“When I forgot or let things go wrong, or when I couldn’t sit still when I was expected to, I could hate myself,” says actress and filmmaker Nora Akachar. “I thought: I’m not smart enough. Or: I can’t do this. But it turns out that I’m just wired differently.”
Akachar (40) started a Facebook group in 2019: Nora’s traumas. She writes, among other things: “In group 3, my father was told that I could not keep up well. I had to go to a school for children with learning difficulties. My father quickly agreed, he had other things on his mind.”
Akachar now knows that her learning problems were caused by ADHD, a mental disorder estimated to occur in… 3.6 percent of Dutch children and 3.2 percent of adults. She was diagnosed when she was almost thirty. “That gave me peace of mind.”
I grant the first few generations of migrants to investigate their complaints
Akachar, who moved from Morocco to the Netherlands as a four-year-old, has worked in care herself. She knew where she could get mental help. But not everyone has that knowledge, she knows. “While I allow the first few generations of migrants to investigate their complaints. Is it ADHD, autism, trauma, or something else?”
Last summer, the Central Bureau of Statistics published about it use of ADHD medication. This has quadrupled in six years, mainly due to a catch-up in diagnoses among women, according to experts. People of non-Dutch origin use less medication than people of Dutch origin. Although little research has been done, practitioners of cultural minorities declare opposite NRC that Dutch mental health care (GGZ) is not set up to treat these groups properly.
Stigmas
“Cultural minorities form a blind spot in mental health care,” says Ki Eun Bae, a practitioner at the Transcultural Therapy Expertise Center (ETT). The ETT was founded ten years ago for that reason: it focuses on people with a migration background.
This blind spot has various causes, says Bae. “First generation migrants mainly focused on hard work, whether they came to the Netherlands for political or economic reasons […] If you are mainly concerned with survival, there is no room to think about your mental state or that of your children. We often only see clients from the third generation.”
There are also stigmas about mental health care and disorders within non-Western cultures, says Bae, who is himself of South Korean origin. “In South Korea, for example, autism is seen as a very serious disease. And ADHD is then dismissed.”
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Many migrants also experience barriers when they try to get mental help, says Bae. “For example, not everyone understands that the GP in the Netherlands is the first step towards treatment.” And once at the psychologist, according to Bae, the “cultural mismatch” continues. “Dutch therapy is often about indicating your own boundaries, with family for example. But many people with a migration background see family as their basic need.” Direct confrontation or breaking contact is then not a workable solution, “while that is the case for the psychologist [die werkt met een westerse toolbox] obvious.”
Care recipients are also wary of psychologists’ prejudices, Akachar explains. “Suppose someone experiences domestic violence. A white psychologist might quickly think: ‘Oh, typical.’ But you want someone to be able to look at such a situation without value judgment about people with a non-Western background.” That gap can certainly be bridged, Akachar thinks. “Only, when you are on the ground – usually only then do people seek help – it is nice to skip that part.”
Discrimination
An exploration was carried out in 2023 discrimination in (youth) care presented to the House of Representatives, compiled by the Verwey-Jonker Institute and Movisie. ‘Cultural intensity’ (a ‘blind spot’), ‘stereotypes’ and a ‘white standard’ lead to unequal and sometimes inadequate treatment, the authors stated, who classified all this under ‘indirect discrimination’.
Bae recognizes the image. “My medical education was very white,” she says. “It would be nice if there was more training on cultural differences and more time was made to get to know the cultural context of a patient.”
Young people with a Surinamese, Turkish or Moroccan background are less likely to end up in youth mental health care than those with a Dutch background, according to the study. And young people with a ‘non-Dutch background’ are over-represented in more serious forms of youth care, such as child protection and youth probation. The researchers call cultural stereotypes in youth care one of the causes (to be further investigated). Prejudices influence which treatment young people receive, they wrote based on previous research, which can influence the diagnosis of disorders.
There is virtually no research into how neurodivergence manifests itself in different cultures
Whether and how disorders are overlooked as a result is difficult to estimate, says child and youth psychologist Victor Kouratovsky, who contributed to the founding of the ETT. According to him, even the guidelines for diagnosis contain blind spots.
Disorders such as ADHD and autism are usually diagnosed in children based on the DSM-5the handbook for psychologists and psychiatrists. “Categories in it are based on procedures by psychiatrists in the US,” says Kouratovsky. “They are based on a ‘WEIRD’ population: Western, educated, industrialized, rich and democratic.”
And that is not without consequences. “Take intelligence tests, which are also used to diagnose disorders. Children of immigrants are more likely to be identified as mentally retarded, because these tests are very culturally determined.”
According to Kouratovsky, diversity is not only lacking in practice, but also in research. Bae: “There is virtually no research into how neurodivergence occurs [anders werkend brein] expresses itself in different cultures.” Tracing the cause of certain behavior – to someone’s culture, trauma or neurodivergent disorder – can therefore prove very difficult, she says. Especially if a practitioner is unfamiliar with a patient’s cultural background.
Need
The Facebook group Nora’s traumas seems to meet a need with almost sixty thousand predominantly Moroccan and Muslim members: talking about (family) trauma in order to be understood and heard. Members share (anonymously or otherwise) their own ‘traumas’ – sometimes humorous, sometimes melancholy, sometimes serious. People respond with advice, including every now and then to undergo therapy. Akachar: “It’s a bit like group therapy.”
At the beginning of this year, Kouratovsky and other healthcare providers founded the Knowledge Center for Inclusive Mental Health Care (KIG). People with a migration background face barriers that can easily be lowered, says Kouratovsky. “For example, having to make an appointment by telephone or having to complete a questionnaire if you do not speak Dutch well.”
But if the Netherlands really considers the mental health of migrants to be important, migrants must be treated differently, says Kouratovsky, who has also worked with refugee children. “Growing up in an asylum center and then moving fourteen times: who is healthy from that?”
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