Perceived discrepancies
The participants clearly distinguished how mental health is perceived in their country of origin and Belgium. They rather compared between continents and often referred to Europe or the 'Western world'. They associated Belgium, and Europe as a whole, with a greater knowledge base and more diversified vocabulary on mental health. In their country of origin, mental illness was often considered as 'craziness' or 'madness'. Someone who is mentally ill is seen as a person who is marginalized from society and who expresses deviant behaviour such as 'throwing stones' or 'running naked'. Some participants explained this as a consequence of their limited knowledge on what mental health entails.
"Mental health is not a sickness. It's not considered a sickness in our country. So, if you have a mental illness, either you…, you know, you are classified as crazy. Even people with things like bipolar, Alzheimer's… Because we don't know much about it." (Woman, age 30–40, arrived between 2020-present in Belgium, of Kenyan descent)
Other issues are instead considered as general health problems, such as physical issues, or not related to health. Issues that would be defined as mental health problems within the biopsychosocial framework, such as extreme anxiety or sadness, were, however, not recognized as mental health problems. When asked what symptoms could indicate that a person is not feeling well emotionally, participants referred to 'a change in behaviour', 'being more quiet', 'being tired', 'having loss of motivation', and 'isolating themselves'. These symptoms however were generally considered inherent to the harsh African life: priorities are to survive, put food on the table, get your children to school, work and have money. These struggles could cause a person to suffer but were not considered a mental health issue. In some conflicted areas in East-Africa, suffering was perceived as part of everyday life.
"Yeah, in Eritrea nowadays, the stress and the depression, it is normal. It is not a mental illness, by the way. Why? Because in Eritrea, the political situation is not good. In Eritrea, the leadership is dictatorship. So all the time the people are stressed and in depression. So for the people in Eritrea, stress and depression is not a mental illness." (Man, age 40–50, arrived between 2010–2020 in Belgium, of Eritrean descent)
Therefore, many participants viewed having mental health problems as a luxury problem: only if a person's basic needs are fulfilled, he can 'worry' or 'be sad'.
Also, (self-)stigma played a role: according to the participants, Africans are supposed to be resilient and strong; talking about negative emotions and potential mental health problems is considered a weakness. Interestingly, this was reflected in their use of language: participants often used wording such as 'challenges' rather than 'issues' or 'problems'. In that matter, they experienced a difference in how it is dealt with in Belgium, where the topic gets relatively more societal attention and is considered less taboo, according to them. However, they also perceived the Belgian, individualized lifestyle with its focus on personal and professional development as more demanding and thus a source of mental health problems. While in their country of origin, the strong social network and community life were experienced as protective factors. There, causes of mental health problems were sought differently: physical causes such as substance abuse or lack of sleep were often mentioned, as well as disrupted social relationships such as divorce or the loss of a loved one. Almost a fourth of the participants also mentioned religious views, stating that 'God is challenging them' or referring to 'spiritual' or 'satanic attacks'.
"But there, one can say that… it might have come from the family… an attack… an attack from his family. Or yeah… Satanic… things like that … and you become crazy… but it was a depression or it was… I don't know, I have never known." (Woman, age 50–60, arrived between 2000–2010 in Belgium, of Burundian descent)
While magical or supernatural forces were also mentioned as potential causes, the majority of participants said not to believe in these. They argued that those beliefs were mainly present among low-educated people living in rural areas in their country of origin. Additionally, those beliefs were thought to be more present in West-African than East-African regions.
Their migration trajectory and their status as migrant within Belgium caused a shift in the perceived primary causes of mental health problems among the participants. Socio-economic problems related to integration, such as finding housing or work and getting a residence permit, were identified as decisive factors. Similarly, the lack or diminishment of community or social networks caused some of them to have feelings of anxiety, isolation, or sadness. Previously mentioned causes were still of relevance but were often linked to the integration process and seen as a symptom or consequence of mental health problems rather than a cause, e.g., substance abuse. Interestingly, participants with a medical training background or another higher education background, distinguished themselves from how mental health is perceived in their countries of origin, describing it as 'how non-educated people from the countryside see it'. They considered themselves more knowledgeable and adhered more to the biopsychosocial approach. However, also in their narratives, elements of their cultural explanatory model were found. For example, one of the participants, a trained nurse, described her mother as having suffered from a spiritual attack in the past.
Healthcare-seeking behaviour
Participants argued that they usually try to cope with their issues themselves and only seek healthcare when the issue becomes very severe. Given that mental health was defined differently compared to the dominant medical discourse in Belgium, participants argued that EA-migrants would rather seek general healthcare instead of mental healthcare. They associated Belgium or Europe, with an individual-based, biomedically oriented form of healthcare, in which use of medicine is central. In first instance, they preferred seeking informal care in their own communities, which also reflected their experience of the limited availability or accessibility of conventional healthcare facilities, financial barriers and distrust in conventional healthcare in their countries of origin. For certain illnesses, cultural habits and beliefs directed them towards traditional or spiritual services, rather than conventional healthcare. They acknowledged therefore that they combined conventional Belgian healthcare with self-medication, and informal, cultural or religious healthcare-seeking behaviours, in the literature referred to as 'medical pluralism' (Olsen and Sargent 2017) or 'healthcare bricolage' (42). Most participants, however, argued that their general healthcare seeking behaviour changed after they moved to Belgium, as they experienced fewer barriers to conventional general healthcare. While they acknowledged to be still postponing healthcare-seeking until health issues were severe, there was greater trust in Belgian healthcare and they considered it to be more efficient and better developed. Additionally, depending on their legal status, they argued that the healthcare system is accessible, and the social security system reduces financial barriers.
Although participants claimed to use conventional healthcare more often in Belgium compared to their country of origin, this did not appear to be the case for mental healthcare. Because there was a higher risk of (self-)stigmatisation within their community, most participants explained that mental support was sought elsewhere and in line with behaviours in their country of origin, withholding them from searching for professional help or following up on a referral to conventional mental healthcare services in Belgium. Participants did not want to be perceived as 'crazy'. They tried to carry the burden on their own rather than seek help because of this internalized stigma: they considered themselves to be strong and resilient Africans. Participants expressed a fear of being expelled from their community or being judged by family members and friends if they openly talked about mental struggles. The stigma was not limited to their own individual social position, being seen as 'a crazy person' could also affect their family's social status within the community, referred to as ‘courtesy stigma’ in scientific literature (43).
Participants argued that there is minimal provision of adequate mental healthcare in their country of origin. Some explained that for certain issues, traditional or religious healers would be consulted. However, this was often related to certain illnesses, which were believed to be caused by supernatural or religious forces. Mental health clinics were mainly limited to urban areas, and in any case focused only on persons with severe mental issues according to the participants.
"I wouldn't say we don't have psychologists, because there is a department of psychology in the university, so… there are definitely psychologists, but the culture is not used to it. (…)unless you know, you get to that stage as where you're considered 'insane', then they take you to the hospital, medical… and we also only have one in Eritrea." (Man, 30–40, arrived between 2010–2020 in Belgium, of Eritrean descent)
Therefore, most participants had little experience with conventional mental healthcare services and had little trust in them. This impeded them to use mental healthcare services in Belgium.
In addition, they did not tend to seek conventional mental healthcare in Belgium, because they conceptualized mental health differently. Emotional or social struggles were not considered to be mental health problems. The participants claimed that these struggles were coped with by consulting informal social support systems, such as community or religious groups. Most participants said that they would turn to their religion to cope with feelings of anxiety or sadness: by praying and talking to their God, they could find relief. Participants with an Eritrean background explained that washing with holy water could help for all kind of health issues. If an issue was deemed to be related to mental health problems, again, help-seeking was postponed until a person could no longer carry the burden on their own anymore. In a next step, many participants claimed they would talk to someone else about their mental health issues, this other person would preferably be someone from their religious community.
"I am a believer, I think religion… within religion is where we can talk, where we can freely complain, talk, about all the weaknesses we have. (…) so at the end of the day, our counsellors and our psychologists are what? Our priests, the pastors and priests… In fact that's what they do (laughs), they are our mental health service providers. That's where we go." (Woman, age 50–60, arrived between 2000–2010 in Belgium, of Ugandan descent)
Others would turn to a trustee, a close relative, or a friend who would handle their issue confidentially. If conventional mental help was sought while living in Belgium, it often happened in a transnational way, where a traditional or religious healer was consulted through social media or by visiting their home country.
Participants thus experienced multiple barriers to accessing professional mental healthcare in Belgium, such as the aforementioned (self-)stigma and differing conceptualizations of mental health. Furthermore, participants did not see the benefit in going into individual mental health treatment when living in Belgium as it would not solve the financial or structural integration problems that were causing their 'challenges'. Also cultural differences in what defines a skilled healthcare practitioner created little confidence in the mental healthcare practitioners in Belgian mental healthcare. For instance, young practitioners were deemed to be less competent, as from the participants' cultural background, only elderly people were believed to have sufficient wisdom to give life advice to others. In addition, they would not feel understood by white Belgian healthcare practitioners as these lacked the same (migration) experiences or cultural background.
"Now the problem is about the culture, about how we have been raised. It's very difficult to go and face someone. And I think, another challenge, I know we are having different cultures, so if I come to you and I tell you about my challenges, you might see my challenges as like… you might not understand me properly. So I've found it difficult to go and express myself to someone who is not from my origin. But I wish there could be someone, from maybe my country, (…) who is a professional; who I can go to and express myself, then this person will understand me better, and maybe I can get the service which I need; the help which I need." (Woman, 30–40, arrived between 2020-present in Belgium, from Tanzanian descent)
A few participants opposed this, as they feared that healthcare practitioners with similar backgrounds might violate their professional secrecy. Again, stigma within the community appeared to be an important barrier to healthcare use.
However, some participants did have a positive attitude towards conventional mental healthcare in Belgium. This could be because of earlier experiences in their country of origin in line with what they consider to be useful mental healthcare practices.
"Me, I went to a boarding school and I started talking about [my issues] with religious people who supervised me. I started to talk, to write, because it felt good talking to someone else who is not from my family. […] Here, with my psychologist, it [talking] really helps me to have confidence in myself, and it also helps me to have someone to whom I can talk, who does not judge me." (Woman, 30–40, arrived between 2010–2020 in Belgium, from Rwandan descent)
Other participants had accepted a referral to a psychologist by their social worker or general practitioner and had positive experiences with it. Also participants with a more biopsychosocial-oriented view on mental health or who deemed the Belgian approach to mental health as more developed, held a more positive attitude towards conventional mental healthcare services, but did not necessarily would make use of it.
The influence of multiple explanatory models
Participants' migration history and experiences after they settled exposed them to different cultural explanatory models of mental health. Depending on their familiarity with the Belgian healthcare system, as well as their exposure to similar practices in their country of origin, participants were more or less in favour of seeking conventional mental healthcare in Belgium. This was particularly noticeable in participants who originated from urban regions in their country of origin. Mental health services similar to those of the Belgian health system were more common in these urban areas, which made participants originating from these regions or previously working in these services already more acquainted with certain concepts and treatments. This was equally true for younger participants who often gained this familiarity through international (social) media channels. Several of these participants stated that mental health knowledge was too limited in their country of origin and that more health education among the general population was needed. They claimed that the Belgian organisation of mental healthcare was more developed and efficiently organised, and were thus more positively oriented towards it.
In addition, integration processes influenced and transformed participants' explanatory models of mental health. While a common cultural base was described within their explanatory models of mental health in their countries of origin, there was a variety in how they dealt with the dominant perception of mental health in Belgium. Some participants pronounced how their perception changed through exposure to and experience with mental health approaches in Belgium. They argued that because mental health is more openly discussed and gains (relatively) more societal attention, they were prompted to change their own thinking.
"But me, when I came to Europe… a small level was stress… I'm like "what is stress?" When I'm running for the bus, that is stressful, but it will go away. Do you understand me? So when I came to Europe I started learning it can… go in phases until your body can't take it anymore (…) that's when I started opening up "what is depression, what is stress, what are they talking about psychosis, what is that ?" (Woman, 40–50, arrived between 2000–2010 in Belgium, of Ugandan descent)
Other participants however, were rather opposed to the conventional mental health approaches in Belgium and held on to the help-seeking behaviour linked to the explanatory model of their country of origin.
"A psychologist? It can't change anything, since the problems you are going to expose, he too has his problems… how is he going to give… first he has to solve the problems he has… But if you are with God, we know that before God, if you pray, if you... if you... spend a long time asking God for something, God gives you that. Because we trust our God more than others." (Man, 40–50, arrived between 2010–2020 in Belgium, of Congolese descent)
These different attitudes translated into participants' healthcare-seeking behaviour: those who perceived their explanatory model to have been transformed by exposure to the dominant medical approach in Belgium, were more in favour in accessing conventional mental healthcare services. The last quote, however, clearly illustrates that those whose explanatory models were not transformed, did not see a benefit in using these services.