services (Abebe et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Bhui et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2003a\u003c/span\u003e; Bhui et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2003b\u003c/span\u003e; Cinnirella \u0026amp; Loewenthal, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Hjelde, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Yet the reasons for that are not understood from quantitative studies. However, these studies do not fully explain the underlying reasons for this trend. To gain a deeper understanding, an idiographic research approach, as suggested by Molenaar (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), is necessary; one that prioritizes qualitative methods to explore individual experiences, cultural idioms and contextual factors influencing mental health care access. Thus, this article underscores the value and importance of qualitative research in understanding the nuanced and culturally embedded ways Somali communities conceptualize mental health. Each person who might be in need for help to cope with mental health issues is a unique individual whom the clinician needs to understand in her or his terms.\u003c/p\u003e \u003cp\u003eThis article is thus guided by two central questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do Somali local communities in Western Europe conceptualize mental health and illness through culturally embedded narratives and expressions?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn what ways do these cultural frameworks influence help-seeking behavior and perceptions of psychiatric care?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis inquiry is particularly pressing in the context of Somali migration to Europe. The Somali diaspora, especially in Northern and Western Europe and Scandinavia, has been shaped by a history of extreme social upheaval. The civil war that erupted in 1991 displaced more than two million people (N\u0026aelig;ss, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Cavallera et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), a crisis compounded by clan-based violence, systemic instability, and environmental disaster. Droughts, famine, and the failure of governing institutions forced many to flee not only due to violence but to survive basic human deprivation (Gundel, 2002; Abdullahi, 2020). The collapse of the Somali state led to mass displacement, trauma, and cultural fragmentation, all of which have profound psychological consequences.\u003c/p\u003e \u003cp\u003eStudies estimate that more than a third of Somalia's population has experienced significant mental health challenges (WHO, 2010), and yet institutional support, both in Somalia and abroad, remains limited or culturally incongruent. Somali migrants often carry the psychological residue of trauma, dislocation, and loss. In host countries like Norway, Sweden, and Denmark, they encounter mental healthcare systems that are unfamiliar and frequently unresponsive to their cultural frameworks (Abebe et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Bhui et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2003a\u003c/span\u003e; Bhui et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2003b\u003c/span\u003e; Cinnirella \u0026amp; Loewenthal, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Hjelde, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2008\u003c/span\u003e), While Western health authorities define mental health as emotional regulation, productivity, and social functioning (APA, 2018; WHO, 2022), these definitions often fail to align with Somali conceptions of the self and suffering. As such definitions offer a broad framework for understanding mental health, they often obscure the lived realities of individuals whose experiences are shaped by cultural, spiritual, and historical factors. For Somali migrants, mental illness is not solely a biomedical condition, it is articulated through culturally embedded idioms of distress, shaped by the legacy of trauma, displacement, and collective memory. When clinicians rely exclusively on standardized diagnostic categories, they risk overlooking how individuals actually experience, express, and respond to suffering. Understanding the person behind the diagnosis is therefore not only a clinical necessity, but a moral and cultural imperative, especially in contexts where incongruent worldviews and systemic mistrust act as barriers to help-seeking. Without this understanding, well-intentioned care may be rendered inaccessible, ineffective, or even harmful.\u003c/p\u003e\n\u003ch3\u003eConcept Clarification and Language Challenges\u003c/h3\u003e\n\u003cp\u003eThe American Psychological Association (APA, 2018) defines mental health as a state of well-being characterized by effective behavioral regulation, strong emotional relationships, and resilience in handling life's challenges. Similarly, the World Health Organization (WHO, 2022) views mental health as an individual's ability to realize their potential, work productively, and engage in society. Scandinavian health authorities echo these perspectives, emphasizing mental health as a dynamic process influenced by multiple factors, including social participation and functioning.\u003c/p\u003e \u003cp\u003eIn contrast, mental illness encompasses severe and enduring psychological conditions that impair emotional and cognitive functions, often meeting diagnostic criteria (APA, 2018; WHO, 2022). Distinctions are made between transient psychological challenges, such as stress or anxiety, and clinically significant disorders. These definitions largely reflect Western biomedical frameworks. However, Somali perspectives on mental health are better understood through culturally specific idioms of distress, as conceptualized by Nichter (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1981\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Im et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). These idioms capture culturally grounded expressions of psychological suffering through metaphors, narratives, or behaviors, providing insight into how mental health challenges are framed and communicated.\u003c/p\u003e \u003cp\u003eOne of us, who is of Somali background and speaks Somali fluently (Abdullahi, A), encountered significant challenges in finding Somali literature to compare with the above definitions. Using a Danish-Somali dictionary (Hussein, Elmi, \u0026amp; Maacaani, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1998\u003c/span\u003e), we noted how direct translations often failed to capture the nuances of meaning. For example, the word \"maskax,\" which directly translates to \"head,\" is also used to mean \"mental.\" Similarly, the term \"psychiatry\" in Somali is translated as \"cilmiga dhaktarka silawa dakta waalan ama sikka ka jiiran,\" which literally means \"the knowledge of medical treatment for crazy people or those struggling with something in the head.\" Anxiety is translated as \"cabsi, naxsan, baqdin,\" which conveys fear, dread, or panic. These differences highlight the lack of specific terms for mental disorders in Somali, where symptoms rather than diagnoses are emphasized, and also illustrate a lack of direct equivalence between biomedical and Somali mental health vocabularies, and highlight the reliance on culturally specific expressions of distress. This reflects Nichter's (1981, 2010) concept of \"distress expression,\" where idioms, metaphors, stories, and behaviors are used to convey psychological discomfort.\u003c/p\u003e \u003cp\u003eThe challenges of linguistic translation reveal how Somali culture communicates mental health concepts differently from Western frameworks. Samatar (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) describes Somalis as a \"nation of poets,\" emphasizing the use of metaphor and poetry to express social problems and personal experiences. This cultural emphasis on storytelling and metaphor suggests that Western technical definitions may not align with Somali modes of understanding. Instead of clinical diagnoses, Somalis often use a continuum of terms and symptoms to describe psychological conditions, further underscoring the cultural differences in conceptualizing mental health (Scuglik et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Kaiser \u0026amp; Weaver, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Gopalkrishnan, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding Somali mental health requires engaging with both continuity and rupture: with long-standing cultural traditions and the collective trauma of displacement. These dual forces, cultural resilience and historical fragmentation, shape how suffering is interpreted and managed. Mental illness, in this context, cannot be seen as an isolated pathology. It is embedded in migration histories, communal memory, and the navigation of healthcare systems that often misrecognize or marginalize non-Western expressions of distress.\u003c/p\u003e \u003cp\u003eAccordingly, there is a critical need for research that elucidates how Somali local communities construct meanings around mental health and illness, and how these culturally embedded frameworks inform patterns of help-seeking within healthcare systems that frequently fail to accommodate non-Western epistemologies of distress.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methodology: A Narrative Literature Review","content":"\u003ch2\u003eRationale for a Narrative Literature Review\u003c/h2\u003e\u003cp\u003eA literature review is an essential step in the research process, offering a systematic way to identify gaps in knowledge and critically evaluate existing studies (Sullivan \u0026amp; Forrester, Chap.\u0026nbsp;3–11, 2019; Shaw, Chap.\u0026nbsp;5, 2019; Frost \u0026amp; Bailey-Rodriguez, 2019; King, N, Chap.\u0026nbsp;3, 2019; Grant \u0026amp; Booth, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). By synthesizing and categorizing prior research, it provides a coherent understanding of the field and highlights areas for further research (Forrester, 2012; Baumeister \u0026amp; Leary, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Among the diverse types of literature reviews, we opted for a narrative review, which is particularly suitable for examining qualitative studies and integrating cultural and contextual insights (Grant \u0026amp; Booth, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Willig, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Willig, Chap.\u0026nbsp;5 \u0026amp; 12, 2013; Halcomb et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Bamberg, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Given our focus on Somali perceptions of mental health in Europe, the narrative review approach allows us to explore how qualitative findings collectively construct a broader understanding. This method aligns with our qualitative focus, enabling an in-depth examination of perceptions, narratives, and cultural dimensions of mental health expressions and understandings within Somali local communities, making it particularly appropriate for our project.\u003c/p\u003e\n\u003ch3\u003eSearch Strategy and Selection Process\u003c/h3\u003e\n\u003cp\u003eScrutiny of analysis of the available literature in psychology and social sciences highlights a persistent lack of knowledge regarding Somali perceptions and experiences of mental health, illness, and care in Scandinavia and Western Europe. Searches in databases including Taylor \u0026amp; Francis, APA PsychNet, and Scopus generated only 212 results when searching for variations of \"Somali,\" \"Mental Health,\" and \"Mental Illness.\" A total of 11 qualitative studies were included in this review. Articles were selected for inclusion based on their focus on Somalis, mental health, and help-seeking behavior, and their use of qualitative methods only.\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eOur inclusion criteria required that articles employ qualitative methods with a focus on Somali perceptions of mental health, illness, and help-seeking behaviors. We prioritized studies from Scandinavia, although research from Western Europe was also included. Articles primarily focusing on somatic illnesses were excluded, while studies on psychiatry and psychosis among Somalis in Europe (excluding khat-induced psychosis and addiction-related research) were deemed relevant. Only peer-reviewed literature about Somalis was included, with a particular emphasis on Somali communities in Scandinavia. However, the review was expanded to include studies from across Europe due to limited Scandinavian research. Literature from the United States was excluded, as adaptation tasks in America differ from those in European and Scandinavian context, making direct comparisons less relevant. Based on the findings from the included articles, the qualitative research on Somali perceptions of mental health predominantly consisted of interviews (n\u0026thinsp;=\u0026thinsp;4), focus groups (n\u0026thinsp;=\u0026thinsp;2), and a combination of interviews and focus groups (n\u0026thinsp;=\u0026thinsp;5). The sample size of the studies ranged from n\u0026thinsp;=\u0026thinsp;1 to n\u0026thinsp;=\u0026thinsp;47, with a mean sample size of n\u0026thinsp;=\u0026thinsp;17.8, indicating that the samples were generally small-scale.\u003c/p\u003e\n\u003ch3\u003eAnalytical Framework and Thematic Synthesis\u003c/h3\u003e\n\u003cp\u003eMost studies analyzed their data using thematic analysis, including general thematic analysis, interpretative phenomenological analysis (IPA), narrative analysis, or anthropological analysis. Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) applied Lincoln and Guba's framework for naturalistic inquiry, while Groen (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), an anthropologist, conducted a clinical interview using the Cultural Formulation Interview (CFI). Most of the studies were interdisciplinary, with a primary focus on psychology, including clinical, pedagogical, and psychiatric aspects. A few studies combined anthropology with psychology and psychiatric research. The included studies were reviewed to identify core themes and narratives about how mental health and illness are conceptualized among Somalis in Europe and to synthesize what the research reveals about Somali help-seeking behaviors regarding mental health and illness. The following findings generated during the review of the literature relating to the conceptualization of mental health and illness were: Understanding mental illness and suffering caused by migration, the toll and challenges of acculturation, understanding mental suffering through physiological manifestations, spiritual and cultural perspectives on mental health and illness, and changing perceptions of mental health.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResults: Thematic Synthesis of Somali Perceptions of Mental Health in Europe\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eMigration, Trauma, and Mental Health in Context\u003c/h2\u003e \u003cp\u003eIn 1991, a clan-based civil war in Somalia forced around 2\u0026nbsp;million Somalis to flee the country, with war, natural disasters, and resource scarcity driving migration (N\u0026aelig;ss, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Cavallera et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Migration processes, combined with the trauma of displacement, are recognized as significant risk factors for mental health issues among Somali migrants (Solberg et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Zimbream \u0026amp; Dahal, 2020). For many, migration represents a forced journey toward safety and opportunities, but the realities of navigating asylum systems and settlement often exacerbate psychological stress. Palmer and Ward (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) highlight how challenges in securing housing, work permits, and employment opportunities intensify migrants' stress, eroding their sense of hope and mastery. They describe how some participants used work as a coping mechanism, while others struggled with the mismatch between their skills and the available opportunities, which further diminished their sense of belonging and control. Groen (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) examines the impact of migration on cultural identity, showing how the shift from a collectivist Somali context to the individualist Western environment can disrupt migrants\u0026rsquo; sense of belonging. One Somali participant expressed their tribal identity as \"the only thing that matters,\" (Groen, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e, p.457) emphasizing its central role in their self-concept. Groen notes that isolation from Somali communities in host countries often limits opportunities for cultural recognition, potentially exacerbating psychological distress. This raises broader questions about how Somali migrants adapt to new cultural contexts and how these shifts influence their mental health.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eThe toll and challenges of acculturation\u003c/h3\u003e\n\u003cp\u003eAcculturation is another aspect that is equally important to mention when we look more closely at the common features shared by the study results. It is primarily a concept that aims to explain an adaptation process with cultural changes as a result of an encounter with a new cultural context (Berry \u0026amp; Sam, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Acculturation can also be considered a factor in the influence of both somatic and mental health (Gupta, Leong, Valentine \u0026amp; Canada, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). One can distinguish between two types of acculturations, where acculturation itself as a concept takes its starting point from the change that occurs in a group. The second type of acculturation is that related to psychological changes that occur at an individual level (Berry \u0026amp; Sam, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). The study by Osman et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) focuses precisely on acculturation in the form of how Somalis in Sweden experience this process. They mention important points as the basis for their research questions, such as how some Somalis, despite their attempts to integrate into the society they live in, experience difficulties related to this (Osman et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The main theme of their findings in this study was \u0026ldquo;longing for belonging\u0026rdquo;. They found that the experience of acculturation for these young Somalis was associated with a feeling of \u0026ldquo;outsiderness\u0026rdquo; in the form of social exclusion and lack of support when it comes to this adaptation process. Sub-themes that the studies found that were closely linked to the difficulties of acculturation included discrimination. Some of the participants reported perceived discrimination with experiences such as racism related to ethnicity, skin color and religion, among other things. Somalis migrate at different ages and in some cases, it may be the case that there are many young Somalis who migrate with their families. In the process of acculturation, we can imagine how these young Somalis are raised in and take part in the societies they settle in. E.g. their identity development becomes a mixture of their parents' culture and the culture they are raised in. Another example of this is how some of the participants in Osman et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) reported a feeling of being \"between cultures\". They explained a challenge such as not fully understanding where they belong. These were participants who were raised in Sweden, where they themselves feel different in terms of appearance and mannerisms that deviate from the typical Swedish. They express how they are not considered Somali if they were to have been in Somalia, nor are they considered Swedish, but feel that they fall into a \"middle in between\" category. This reminds us of the \"third-culture kid\" concept that aims to explain how children raised outside their parents' home country/culture struggle with the feeling of being in a \"neither or\" place. A place between their parents' culture, and the culture they themselves were raised in (Pollock, Van Reken, \u0026amp; Pollock, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eUnderstanding mental suffering through physiological manifestations\u003c/h2\u003e \u003cp\u003eWithin the literature, Somalis in Europe's conceptualization of mental health and suffering is, among other things, based on physiological/somatic symptoms. Ex. all authors describe, that Somalis in Europe conceptualize mental health and suffering as physical manifestations and consequences of war and migration (N\u0026aelig;ss, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; M\u0026ouml;lsa et al., 2011). Linney et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) describe that the majority of the focus group participants described a connection between mental and physical health (2020). The participants described mental illness as somatic or visible symptoms, e.g. such as physical pain to 'unusual behaviour' such as being \"violent\" or not dressing properly (Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In particular, the participants explained that mental illness and distress start with and are described to a general practitioner as a headache (Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Specific to this study, it is a new finding that Somali women explained that mental illness starts with the physical symptom of headache, as it has not been described in the other studies. Palmer \u0026amp; Ward also describe that the Somali participants described physical symptoms more prominently than the other ethnic groups, although the importance of headache was not mentioned (2007). In relation to this, the aticle's introduction elaborated on some Somali words that further support this, e.g. with the word Maskax which directly translated means head, but in the dictionary, it is translated to mental. If head and mental are linguistically the same in Somali, it is not a surprise if Somalis translate mental pain into headache. This illustrates the conceptualization of mental illness symptoms in Somali society, which may differ from conventional beliefs about illness. This is important clinically, as the presentation of headaches in women can be a description of distress or psychological problems\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThe Spectrum of Suffering: Sane or Insane?\u003c/h2\u003e \u003cp\u003eIt is clear that there are some contradictory features if we compare the traditional Somali perceptions of mental health and suffering with the Western psychiatric framework of understanding. Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and Wedel (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) describe this contrast as, that Western doctors operate with specific categories e.g. illustrated by categorization in ICD-11 and in DSM-5, where the traditional concepts and categories for suffering in Somalia are much more fluid. In particular, Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) illustrates how this can be understood along a continuum, which starts with mild suffering and challenges and ends with madness, where it is only at this stage when someone has become 'waali'/crazy, that it is classified as a medical problem. There are traditional Somali terms to denote different kinds of mental conditions, which are said to be about mental ill health, where in connection with this we have identified particularly prominent expressions, across the studies, which are commonly understood and used among Somalis in Europe to describe mental illness; Dhimir, Murug, Buufi, Waali and Jinn (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al., 2010; Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). These terms, in the order written, describe the continuum. Some informants in Johnsdotter et al. used the term, Dhimir, which generally denotes poor mental health, however, all informants were not familiar with this term, which may be due to different local languages ​​(2011). The expression, \u003cem\u003emurug\u003c/em\u003e, describes the state where you feel that you have many challenges, \"feeling low\", and when you are in a state of worry. This term refers to everyday situations, e.g. that one's financial condition can result in this (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Further along the continuum, the term \u003cem\u003eBuufi/Buufis\u003c/em\u003e, which translated means \"to withhold breath\" (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003ep. 744) or \"to be filled with air\" (M\u0026ouml;lsa et al., 2010, p, 286), characterizes a state where one is tense and paranoid. The informants in both M\u0026ouml;lsa et al. (2010) and Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) relate buufis to an anxiety-like condition, characterized by \"sadness\" and \"distress\", as a result of civil war and clan conflicts, which have destroyed social networks. \u003cem\u003eWaali\u003c/em\u003e is at the extreme end of the continuum and is widely understood among Somali communities to mean \u0026ldquo;crazy\u0026rdquo;, \u0026ldquo;crazy person\u0026rdquo; or \u0026ldquo;mentally unfit,\u0026rdquo; and is perceived as significantly more stigmatizing than milder idioms like \u003cem\u003emurug\u003c/em\u003e. As reported by all participants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and Carroll\u0026rsquo;s (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) study, \u003cem\u003ewaali\u003c/em\u003e is used to describe individuals exhibiting behaviors such as talking incoherently, wandering aimlessly, dressing inappropriately, or showing signs of severe disconnection from reality. These behaviors are interpreted as symptoms of profound psychological disturbance, often following extreme trauma or shock. Importantly, \u003cem\u003ewaali\u003c/em\u003e also carries a high level of social stigma and is associated with unpredictability and potential violence, which contributes to the social distancing and exclusion of those labeled in this way. Informants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) point out, that it is difficult as a local community to help and heal the illness that a Waali person suffers from. Here we understand that the limit to help from the local community is at waali/insanity. Several of the informants in particular attributed murug, buufis and waali mainly to traumatic refugee experiences, as described in the above section, the greater socio-political destruction of civil war and famine and in some cases post-migration stress factors (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al., 2010; Carroll, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe term \u003cem\u003eJiin\u003c/em\u003e, an evil spirit that can possess you, is often used across the studies, as a perception of, among other things, schizophrenia (Azaunce, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Islam \u0026amp; Campell, 2014), this is further elaborated in the section below, on spiritual and religious perceptions of mental health and illness (M\u0026ouml;lsa et al., 2010; Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Loewenthal et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Whittaker et al., 2020).\u003c/p\u003e \u003cp\u003eTo enhance understanding of culturally specific mental health expressions among Somalis in Europe, the following table (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) summarizes key idioms of distress as documented in qualitative studies, along with their translations, contextual meanings, and associated clinical relevance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eoverview of idioms of distress:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomali Idioms of distress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiteral and conceptual translation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssociated causes and cultural context\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Relevance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKey Reference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDhimir\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral poor mental health / mental disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral psychological strain or distress; can be due to multiple life stressors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMay be under-recognized in Western diagnoses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJohnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e); M\u0026ouml;ls\u0026auml; et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMurug\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeeling low, sadness, worry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDaily stressors such as financial problems, unemployment, loneliness, or unresolved worry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCould resemble mild depressive or adjustment disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJohnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBuufi/Buufis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;To withhold breath\u0026rdquo; / be filled with air (anxiety-like state)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety, sadness, distress related to traumatic displacement, social disconnection, civil war; anxiety and paranoia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparable to anxiety or stress-related disorders, possibly PTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026ouml;lsa et al. (2010), p. 286; Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWaali\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMadness/Insanity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSevere mental disturbance marked by erratic or socially inappropriate behavior (e.g., incoherent speech, wandering, disrobing), often seen as the result of extreme trauma; highly stigmatized and associated with unpredictability or violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLikely corresponds to psychosis or schizophrenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJohnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e); M\u0026ouml;ls\u0026auml; et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e); Carroll, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eJinn\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpirit possession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttributed to supernatural possession by evil spirits in Islamic cosmology, often associated with psychosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCorresponds to psychosis. Jinn possession is believed to cause schizophrenia (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Help is commonly sought through Islamic healing practices such as Quranic recitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJohnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e); M\u0026ouml;lsa et al. (2010); Carroll, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Azaunce, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e); Loewenthal et al. (2007)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSpiritual and cultural perceptions of mental health\u003c/h2\u003e \u003cp\u003eIn contrast to physiological manifestations of mental health, all articles in this review touch, to varying degrees, on the importance of spirituality and religion for Somalis in Europe's perception of mental health and suffering. Overall, there are two pervasive views of mental health and suffering, which touch on spirituality, the prevailing view, which focuses on Islamic cosmology and the other, which focuses on traditional Somali narratives. Both start from spirit possession and how this causes mental illness (M\u0026ouml;lsa et al., 2010; Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Loewenthal et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Whittaker et al. \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Individuals can either be possessed by jinn, which are evil spirits in Islamic cosmology, or by traditional Somali zar/saar spirits, which many of the study's informants consider to be 'un-Islamic' (M\u0026ouml;lsa et al., 2010; Johndotter et al., 2011; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Whittaker et al. \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Symptoms or behaviour, which are interpreted as mental disorder in a biomedical framework, e.g. schizophrenia, is considered by many Somalis in Europe to be caused by either supernatural forces, such as spirits, or by humans through mechanisms such as the 'evil eye' or a curse (M\u0026ouml;lsa et al. 2010: Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wedel \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). M\u0026ouml;lsa et al. (2010) point out, that according to Islamic theology there are jinn everywhere. Ex. describes an informant in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), how he developed schizophrenia:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Here is where the jinni hit me, you know of the jinn, right? (...) This vibration in my head, I was crying sometimes. At night when I was going to sleep, it was like \u0026hellip; [makes a noise to show vibration], the vibration, from here, the side of my head. They said it was jinn. The sheikh [religious scholar] said it was jinn\"\u003c/em\u003e (Johnsdotter, et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, p. 744)\u003c/p\u003e \u003cp\u003eThe informant is medicated for schizophrenia, but his perception of the illness is based on a religious framework. The informants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), who have developed schizophrenia described symptoms of jinn possession as anxiety, obsessive-compulsive symptoms, aggression attacks, nightmares, physical pain, sadness, headaches, insomnia and hallucinations. These symptoms are also described by the participants in M\u0026ouml;lsa et al. (2010) which further includes symptoms such as nausea, vomiting, reduced appetite, apathy, aggressive behaviour, suicidal thoughts and behavior and violent bodily restlessness (2010). Both the participants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), M\u0026ouml;lsa et al. (2010) and Loewenthal et al. (2007) believed that within Islam one's belief in Jinn affects the perception of mental illness and how mental illness can be treated, but that Western health professionals do not understand this. This is pointed out by an informant from M\u0026ouml;lsa et al. (2010);\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"But the jinn they [Finnish doctors] can't heal and can't understand the way we perceive it; they don't believe in the etiology. To us as Somalis and Muslims, it is a real thing that causes mental illnesses.\u003c/em\u003e (Individual interview, Somali healer)\" (p.290).\u003c/p\u003e \u003cp\u003eAccording to interviewees, Islamic knowledge and reading the Koran are necessary to fight and heal diseases caused by jinn. In these cases, biomedicine is considered insufficient (M\u0026ouml;lsa et al. 2010; Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Among Somalis in Europe, spirits can also be understood within the framework of the possession cult, saar/zar, which is evoked in special ceremonies (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The traditional zar spirits are divided into subcategories, such as mingis, waddadu and borane, and are to be evoked by rituals involving song, dance, trance and speaking in tongues (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al. 2010). The various spirits are loosely connected with the clan system, that a person is more likely to be possessed by a particular spirit depending on their class affiliation. Like Jinn, these zars are generally malevolent and are associated with dirt and unhygiene (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al. 2010). The informants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)d lsa et al. (2010) maintained that Somalis generally trust the Finnish and Swedish health services when it comes to somatic, non-chronic diseases, where diagnosis and treatments are easily available. According to Somali tradition, mental health and suffering are also largely related to the social world and especially to the transcendental world. In that sense, mental illness is in a certain sense located outside the individual: It is about one's relationship with God, and with jinn and other spirits (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al. 2010; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For example, this understanding of illness becomes clear when informants there suffer from schizophrenia in Johnsdotter et al. describes that this disease is 'placed' in them, and is not part of them (2011) Particularly in this study, a schizophrenic Somali woman pointed out that she is hesitant to accept antipsychotics from her Swedish doctor, where she says;\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIn our country, people may be mentally ill, but they get well again with the Koran and medication, and when they have recovered, nobody will notice that they've been ill. But here they make you take medicine until the day you die. Here you can see who is on medication for mental problems, their faces are hanging, they gain weight, they walk differently\u003c/em\u003e\" (Johnsdotter et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, p.749).\u003c/p\u003e \u003cp\u003eThis quote illustrates the above point about the Somali perception of mental health and health being closely connected with the social and spiritual spheres. Mental disorders are often seen as related to one's connection with God, spirits and community, rather than solely as individual somatic or medical issues.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEvolving narratives and Changing Perceptions in the Diaspora\u003c/h2\u003e \u003cp\u003eHowever, there is a big difference between whether one believes in jinn or zar spirits. Overall, there is a general consensus in the literature that the prevailing perception of mental health and illness among Somalis in Europe is based on an Islamic framework of understanding. It also appears that zaar possession is to a large extent a stigmatized practice, with the study's informants pointing out that it is Somalis in Somalia in particular who are more likely to believe in zaar than those in Europe. Ex. tells a religious healer, as M\u0026ouml;lsa et al. (2010) have interviewed that the zaar possession culture is defined as non-Islamic by the Somali Islamic religious community, where the other informants, in the same study, reveal that there are actually only a handful of people who practice zaar, secretly in Finland. Similarly, Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and Wedel (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), that in Sweden this is a stigmatized practice, which is carried out by a small group of individuals. This makes us wonder about the change of the spiritual in Somalis' perception of mental health and suffering and what factors play a role in the change? Based on the literature reviewed, we identify a tendency among Somalis, which indicates that traditional perceptions of mental health, mental illness and help-seeking behavior are challenged and changed due to the encounter with the new culture, to which one has fled or migrated. We can build this argument on the basis of research, which has looked at the meeting with e.g. the Finnish and British biomedical system and due to new religious interpretations supported by the Islamic faith community (M\u0026ouml;lsa et al. 2010; Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). As described in the above section, acculturation refers to the process through which individuals or groups from one culture come into contact with and adopt elements of another culture, which leads to cultural changes in behavior and perceptions (Berry \u0026amp; Sam, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). In the context of understanding changing perceptions of mental health and suffering among Somalis in Europe, we consider the concept of acculturation to be a valuable frame of reference for understanding how the process of adaptation and integration affects their perception of mental health. Both informants in M\u0026ouml;lsa et al. (2010) and Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) study describes their perceptions of mental health and illness to have changed since they fled Somalia. Newly arrived young Somali female asylum seekers, who had more traditional beliefs and familial experiences of zar possession in Somalia, expressed concern and fear that the zar would control them (Whittaker et al. \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Whereas the women who had been in the UK for a longer time were very skeptical of the existence of zars and were more likely to perceive them as weak-minded and describe it as \"Nonsense\" and \"it was a way that older Somalis tried to hold onto cultural beliefs in the UK\" (2005, p.186). We understand this to mean that spirit possession can function as a way of concretizing and externalizing psychological difficulties for refugees and newcomers. This can further support our point, from the acculturation section, that a higher degree of acculturation results in increased integration of western understanding of illness, and the distancing from traditional understanding based on saar possession. Of this, the informants point out in both Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e)d lsa et al. (2010), that through migration their faith in Islam has been strengthened. In addition to the fact that migration and acculturation lead to an increased integration of Western understanding of illness, we consider that this also leads to an increased integration of an Islamic-based understanding of illness, which results in a further distance from zar spirits and thus a further change in the perception of mental illness\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below summarizes the main thematic findings from the reviewed qualitative literature, offering a structured overview of how Somali communities in Western Europe understand, experience, and articulate mental distress. While not intended to provide a fully tailored diagnostic framework, the synthesis highlights the importance of clinical curiosity and cultural humility in exploring spiritual, religious, and cultural idioms of distress. Attending to these perspectives can foster trust, improve therapeutic engagement, and support more context-sensitive mental health care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Thematic Findings on Somali Perceptions of Mental Health in Western Europe\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme Summary\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey findings:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative insight\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCitied studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical or Policy Relevance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigration, trauma, and mental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMigration and displacement increase psychological vulnerability; barriers in host countries exacerbate distress.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"The only thing that matters is your tribe.\" (Groen, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) - loss of identity and belonging post-migration.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u0026aelig;ss, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Groen, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Palmer \u0026amp; Ward, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHighlight need for trauma-informed care and culturally sensitive psychosocial support.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcculturation and belonging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung Somalis face identity conflicts and social exclusion during acculturation, experiencing a sense of being 'between cultures' (Osman et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Between cultures\" - young Somalis raised in Europe often feel neither Somali nor European (Osman et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsman et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Pollock et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEncourage youth-specific services that addresses bicultural identity and belonging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological manifestations of mental distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental distress is often described somatically (e.g., headaches, pain), highlighting a linguistic and cultural conceptualization of suffering.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMental illness first reported as headache or physical pain; 'maskax' links head/body and mind linguistically (Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLinney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Palmer \u0026amp; Ward, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealthcare providers should explore somatic symptoms as potential signs of psychological distress.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural Idioms and Continuum of Suffering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomali idioms (Dhimir, murug, buufis, waali) describe a continuum from mild distress to madness; terms are tied to trauma, stigma, and social implications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTerms like 'murug' and 'buufis' describe worry and anxiety; 'waali' indicates psychosis and social exclusion (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJohnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; M\u0026ouml;lsa et al., 2010; Carroll, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAvoid misdiagnosis by recognizing culturally specific idioms to build culture-sensitive frameworks.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpiritual and Religious Understandings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpiritual and religious frameworks (jinn, zar) shape understanding of mental illness; treatment often sought through Islamic or traditional healing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn particular is Jinn believed to cause mental illness; healing sought through Quran and religious scholars.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026ouml;lsa et al., 2010; Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wedel, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2014\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhile biomedical systems cannot fully adopt spiritual etiologies, providers should remain open and curious about patients\u0026rsquo; cultural, spiritual, and religious explanations of illness, not to confirm these understandings, but to validate lived experiences and foster trust, thereby enabling culturally sensitive and safer therapeutic relationships.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChanging Perceptions and narratives around mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMigration and acculturation lead to re-evaluation of traditional beliefs, greater integration of Islamic frameworks and biomedical frameworks, and distancing from zar practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZar beliefs diminish in diaspora; younger Somalis describe traditional views as 'nonsense' (Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; M\u0026ouml;lsa et al., 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnderstanding evolving perceptions can help tailor interventions for second-generation migrants and inform long-term mental health strategies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBuilding on the findings of how Somali communities in Europe perceive mental health and suffering through religious and spiritual lenses, the following discussion explores how these perceptions may influence their expression of distress and help-seeking behaviors. This is examined in the context of discriminatory attitudes, both within and outside their communities, which shape and potentially hinder their access to mental health care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFrom Stigma to Discrimination: Reframing Barriers to Somali Mental Health?\u003c/h2\u003e \u003cp\u003eIn examining Somali perceptions of mental illness and their interaction with mental health systems in Western Europe, it is crucial to distinguish between the concepts of stigma and discrimination. Stigma, as a sociological concept, provides a critical lens for understanding how individuals are marginalized and discredited within societal structures and as Goffman (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2009\u003c/span\u003e, p.8) famously defined stigma as \u0026ldquo;a characteristic that is deeply discrediting,\u0026rdquo; emphasizing how it marks individuals as deviating from the \u0026ldquo;normal\u0026rdquo; behavior expected within society. He conceptualizes stigma as something a person is perceived to \"carry,\" which sets them apart. Similarly, Arboleda-Fl\u0026ograve;rez and Sartorius (2008, p.5) describe stigma as a prejudiced and negative attitude, suggesting that those subjected to it are pushed to the margins and kept at a distance. While Goffman\u0026rsquo;s definition offers valuable insights, we approach it with caution when interpreting the experiences of participants in the selected studies. Scholars such as Tyler (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) critique Goffman\u0026rsquo;s focus on individualistic experiences, arguing that it neglects essential dimensions such as racial stigma, historical context, and the influence of power dynamics on the formation and perpetuation of stigma. This is because Goffman\u0026rsquo;s framework tends to frame the problem in psychological or interpersonal terms. In contrast, discrimination emphasizes structural, institutional, and externally imposed forms of exclusion.\u003c/p\u003e \u003cp\u003eThis distinction is particularly relevant in the context of Somali experiences, where community-based stigma (e.g., shame or fear of being labeled \u003cem\u003ewaali\u003c/em\u003e) functions differently from racialized or cultural discrimination encountered in the broader societal context (e.g., Islamophobia, xenophobia, or institutional mistrust). Idioms of distress such as \u003cem\u003emurug\u003c/em\u003e or \u003cem\u003ebuufis\u003c/em\u003e often reflect internal struggles that remain hidden due to communal stigma, whereas reluctance to seek formal help can be tied to broader systemic discrimination. Maintaining this distinction is essential not only for theoretical precision, but also for understanding the complex barriers to help-seeking behavior. Where stigma may produce silence and shame within the Somali community, discrimination, experienced through exclusion, marginalization, or mistrust in services, can create profound structural barriers to accessing care. Recognizing how these forces operate differently, yet interactively, allows for a more nuanced and clinically relevant analysis. It helps avoid over-psychologizing what are often sociopolitical constraints and directs attention to both culturally informed mental health interventions and the need for systemic reform.\u003c/p\u003e \u003cp\u003eWe therefore apply Goffman\u0026rsquo;s concept of stigma to understand how individuals with mental illnesses are perceived and treated within Somali society. However, when examining discrimination experienced outside Somali local communities, we frame it as prejudice and discriminatory attitudes rather than \"stigma,\" recognizing that its meaning shifts in the context of being outsiders in a society and culture different from their own. An example of this is how the participants in Osman et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) discuss the experience of discrimination as part of their acculturation process in Sweden. They explain an experience of exclusion and being an outsider in school situations that they describe as related to their skin color, ethnicity and religion. In such cases, the term \"stigma\" fails to fully capture or account for the participants\u0026rsquo; experiences.\u003c/p\u003e \u003cp\u003eWe find it more appropriate to use terms like \"racism\" and \"discrimination,\" which more accurately reflect the nature of what they are encountering. As mentioned, Goffman (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) describes stigma as something that one \u0026ldquo;carries\u0026rdquo;. While this definition emphasizes the burden on the individuals, we argue that it risks portraying those who experience discriminiation as inherently flawed or unchangeable. This perspective fails to consider that stigma is shaped by social and individual interactions, as well as structural discrimination.\u003c/p\u003e \u003cp\u003eTherefore, we argue that the participants' experiences of negative attitudes and exclusion, which primarily stem from outside their Somali communities, are better explained using terms such as discrimination and racism. Furthermore, it is noteworthy that most participants in the selected studies do not commonly use the term stigma to describe their experiences. Instead, they refer to the concepts like \"shame\" and \"discrimination\", \"racism\", \"exclusion\" and \"labelling\". Accordingly, we will adopt this term to more accurately reflect their lived experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eExperiences with discrimination\u003c/h2\u003e \u003cp\u003eDiscrimination linked to the acculturation process can also originate within Somali communities themselves. Bowie, Wojnar, and Isaak (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) highlight how Somali families fear their children adopting \"American bad traditions,\" such as involvement in drugs or gangs, as they prioritize preserving Somali cultural traditions. Several studies also discuss this in the context of intra-community discrimination, where acting differently in Somali society, such as being perceived as \"too Western,\" often leads to judgment and labeling as \"crazy.\" This fear of deviating from traditional norms stems not only from concerns about cultural preservation but also from stigmatizing attitudes towards transparency about mental health struggles. For instance, Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) explain that participants feared being labeled as \"mad\" or \"obsessed\" if they were perceived as overly \"Westernized\" or as challenging their religious beliefs. This fear is particularly pronounced in Somali communities in the UK. While studies highlight this negative perception of \"Westernization,\" they do not provide definitive explanations for why it exists. However, factors such as religion and the loss of cultural identity appear to contribute to this stigma. Many participants in the reviewed studies reported hiding their struggles from close family and the broader Somali community due to fears of being branded or judged. This recurring theme of \"keeping hidden\" underscores the role of discrimination in discouraging openness about mental health. Associating mental illness with stigma and discrimination creates significant barriers, preventing individuals from seeking help. Additionally, societal gender roles and expectations further influence help-seeking behavior. Most individuals tend to first turn to their families for support, as families are often seen as the primary source of help in times of difficulty (Whittaker et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; N\u0026aelig;ss, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSuffering in silence\u003c/h2\u003e \u003cp\u003eA Somali woman's role in her family is an important role and if she shows her weakness, her conduct can reflect negatively on the family. We understand the recurring theme of having to \"keep it hidden\" as primarily associated with this role and the desire not to appear weak or \"sick\" within their local community. The latter reason is also linked to the previously mentioned point about how it is also the fear of being labeled \"crazy\" or \"spirit possessed\". This is also explained by N\u0026aelig;ss (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), where he elaborates on the same point where he says that a Somali woman's domestic role limits her in seeking help, as disclosure of her mental state can, among other things, reflect negatively on Somali men in their roles as head of the household. This is why we assume that the need to keep \"hidden\" is primarily due to this role. In addition, we will also point out how the barrier to help-seeking behavior also revolves around the expectation that the family is the one they must rely on for help and if the condition cannot be handled by the family alone, then outside help must be assessed. In Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) the participants explain precisely this, where they say that if one seeks help from outside, this could result in criticism and dissatisfaction from Somali society. Specifically, the participants in Whittaker et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) who were all young Somali women, also about the vulnerability associated with sharing personal difficulties. Something that gives us an understanding of why the tendency to want to \"keep hidden\" is central among Somalis, since the reality is that you risk being socially ostracized or looked down upon.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe role of shame and stigma in social ostracism\u003c/h2\u003e \u003cp\u003eAs described earlier, Somalis refer to mental illness as a continuum ranging from sane to insane (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Selman et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Linney et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Palmer \u0026amp; Ward, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Based on how this particular perception is repeated among the Somalis in all the selected studies, we gain a unique glimpse into why stigma is strongly associated with mental disorders and suffering. Interestingly, as the continuum ranges from sane to insane, the study participants' statements show that a reality also exists where one is quickly categorized into a dichotomy of either being sane or insane. If categorized based on two categories like \"crazy\" or \"sane/normal,\" it is not strange how one can fear being labeled \"crazy\" at the first sign of mental difficulties. Therefore, it is understandable how one has a \"suffer in silence\" mentality where one is both expected to keep the suffering hidden, but also knows and fears the consequences of being transparent about one's difficulties can lead to social ostracism. Participants in Johnsdotter et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) highlight how \"shame\" strongly relates to psychological difficulties. Similarly, Palmer and Ward (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) describe how shame prevents individuals from seeking help due to fears of breaching confidentiality and their condition becoming known within the Somali community. This reveals two key factors: 1) the reluctance to disclose mental health difficulties and 2) the fear of seeking help. Stigma and social ostracization are not limited to individuals with mental health challenges; having a family member with such difficulties can also lead to discrimination and exclusion. Selman et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) discuss how parents of children with autism face stigmatization, often through derogatory language used by others in the Somali community. Phrases like \"your sick son\" or \"she with the sick child\" are common, reflecting a lack of a Somali equivalent word for autism, and the use of terms such as \"Doqon\" (retarded) to describe mentally disabled children. This stigma often extends to parents, who are associated with their child's condition and subjected to judgment and social exclusion. Goffman (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) describes how stigma can spread within families, with examples of parents being socially excluded and judged for their child's behavior. Although the stigma initially targets the child, parents also lose community support and understanding upon the disclosure of their child's challenges and illness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to help-seeking\u003c/h2\u003e \u003cp\u003eWe believe that stigma and discriminatory attitudes associated with the understanding of mental disorders are not only challenging for those it affects, but can also act as a barrier in seeking help for those who need it most. This argues where we refer to our previously mentioned point about how the participants in our selected studies themselves report perceived discrimination and stigma associated with mental difficulties and disorders. This is based on how mental disorders are perceived within their society and then why one does not seek help. Another important factor that we consider to be a barrier is also an opinion expressed by the participants in the selected studies which indicates that it is a lack of cultural understanding on the part of healthcare personnel. Seeking help from outside is considered a \"last resort\" as they feel that the Western aid service does not have knowledge or understanding of the cultural and religious treatment methods (Johnsdotter et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Loewenthal et al., 2011). We estimate that this may also have a connection with a fear of xenophobia towards Western aid services which inhibits help-seeking behavior, as it may also be a lack of information Somalis have about aid services in general. Another aspect of this that we have experienced ourselves is how a number of Somalis may fear the involvement of the child protection services if they should have sought help for their mental difficulties. This is something N\u0026aelig;ss (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) also punctuates by saying that news among Somalis in Norway travels quickly and that if some Somalis should have had a bad experience with the Norwegian system such as child protection, this will help to influence other Somalis to fear the system as it can also happen to them. Something we then realize can reinforce the avoidance of seeking help. However, what we believe can also play a role in the two-sided opinion about lack of understanding is language. Language barrier, in line with the other barriers mentioned, is mainly also a factor in help-seeking behavior. Palmer and Ward (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), Loewenthal et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) and Linney et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) all point out how the language barrier can be a barrier in help-seeking behavior where Somalis can be discouraged from seeking help. We believe that the importance of language is an important reason why Somalis report a feeling of lack of understanding by healthcare professionals. This can make it difficult to express yourself the way you want, and it can also be difficult for healthcare personnel to pick up concretely what it is that Somali patients need. Of course, this also depends on having a cross-cultural understanding and sensitivity. At the same time, we can see that it is perhaps the fear of involving a Somali interpreter which can also be an influencing factor in the already sensitive fear of confidentiality and that information may get out. In particular, we can imagine that it is the fear of xenophobia where you cannot fully trust health personnel who are different from your own to have your best interests at heart. Ex. explain the participants in Linney et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) that they experience a great deal of mistrust with regard to institutionalization or confiscation of their driver's license if they express themselves about their mental state. To conclude, we understand that perceptions of mental health and suffering are leading in how Somalis choose to act and how they seek help. We also see how perceived discrimination can originate both from within and from outside their local community, where they experience stigmatization within their culture and discrimination outside. There is a lot of shame they relate to that is linked to suffering psychologically, at the same time it is also the act of \"leaving\" one's cultural way of being and integrating into society which is also looked down upon as it is perceived as a negative thing. We would say that it is fear of xenophobia, language barrier and mistrust of services that are and affect the help-seeking barrier.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn light of the above findings, it is evident that Islam, culture, and the biomedical framework form the foundation for how Somalis in Europe perceive mental health and suffering. Our literature review highlights how the conceptualization of symptoms shapes the frameworks through which suffering is understood, as well as the interplay between physiological and psychological symptoms in the perception of mental health. Among Somalis, mental difficulties and suffering are often placed along a continuum ranging from \"normal\" to \"waali,\" which contrasts with the categorical approach of ICD-10, widely used in Western Europe.\u003c/p\u003e \u003cp\u003eThe literature further reveals that Somalis perceive somatic illness as a test from God, while mental illness is often viewed as self-inflicted, resulting from a strained relationship with God. This perception ties closely to the concept of shame, which is a significant barrier to seeking help for psychological difficulties. Just as Somalis are selective in the frameworks, they use to understand illness, they are equally selective in their help-seeking behaviors, where shame often determines their choices. Additionally, fear of discrimination serves as another major obstacle, as many Somali informants in the reviewed studies highlight the lack of cultural insight and acceptance among healthcare personnel as a barrier to accessing effective care.\u003c/p\u003e \u003cp\u003eAcculturation to Western European societies has influenced the perception of mental health and suffering among Somalis, alongside the inclusion of cultural factors in frameworks like DSM-5 and ICD-11. Lewis-Fern\u0026aacute;ndez and Kirmayer (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) explore this cultural interplay by distinguishing between psychiatric disorders and cultural concepts of distress (CCD). CCDs encompass a broader spectrum of culturally specific symptoms, which, unlike standardized diagnoses, reflect varying levels of severity and meanings rooted in culture. For Somalis, terms like \"waali,\" \"buufis,\" and \"murug\" are not merely symptoms but culturally embedded conditions, underscoring that mental health perceptions are not universal but culturally situated. Groen (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) emphasizes the importance of culturally enriched interviews, suggesting that healthcare professionals must validate and respect Somali patients' cultural perspectives. For example, a Somali patient's belief that schizophrenia is caused by Jinn underscores the need for empathy and curiosity in clinical encounters. This aligns with Kirmayer and Ryder's (2016) discussion of \"culture and psychopathology,\" which emphasizes the need to integrate cultural concepts of distress into psychiatric care. Similarly, Kirmayer (1992) highlights how metaphors and narratives shape illness experiences, underscoring the importance of understanding patients lived experiences within their cultural contexts\u003c/p\u003e \u003cp\u003eThe findings also reveal significant research gaps, particularly regarding young second-generation Somali immigrants. Future studies should explore how generational differences influence mental health perceptions and help-seeking behaviors. Additionally, a focus on young Somali men, who are often underrepresented in the literature, would provide valuable insights into the evolving narratives of mental health within Somali communities. Reflecting on these insights, it becomes clear that the Western biomedical model alone is insufficient to address the complexities of Somali perceptions of mental health. Instead, a cross-cultural approach that incorporates cultural idioms, religious frameworks, and metaphors is essential. This integration not only enhances patient care but also fosters trust and understanding between healthcare providers and Somali patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth authors contributed equally to the study conception, literature review, analysis, and writing. Both authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by the Ethics Committee of Aalborg University and supervisor Jaan Valsiner.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbebe, D.S., Lien, L., \u0026amp; Elstad, J. I. (2017). Immigrants\u0026acute; utilization of specialist mental healthcare according to age, country of origin, and migration history: a nation-wide register study in Norway. Social Psychiatry and Psychiatric Epidemiology, DOI: 10.1007/s00127-017-1381-1 \u003c/li\u003e\n\u003cli\u003eAmerican Psychological Association. (2018). Mental Health. 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Idioms of distress: Alternatives in the expression of psychosocial distress: A case study from South India. Culture, medicine and psychiatry, 5(4), 379-408. \u003c/li\u003e\n\u003cli\u003eNichter, M. (2010). Idioms of distress revisited. Culture, Medicine, and Psychiatry, 34, 401-416 \u003c/li\u003e\n\u003cli\u003eN\u0026aelig;ss, A. (2019). Migration, gender roles, and mental illness: The case of Somali immigrants in Norway. International Migration Review, 54(3), 740-764. DOI: https://doi.org/10.1177/0197918319867381\u003c/li\u003e\n\u003cli\u003eOsman, F., Mohamed, A., Warner, G., \u0026amp; Sarkadi, A. (2020). Longing for a sense of belonging\u0026mdash;Somali immigrant adolescents\u0026rsquo; experiences of their acculturation efforts in Sweden. International journal of qualitative studies on health and well-being, 15(sup2), 1784532.DOI https://doi.org/10.1080/17482631.2020.1784532 \u003c/li\u003e\n\u003cli\u003ePalmer, D., \u0026amp; Ward, K. (2007). \u0026lsquo;Lost\u0026rsquo;: listening to the voices and mental health needs of forced migrants in London. Medicine, Conflict and Survival, 23(3), 198-212. DOI: https://doi.org/10.1080/13623690701417345 \u003c/li\u003e\n\u003cli\u003ePollock, D. C., Van Reken, R. E., \u0026amp; Pollock, M. V. (2017). Where is home? In Third Culture Kids: Growing up Among Worlds (3rd ed.). Nicholas Brealey Publishing. Riess\u003c/li\u003e\n\u003cli\u003eSamatar, S. (2016). Sarbeeb: The Art of Oblique Communication in Somali Culture. Wardheer News. https://wardheernews.com/wp-content/uploads/2016/11/Sarbeeb-Prof-Said-S-Samatar-1.p df \u003c/li\u003e\n\u003cli\u003eScuglik, D. L., Alarc\u0026oacute;n, R. D., Lapeyre III, A. C., Williams, M. D., \u0026amp; Logan, K. M. (2007). When the poetry no longer rhymes: Mental health issues among Somali immigrants in the USA. Transcultural psychiatry, 44(4), 581-595.\u003c/li\u003e\n\u003cli\u003eSelman, L. E., Fox, F., Aabe, N., Turner, K., Rai, D., \u0026amp; Redwood, S. (2018). \u0026lsquo;You are labelled by your children\u0026rsquo;s disability\u0026rsquo;\u0026mdash;A community-based, participatory study of stigma among Somali parents of children with autism living in the United Kingdom. Ethnicity \u0026amp; Health, 23(7), 781\u0026ndash;796 DOI https://doi.org/10.1080/13557858.2017.1294663 \u003c/li\u003e\n\u003cli\u003eSolberg, \u0026Oslash;., Vaez, M., Johnson-Singh, C. M., \u0026amp; Saboonchi, F. (2020). Asylum-seekers\u0026apos; psychosocial situation: A diathesis for post-migratory stress and mental health disorders?. Journal of Psychosomatic Research, 130, 109914\u003c/li\u003e\n\u003cli\u003eSullivan, C., \u0026amp; Forrester, M. (2019). Doing Qualitative Research in Psychology: A Practical Guide. 2nd edition. Chapter 3, 4, 5 \u0026amp; 11, London: Sage \u003c/li\u003e\n\u003cli\u003eChapter 3: King, N (2019) Research Ethics in qualitative research . In: C. Sullivan \u0026amp; M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 35- 60, London: Sage \u003c/li\u003e\n\u003cli\u003eChapter 4: Frost, N \u0026amp; Bailey-Rodriguez, D (2019) Quality in qualitative research reviews. In: C. Sullivan \u0026amp; M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 60- 78, London: Sage \u003c/li\u003e\n\u003cli\u003eChapter 5 Shaw, R. (2019) Conducting literature reviews. In: C. Sullivan \u0026amp; M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 78- 96, London: Sage \u003c/li\u003e\n\u003cli\u003eChapter 11: Bailey-Rodriguez, D., Forst, N. \u0026amp; Eliechoaff, F (2019) Narrative analysis. In: C. Sullivan \u0026amp; M. A. Forrester: Doing Qualitative Research in Psychology. A Practical Guide. 2nd edition. Pp. 209-233 , London: Sage \u003c/li\u003e\n\u003cli\u003eTyler, I. (2018). Resituating Erving Goffman: From stigma power to black power. The Sociological Review, 66(4), 744-765. \u003c/li\u003e\n\u003cli\u003eWedel, J. (2014). Religion and healing among Somalis in Sweden when experiencing illness and suffering. In African Dynamics in a Multipolar World: 5th European Conference on African Studies\u0026mdash;Conference Proceedings (pp. 2346-2358). Centro de Estudos Internacionais do Instituto Universit\u0026aacute;rio de Lisboa (ISCTE-IUL) DOI: 10.13140/2.1.4576.5767\u003c/li\u003e\n\u003cli\u003eWhittaker, S., Hardy, G., Lewis, K., \u0026amp; Buchan, L. (2005). An exploration of psychological well-being with young Somali refugee and asylum-seeker women. Clinical Child Psychology and Psychiatry, 10(2), 177-196. DOI https://doi.org/10.1177/1359104505051210 \u003c/li\u003e\n\u003cli\u003eWillig, C. (2013). Introducing Qualitative Research in Psychology (3rd ed.). Open University Press, McGraw-Hill Education. \u003c/li\u003e\n\u003cli\u003eChapter 5 Willig, C.(2013). Putting together a research proposal.. In Introducing Qualitative Research in Psychology (3rd ed., pp.47-54). Open University Press, McGraw-Hill Education. \u003c/li\u003e\n\u003cli\u003eChapter12: Willig, C. (2013). Narrative Psychology.. In Introducing Qualitative Research in Psychology (3rd ed., pp.143-154). Open University Press, McGraw-Hill Education. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2010). A Situation Analysis of Mental Health in Somalia. [https://applications.emro.who.int/dsaf/EMROPUB_2010_EN_736.pdf?ua=1 \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2022). Concepts in mental health. Hentet fra https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-respo nse \u003c/li\u003e\n\u003cli\u003eZimbrean, P. C., \u0026amp; Dahal, R. (2020). Risk Factors and Prevalence of Mental Illness. I Refugee Health Care, An Essential Medical Guide. Department of Psychiatry, Yale University, New Haven (s. 195-214) DOI: https://doi.org/10.1007/978-3-030-47668-7_13 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Somali mental health, Cultural perceptions of illness, Help-seeking behavior, Cross-cultural healthcare, Stigma and mental health, Qualitative research, Religion","lastPublishedDoi":"10.21203/rs.3.rs-7716329/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7716329/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAim: This qualitative literature review examines Somali perceptions of mental health and illness in Western Europe, focusing on how cultural, religious, and biomedical frameworks intersect to shape experiences and help-seeking behaviors. Method: Using a narrative literature review, we analyzed 11 qualitative studies from Scandinavia and Western Europe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: \u0026nbsp;Findings reveal that Somalis understand mental health from cultural and religious perspectives. The relationship with God is considered crucial, while recognizing external factors such as war and migration that can affect mental health. Somalis conceptualize mental health along a continuum, often using culturally specific idioms of distress rather than biomedical diagnoses. Shame, stigma, and fear of discrimination within and outside Somali communities present significant barriers to seeking mental health care. Additionally, the challenges of migration, acculturation, and cultural differences with healthcare systems further complicate access to support.\u003c/p\u003e\n\u003cp\u003eDiscussion: The discussion emphasizes the importance of cross-cultural competence in clinical care and identifies gaps in research, particularly regarding second-generation Somali immigrants and their evolving mental health narratives. Additionally, there is a need for qualitative data to better understand the perceptions and experiences of young second-generation Danish-Norwegian-Somali individuals regarding worries of the mind and their approaches to seeking help.\u003c/p\u003e\n\u003cp\u003eConclusion: \u0026nbsp;Future studies should explore how generational differences influence mental health perceptions and help-seeking behaviors Future studies must address these gaps to inform culturally responsive interventions for Somali communities in Europe.\u003c/p\u003e","manuscriptTitle":"A Literature Review of Mental Health Perceptions and Help-seeking Behavior in Somali Communities in Western Europe","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 10:43:00","doi":"10.21203/rs.3.rs-7716329/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-07T07:18:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T08:20:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T09:10:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45978115067488336967692721616762142839","date":"2026-04-15T08:38:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192339243232724248954196013183248213997","date":"2026-04-11T17:40:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248326843463838377779565226861399259024","date":"2026-04-02T04:22:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T10:06:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273370593947051112989723750413103131788","date":"2026-02-11T09:02:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329960364750245487451844189239393431562","date":"2026-02-09T08:59:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T07:20:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T16:40:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-31T06:07:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-25T08:17:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Humanities and Social Sciences Communications","date":"2025-12-25T08:09:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"36634e3e-9f98-497e-8f4f-8d2d05388275","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-07T07:18:15+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[{"id":62617011,"name":"Social science/Anthropology"},{"id":62617012,"name":"Health sciences/Health care"},{"id":62617013,"name":"Humanities/Health humanities"},{"id":62617014,"name":"Humanities/Medical humanities"},{"id":62617015,"name":"Biological sciences/Psychology"},{"id":62617016,"name":"Social science/Psychology"},{"id":62617017,"name":"Social science/Sociology"}],"tags":[],"updatedAt":"2026-05-07T07:24:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 10:43:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7716329","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7716329","identity":"rs-7716329","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}