Moroccan women in the Netherlands in psychotherapy

Hans Rohlof, M.D.
Centrum '45 Rijnzichtweg 35 2342 AX Oegstgeest- the Netherlands

Introduction

Despite the fact that the Netherlands does not promote itself as an immigrant country, many immigrants came to this country since the sixties of the twentieth century. Working migrants from Turkey an Morocco were recruited in the sixties and seventies to fill the gaps in low-paid and low-level functions which native Dutch people abandoned. Later on, when possibilities to get work permissions became more difficult, persons from these countries came under the umbrella of family reunion. Also, in the nineties a lot of refugees from war-inflicted countries fled to the Netherlands, like Bosnians, Iraqi, Iranians, Somalis, and groups from other countries in Africa and Asia.
The total number of people from non-Western origin, first and second generation, in 2007 in the Netherlands is 1,7 million, which is around 10 % of the total population (Central Office for Statistics, 2007). But specially in the western part of the country, where the bigger cities are, the percentage of migrants is much higher. The prognosis for 2015 is that 12 % of the population will be of non-Western origin. Among these migrants, there are 329,000 persons from Moroccan origin (1.1.2007), 170,000 males and 159,000 females.
In the first years they were staying in the Netherlands, migrants did not show a great consumption of mental health care. This had to do with perceived mental health, but also with mental health care seen by the migrants as stigmatising, meant only for those who are mentally retarded or psychotic. In the latest years, however, this is changing. Research in Rotterdam, the second largest city of the Netherlands, showed that migrants are finding their way to mental health care more and more easy since the nineties. Among them, young men are found more in acute psychiatric settings and in-patient clinics, while young women people are more often in non-acute and out-patient departments. It seems that young male patients still are waiting till their psychiatric problems come to a crisis, while female patients are looking for referrals to mental health care themselves, in free will. Older Moroccan women are still the lowest users of mental health care. Among the young male patients, Moroccan men are more prominent since they show a greater tendency to become psychotic and to develop schizophrenia. Females, and older patients, show more depressive syndromes (Mulder et al, 2006).

Moroccan culture

Moroccans in the Netherlands form a rather coherent but steadily changing culture. Ties between them are close, because families are not only tied by marriage but also by kinship. When a girl or boy grows up, it is used that a wife or a man will be found in the home country, and they are mostly from within the family, nephews or nieces. This has a cultural background, but also an economical. Since differences in wealth between Morocco and Europe are still great, and there is the problem of unemployment in Morocco, specially among higher educated youngsters, many young people in Morocco only have one wish: a ticket to Europe. They only get a legal permit to stay in Europe when married to a citizen with a passport of one of the European states, and finding a relative with such a passport is the key to that. The marriages are traditionally arranged for by the fathers of the girl and the young man, but that is changing due to cultural changes in the Moroccan society in the Netherlands and the life in Morocco itself.
Young Moroccans in the Netherlands are looking for different ways to develop themselves. Since girls are left less freedom in going out on the streets like boys can, girls have started to find their way into higher education. This means often they they are less and less satisfied with a traditional arranged marriage and want to look for their own marriage partners.
Moroccans are Muslims, and being a minority in the Netherlands, try to find their identity in Islam more and more. Traditional clothing became more popular in recent years. Traditional Moroccan beliefs are striding with the official Islamic statements. Islamic imams are of very different level of education, sincerity and fundamentalism. The most fundamentalist imams preach against all Western habits, including Western justice, health care, and democracy. Followers of these imams are however small in amount. Discussion on these topics is quite open in the Netherlands, on television, radio and in the written press.
Beliefs in black magic, in the evil eye, and in a whole world of demons, which are connected with places where water is, are ubiquitous among Moroccans. Mental health problems are not seldom connected with these traditional beliefs.
75 % of the Moroccans in the Netherlands are from the so-called Berber region in the North-east of Morocco: a agricultural and mountainous region, low developed, and seen as backwards in Morocco itself. People from this region had to struggle against invaders, and against hostile neighbours: some explain the somewhat paranoid attitude of Moroccans because of this origin. Because of the importance of the strength of the body for surviving, less of somatic strength and functions are seen as more dangerous than less of psychological functions.

Psychotherapy

Moroccan women in psychotherapy are a challenge for the therapist. Therapists should have a profound knowledge of the Moroccan culture, religion and folk beliefs to fully understand all the dilemmas Moroccan women have to cope with. Moroccan women are bound to their families, but sometimes have to make own choices within these boundaries.
Therapists can help them with making these choices. Therapists can also give them more psychoeducation about the interaction between somatic and psychological factors. Moroccan people do not seem to divide soma and psyche like European-born individuals, so an explanation about different aspects of illness is in place than explaining the interaction itself. The practice of a psychiatrist is more suited for treatment of migrant women since the psychiatrist is accepted as a real doctor, and can combine psychotherapy and pharmacotherapy. When Moroccan women start to talk about seeing demons or being victim of an evil eye, the therapist should not consider this as a psychotic phenomenon, but instead try to understand the meaning of these ideas, seen in the light of their culture.
The therapist should also accept that the patient is consulting alternative healers, too. Cooperation with alternative healers is not always easy, since they reject sometimes regular medicine. Cooperation is also dependent on the view the therapist has on alternative medicine.
Sometimes patients seek help because of other interests: for instance they need a better house or desire to stay ill from work. For that, they need a statement from a doctor. In cases when improvement does not occur, the clinician should consider that there is a need for medical statements.

References:
Emergency psychiatry, compulsory admissions and clinical presentation among immigrants to The Netherlands CORNELIS L. MULDER, GERRIT T. KOOPMANS and JEAN-PAUL SELTEN BRITISH JOURNAL OF P SYCHIATRY ( 2 0 0 6), 18 8 , 3 8 6 - 3 91