Lay accounts of depression amongst Anglo-Australian residents and East African refugeesRenata Kokanovica,*, Christopher Dowrickb, Ella Butlera, Helen Herrmanc, Jane Gunna

a Primary Care Research Unit, Department of General Practice, University of Melbourne, Melbourne, VIC 3053, Australiab Division of Primary Care, University of Liverpool, UKc Australian International Health Institute, University of Melbourne, Australia

Please cite as follows:

Kokanovic, R., Dowrick C, Butler E, Herrman H, & Gunn J. (2008) Lay accounts of depression amongst Anglo-Australian residents and East African refugees. Social Science & Medicine [P], vol 66, issue 2, Elsevier, Amsterdam Netherlands, pp. 454-466.

Note: This article may not exactly replicate the final version published in the journal. It is not the copy of record. The final published version can be found here (doi: 10.1016/j.socscimed.2007.08.019)

1

2

Abstract

Layperson accounts of depression are gaining increasing prominence in the health research literature. This paper considers the accounts of lay people from a cross-cultural perspective. By exploring lay concepts of distress from Anglo-Australian, Ethiopian and Somali communities in Australia, we describe commonalities and divergences in understandings of depression. A total of 62 Anglo-Australians were interviewed, and 30 Somali and Ethiopians participated in focus groups and individual interviews. Anglo-Australian accounts frequently portray depression as an individual experience framed within narratives of personal misfortune, and which is socially isolating. In the accounts of distress from the Somali and Ethiopian refugees living in Australia, family and broader socio-political events and circumstances featured more frequently, and ‘depression’ was often framed as an af iction flthat was collectively derived and experienced.

Keywords: Australia; Depression; Somali; Ethiopian; Anglo-Australians; Cross-cultural

3

Introduction

Depression is a troublesome concept. Medicine does its best togive an impression of certainty about its aetiology and management, but confusion looms beneath a thin veneer of consensus (Dowrick, 2004). Lay opinion is a useful counter-reality to medical orthodoxies (Prior, Wood, Lewis, & Pill, 2003), including explanations for distress, its causes and effects and appropriate sources of supports (Gray, 1995; Greg & Curry, 1994; Kleinman, 1980; Okello & Ekblad, 2006). We suggest, however, that there is great diversity within lay accounts that are highly context dependent. In this paper we examine the diversity of lay accounts and attached social meanings imputed in health in different populations (Smaje, 1996).

Research into lay accounts of depression within af uent flWestern societies tends to emphasise the prevalence of a socially derived lay view with its attendant scepticism about the ef cacy of professional treatments and a concurrent fipreference for informal avenues of support (Kangas, 2001; Lauber, Falcato, Nordt, & Rossler, 2003). Recent migrants to the West from several African societies are also unlikely to accept a biomedical model as an explanation for distress. Their understandings may be in uenced by cultural variations flin expressing depressed mood, value systems and linguistic symbols (Kirmayer, 2001; Kleinman, 1998). Many Ethiopians and Somalis, for example, do not associate feelings of depression with a classi cation of ‘‘illness’’, and therefore are fireluctant to use professional services for these problems (Alem, Jacobsson, Araya, Kebede, & Kullgren, 1999; Carroll, 2004; Papadopolis, Lees, Lay, & Gebrehiwot, 2004; Silveira & Allebeck, 2001; Tilbury & Rapley, 2004).

Western respondents with high levels of education, however, tend to feel more comfortable with professional concepts of depression and view medical methods of treatment more favourably (Jorm et al., 2000). We postulate this difference is due to increased acculturation to biomedical explanatory models within Western societies, with immigration and education providing the basis for increased exposure to

4

professional representations, leading to transformations in the ways lay people conceptualise illness (Angel & Thoits, 1987).

This process of acculturation has led Shaw (2002) to problematise the validity of lay beliefs as an analytical category, arguing that in Western society, lay people are inundated with biomedical discourses in or throughout their daily lives. The very category of a lay perspective, independent and easily demarcated from professional paradigms of illness, is empirically tenuous. Similarly, Skultans (2003)argues that consultations with medical professionals function as instruments of socialisation, structuring the lay person’s experience of illness. Radley and Billig (1996) have called for a shift in focus from lay beliefs to lay accounts, arguing that illness accounts involve a negotiation of identity between the speaker and the listener, and are thus not representations of immutable belief systems. Rather, they are constitutive actions that locate individuals within a broader social discourse. Therefore, we contend that illness accounts are always—and necessarily—de ned contextually.fi

In this paper, we investigate the views of two contrasting groups of people—settled Anglo-Australians, and Somali and Ethiopian refugee migrants—in order to explore the heterogeneity and context-dependence of lay accounts of depression. The experience of holding refugee status versus being settled in one’s home country are necessarily divergent,and we use this to discuss how the concept of ‘depression’ canbe used to frame a range of experiences in varying contexts. We recognise here that the accounts of Somali and Ethiopian refugees may differ from those living in their home countries.In this paper, we focus on the contextual nature of concepts of depression. We assess similarities and differences in viewsabout depression, its causes and consequences, and how it should be managed or treated, in attending to participants’ interpretations that could successfully be incorporated into the practice of health care (Jadhav, Weiss, & Littlewood, 2001).

5

Methods

Sample

Anglo-Australian participants were drawn from diamond (Gunn, 2006), a longitudinal study of depression in primary care in Victoria, Australia. Participants were 62 women and men, recruited through general practices on the basis of experiencing ‘depressive symptoms’; however half of the samplehad not received a formal diagnosis of a mental health problem. They completed a computer-assisted telephone interview (CATI) with a trained interviewer between January and April 2006. Most Anglo-Australian participants lived with a partner or other family members; 15 participants lived alone.

Ethiopian and Somali participants were drawn from a study examining lay accounts of distress in eight ethnic groups in Perth, Western Australia. The data were collected in 2002 and 2003. Thirty Ethiopian and Somali men and women were recruitedthrough collaborations with ethnic community groups and NGOs providing support to newly arrived refugees. The recruitment process did not have as its focus identi cation of particular fiethno-cultural groups, as the research aimed to explore commonalities in the experiences of those identifying as Somali and Ethiopian (Coker, 2004). Despite differences in localised ethnic identity, participants frequently referred tothemselves as ‘‘we Ethiopians’’ and ‘‘we Somali’’—not surprising given their shared experience as refugees and the associated trauma and dislocation that this entails. Most Somali and Ethiopian participants were living with some familymembers, mainly couples with children. A small number of Somali women lived with their children only, or some of their children, while trying to nd a way to bring the rest of theirfifamily members, husbands and other children, to Australia. Sometimes the fate and the whereabouts of these people were unknown. A few participants were living alone.

6

Data collection

Anglo-Australian participants were interviewed using a semi-structured interview guide that explored participants’ views on what depression is, what causes depression, and what the best way to manage the condition is. Most interviews were 1 hour long. Responses were typed verbatim into a database designed for that purpose.

Information from Somali and Ethiopian participants was collected through focus groups and individual interviews. Three focus groups were conducted in community organisations, one at the home of the facilitator. Interviews were conducted outside participants’ homes, at places of their choice. Separate focus groups were conducted with men and women. A semi-structured interview guide was used, exploring understandings of depression, social and emotional well-being,and ways to address problems associated with distress. Interviews were from 1 to 2 hours long, audio-taped, transcribed and translated when conversations were in languages other than English. Most of the interviews with Somali and Ethiopians were conducted by trained research assistants who were Somali, Amharic and Tigrinya speaking. They also transcribed and translated interviews into English. During translation of transcripts all efforts were made to ensure completeness and accuracy by re-examination of the original text by an additional native speaking researcher.

Combining individual interviews and focus groups as data collection is useful when exploring individual and collective perceptions and is used in a number of studies researching layconcepts of health and illness in refugee populations (Coker, 2004; Okello & Ekblad, 2006; Whittaker, Hardy, Lewis, & Buchan, 2005). This has proved helpful to increase the richness of the data and increase the researchers’ cultural understanding (Whittaker et al., 2005).

Although the interview schedules were not identical between Anglo-Australian and Somali and Ethiopian samples, they addressed the same content areas.

7

Analysis

Iterative/thematic analysis was conducted following Mays and Pope (1995) and Pope’s (1995) framework for qualitative research and analysis in health care. Following transcription,the rst and third authors read transcripts several times and fianalysed them independently to identify themes and categories.For Somali and Ethiopian data, individual interviews and focusgroup data were analysed and themes identi ed separately. As fithe group and individual interview guide was the same and themes identi ed were similar, they were combined and are fipresented together. Meanings discussed by participants were used as units of analysis. The results of the independent analysis were compared and discrepancies discussed. Further thematic categories were added as the analysis developed. Thisprocess was repeated until all themes that we report here wereidenti ed. In presenting data below, we refer to all fiparticipants by pseudonym.

Transparency in analysis and reporting was achieved by providing extensive verbatim quotes and independent assessments of transcripts and themes (Yardley, 2000).

Ethics

Ethics approval for the study with Anglo-Australians was granted by The University of Melbourne. For the study conducted with Ethiopian and Somali participants, ethics approval was granted by the Ethics Research Committee at the Royal Perth Hospital, Western Australia.

Findings

We found considerable variation between the Anglo-Australian and East African samples, in particular in the framing of distress. In Anglo-Australian accounts ‘depression’ was described as inherently individual, ambiguous and phenomenological, whereas in Somali and Ethiopian accounts

8

‘depression’ was used to contextualise aspects of structural and social inequality, and geographical, cultural and social dislocation and fragmentation. Signi cantly, neither group fireached consensus when de ning ‘depression’. The thematic ficategories identi ed were similar between Ethiopian and Somalifisamples, and we present these groups together. We attribute this similarity to the common experience as migrant refugees: their shared identity as refugees provided the backdrop to their responses, and this fabric of experience was prominentlyused across the samples to ‘talk with’ the concept of depression.

Causation of depression: Anglo-Australian accounts

Anglo-Australian participants often presented multilayered explanatory models. Everyday life was powerfully incorporated in narratives about the experiences of living with depression.Participants presented accounts of major loss of health— theirown and of their loved ones; loss of employment or major changes to their professional position and career, such as loss of status related to their working position; bereavement and problems in relationships with partners, parents and friends. They reported unful lled desires, hopes and ambitionsfiand re ected on feelings of letting themselves and others fldown; they re ected about the stress of everyday living, and flaccumulation of stress over a long period of time. They talkedabout traumatic experiences, feelings of isolation, profound loneliness, unhappiness, lack or complete absence of social support, and nancial pressures. Some provided self-re ective fi flaccounts on early childhood experiences of parental neglect and abuse and spoke of being prone to depression because of low self-esteem, ‘genetic predisposition’, and an inability totalk about their emotions.

Everyday life was often described as too stressful, ‘a build-up of too many things happening too fast, getting snowed down under lots of trivial stuff’ (Mark) or ‘the let-down of thingsfrom day-to-day life that nally catches up with you’ (Linda).fiThis was usually combined with the lack of a sense of

9

belonging and a lack of social understanding and support. Manyunderlined feelings of being left on their own and consequently losing motivation and interest in life. The experience of depression was described as an individualised sense of isolation.

Dif culties in ‘‘coping’’ emerged as a recurring theme. fiExperiencing depression was described as an understandable response to a culmination of dif cult life circumstances and fievents. Situations people had to ‘‘cope with’’ included chronic illness in the family, having a ‘‘dysfunctional family’’ and being responsible for dealing with other peoples’problems:

Depression means that the mind is not able to cope with all the problems that you have. It’s like it overloads and it’s just I have so many issues that I just can’t cope with them all (Beth).

‘‘Coping’’ implies an ideal state of individual behaviour, whereas ‘‘not coping’’ is the failure to achieve this state. External pressures may contribute to the onset of depression, but after that it was represented by respondents as a more or less permanent state that af icts the sufferer despite their flenvironment. For instance, one interviewee described depression as ‘‘feeling low no matter what’s going on’’ (John).

Anglo-Australian participants did not generalise the causationof depression, situating it mostly within personal contexts and emphasising the subjective nature of distress. Despite accounts of the experience as one of profound depth, its conceptual parameters were not clearly de ned. Participants fioften initiated descriptions with statements such as: ‘‘I’ve got no idea …’’; ‘‘I don’t even think I can explain …’’; ‘‘Howcan I explain this?...’’; ‘‘I don’t know what it is actually …’’. Even when participants were not fully able to describe the nature of ‘depression’ they were certain that the

10

experience was something they did not want ‘to have’: ‘‘I’ve got no idea. Something you do not want to have. That’s all.’’ (Paul)

What is depression? Um, it’s the most awful feeling. You know, that sums it up. It is the most awful feeling. I had a taste of what it is like when people want to take their own lives. It is awful. I can handle pain, but not that (Simon).

Most participants did not have dif culty in classifying their fiexperience as ‘depression’, despite their attached meanings being both indeterminate and highly subjective. ‘Depression’ was described mostly as individuating, creating a mental spaceinto which others cannot penetrate and contributing to a stateof social isolation: ‘‘you just get into a world of your own’’(Sara). The central feature of individuated accounts is highlighted in the personal pronouns used by participants. Anglo-Australian participants continually used rst-person fipronouns in their accounts, describing the experience with statements such as: ‘‘my depression is …’’; ‘‘for me it is …’’; ‘‘in my case …’’; ‘‘when I …’’; ‘‘I have …’’; ‘‘I usually…’’. Depression is represented in these accounts as an experience that is inherent in the individual. This was despite the general nature of the interview question, that asked ‘what do you think causes people to become depressed?’

Metaphors were often used to describe the experience of depression. Among these, metaphors of dark colours tended to dominate: ‘‘a sense of darkness’’; ‘‘a black hole, just black’’; ‘‘a heavy black blanket being thrown over you’’; ‘‘a big hole—a big hole that you can’t get out of’’. Other metaphoric descriptions include weight and heaviness: ‘‘the weight of the world …’’; ‘‘feeling down’’; ‘‘feeling low’’.

One respondent described her depression as an emotional disease: ‘‘it’s like a cancer of your self-esteem’’ (Karen). In these imageries depression is portrayed as something that

11

consumes and overwhelms the individual. Experiencing depression was related to reducing one’s self-esteem and challenging one’s self-image, in some ways mirroring societal values that place signi cance on individuals being in control fiof their selves.

Individuals become unable to realise their optimum ‘sense of self’. Some described depression as ‘‘when you just don’t feelgood within yourself, you don’t think you can do anything right’’ (Gillian); ‘‘[depression] can just affect … the way you feel about yourself’’ (Diana). Others described ‘‘a general feeling of … feeling inadequate, inferior, no self con dence’’ (Harry). One interviewee posited depression as a finegative refashioning of self: ‘‘you just lose the plot and all the values which you’re proud of suddenly disappear’’ (Aidan). In these accounts the family often appears either as a causal and stress-inducing element contributing to depression, or the person experiencing depression is self-represented as a rupture in family life. An ideal self, rationally in control of emotions, was juxtaposed against the depressed self, unable to cope; this loss of control was presented as a form of failure and defeat.

Many accounts had a temporal dimension. Several participants spoke of when they ‘‘got’’ depression, indicating a point in time at which depression ‘‘happened’’. Participants often talked about distinct selves, distinguishing between life ‘‘before’’ and ‘‘after’’ depression.

I used to be very fanatical about my sport, cricket and football, and now I don’t even watch it, which is a bit strange for me. I tend to worry a lot more than I used to. I never used to worry about anything really. Every now and then I’m looking at the worst case scenario, I used to be very optimistic but now I’m not. (John)

Although most participants described their distress through complex personal accounts, a few framed their discussion using

12

a primarily biomedical explanatory model. Prevalent among these was a causal account combining biological predispositions ‘‘triggered’’ by environmental factors:

The big thing that I have learned about it is that it’s an imbalance in the electromagnetic eld of the brain, fiwhich is in a sense reassuring because you understand that there is a medically recognised underlying cause fordepression and that’s exacerbated by daily life and experiences. (Jenny)

Biomedical explanation appears to complement the uncertainty many respondents expressed regarding the cause of depression. By identifying a physical, innate, and unavoidable basis for depression, respondents both lend an interpretive clarity and legitimacy to their experience and absolve themselves from ‘‘blame’’. However, this objecti ed account of distress may befiin tension with the emotional depth of subjective experience:

I think depression is a depletion of neurotransmitters and can be partly biological and can be partly environmental, it is identi ed by a certain number of fisymptoms that last for a period of usually more than two weeks. I think it’s disgusting. I detest it, I think it’sthe anti-life and I hope I don’t get it again. (Sally)

It is signi cant that many respondents who provided biomedicalfiaccounts framed this against the background of their personal life experiences, suggesting that, as the distinction in social science literature between ‘disease’ and ‘illness’ indicates (Kleinman, Eisenberg, & Good, 1978), the biomedical explanatory model insuf ciently encompasses the lived fiexperience of depression.

Somali and Ethiopian participants’ accounts of ‘depression’

13

When asked if they have concepts in their culture/ language similar to what is in Australia known as ‘depression’, both Somali and Ethiopian respondents emphasised that the existenceof many dialects and other language features made such discussion complex. Ethiopian participants commented that the concept and interpretation of ‘depression’ depends on the local geographical area with differences noted between urban and rural populations. Ethiopians living in urban areas tend to have a greater familiarity with Western medical discourses of ‘depression’. As with Okello and Ekbland’s (2006) research with the Baganda of Uganda, most Somali participants equated a‘depression-like’ state with ‘‘too much worrying’’ or ‘‘too much thinking’’ and by the use of formulations such as ‘‘he’s unhappy’’, or ‘‘he’s got some kind of problem’’. Several Somali participants commented that there were ‘‘few words’’ inthe Somali language which indicated that people were not ‘‘emotionally well’’. However, these words do not fully correspond to their understanding of how the concept of ‘depression’ is translated within the dominant culture in Australia.

A Western conceptual model of ‘‘mental language’’ appeared to be dif cult for respondents to comprehend. One Somali woman fidescribed her understanding as

We say like that person is worried, it is a worry thing inside the head. It is hard for us to nd words like the fidepression and all those kind of mental language … It is a sort of like that person is a worry, like when they geta lot of worry that just happens to them. (Ayan, Somali woman)

‘‘Worrying’’ was determined by the context and was related to living through a civil war, time spent in refugee camps, various socioeconomic problems, and negative post-migration experiences.

There was a general consensus that the concept of ‘depression’, describing a form of mental illness, does not translate cross-culturally. Although participants often

14

stipulated that within their culture there was no concept of ‘depression’ as it is understood in Australia, they did not reject it altogether; they used discussion of ‘depression’ instead as a vantage point from which to describe a variety oflife circumstances. Some level of acculturation to a Western model of emotional distress could be observed among participants with educational backgrounds in medicine or psychology:

Depression is the stage you gave up everything … you don’t know what to do and you do know that you have a problem and no solution … giving up … stop talking to your friends, you stop contacting them … stop sharing with other people your happiness … and you will be isolated from your group. (Asad, Somali man)

A biomedical model of distress was absent from the accounts given by Ethiopian and Somali participants.

Participants stated that they have experienced emotional distress, but these experiences were not conceptualised as medical problems. Rather, they were described as inextricably linked to social context. This social representation of distress has two main aspects. First, social networks were said to protect against experiences of depression, and even cited as a reason for the lack of a corresponding concept in Ethiopian and Somali culture:

[depression] is not understood the way that it is looked at in such a speci c manner in the Western culture and itfiis not that much experienced … because if someone feels alittle bit down there is always someone around. (Azmera, Ethiopian man)

Following from this, a lack of adequate social interaction acts as a ‘depression’-causing factor:

15

What causes to be less good [mental health] is lack of integration … I feel under stress, because I cannot socialise with the rest of the community in which I am living … We would like to be socialised with the wider community but there are obstacles such as language barrier. (Deka, Somali woman)

The second aspect is participants’ use of the concept of ‘depression’ to describe collective experiences related to being a refugee. Accounts of the causes of distress frequentlyincorporated a socio-political critique of the cultural and systemic conditions encountered after immigration to Australia:

your social [well being] and health depend on our settlement situation, I think it’s clear that if you are not resettled well you cannot have … social and mental health. (Dalmar, Somali man)

Narratives of ‘depression’ included experiences of discrimination, racism, not having quali cations recognised, fiunemployment, poverty, isolation from members of the dominant culture who ‘‘don’t want to share with you your cultural things’’ (Labaan, Somali man), prolonged emotional distress asa result of not knowing the fate of relatives left behind, theseparation from family members yet to migrate, and structural constraints of Australian law and bureaucracy that participants perceived as infringing upon and destabilising the family unit— in particular immigration laws relating to family reunion.

If we want to talk about refugee mental health issues I would say the government is creating the refugee mental health problems, so I would 100% be thankful to the

16

government if they reject one’s application in the rst fiplace, if they are not going to solve the family reuni cation issue (Ghedi, Somali man).fi

Inability to ful l expectations for nancial assistance held fi fiby many family members in Africa contributed to the distress and the postponement of desired return visits, despite a longing for family reunion:

When you come here [to Australia] you nd life totally fidifferent from what you thought of and expected. In fact,you start worrying about what your families back home areto think of you and about you. After staying many years abroad you feel like not going home because you know whatthey expect [ nancial assistance and presents] and you fican not do what they expect. (Bikila, Ethiopian man)

Men tended to emphasise their experiences of negotiating settlement in the new Australian environment, such as dealing with unemployment, economic disenfranchisement and racism. Both Somali and Ethiopian women emphasised family separation as the most pervasive source of emotional distress: the loneliness of being separated from family, concern about thoseremaining in other countries, and frustration with the administrative procedures in securing immigration visas for family members:

Well, about how to overcome missing family, for example you come here, for example, I came here myself and my children are well fed but we do not have … my kids do nothave a father, an auntie, for example their father is back home and they don’t know what could possibly happen to him. (Zahara, Ethiopian woman)

17

For Ethiopian and Somali respondents, distress was necessarilycontextualised in response to family and social relationships,and structural inequality. The experience was often described in the collective, such as ‘‘we say … .’’; ‘‘our social (well being) and health depends on …’’. This collective rhetoric wasmost prominent in discourses of structural inequality and cultural hegemony. In the following example, a clear demarcation is made between the collective, transcultural refugee experience and the perceived agenda of the political ‘other’:

One most important thing I want you to tell them emphatically is that we have a very old tradition and lawof social life and bond. They are destroying this bond in the old colonial fashion .....After coming here, they havetaken care of our health. We thank them. But there is onebig thing which they have not done for us. It affects us and many others and that is our inability to live according to our culture. While destroying our culture they tell us be this, to live like this or that. This is going to be a major problem for us. (Selassie, Ethiopian man—emphasis added)

The rhetoric of this interview clearly demarcates group identities, in contrast to the individualism in Anglo-Australian narratives. It might be argued that post-migration experiences in uenced the shaping of meaning in Ethiopian and flSomali respondents, particularly in relation to their experience of isolation within broader Australian society. In all Anglo-Australian, Ethiopian and Somali responses however, the use of personal pronouns indicates themes of profound feelings of isolation.

In Somali and Ethiopian interviews, metaphors of the phenomenology of depression appeared less frequently than in Anglo-Australian accounts. Metaphors were used to depict the experience of the self in a dif cult and dramatically fidifferent social and cultural environment:

18

I am like a bird without wings. (Malik, Somali man)

You see yourself like a sh which was taken out from the fiwater. (Dalmar, Somali man)

Metaphor was also used to convey the social position of refugees as a group: ‘‘… they are really isolated in one room so let us open a door for them and give them a chance to be part of the community’’ (Asad, Somali man).

In contrast to the Anglo-Australian emphasis on ‘self-esteem’,Somali and Ethiopian participants were concerned about the lack of opportunity to ful l their social role within the ficommunity:

… the whole role changes you know, because there are rolechanges for women here … and men, some men would feel they have been disempowered, disempowered because of new situation … (Iman, Somali man).

While recognising that Anglo-Australian concepts such as ‘self-esteem’ are imbued with moral imperatives that are grounded in the social, the impetus for these effects appears to be, in the Anglo-Australian accounts, an ambiguous, internal change—‘depression’—whereas in Ethiopian and Somali accounts it is due to external environmental conditions.

Somali and Ethiopian respondents, like Anglo-Australians, saw a temporal dimension to distress, but in their accounts this was based on a distinction between Africa pre-migration and Australia post-migration. Differences in lifestyle and social networks in Australia were integral conditions on which this distinction was made.

In Africa, one was strong and resilient, but this has changed in the ‘new’ country. This is largely attributed to social factors, principally the dissolution of community networks:

19

The way it is understood here [in Australia] … for most people … until they came to another country the word depression is not in y I can’t nd a speci c word for it fi fi… because it is always this extended family being around,the whole village being like, looked at as a family …. (Jahzara, Ethiopian woman)

Also important was the sense of disappointment when life in the new country did not meet expectations, which partly resonates with accounts of disappointment in Anglo-Australian responses. Depression-like feelings are related to the loss ofcherished dreams and hopes:

… what people expected in Australia and what they really faced even in terms of nance … There are many people whofihave had businesses and heaps of money. And for these people to come here and be on the dole and just sit and talk to the kids and … you know … that affects marital relationships. (Tamirat, Ethiopian man)

In both the Anglo-Australian and Ethiopian and Somali dialogues, therefore, discourse of ‘depression’ is temporally bounded. Whereas for Anglo-Australian respondents this is described around an internal and inherent change, Somali and Ethiopian respondents outline a change that is material and external to the individual.

What helps people to recover from depression?— Anglo-Australian accounts

Anglo-Australian participants offered a range of solutions theindividual could introduce in their immediate environment. Social support was deemed important, and located within personal social networks. Relationships centred on the action of the individual and were articulated from a subjective standpoint. ‘‘Talking about it’’ was frequently referred to,

20

often with an unspeci ed person. Therefore, the speaker’s fiposition is emphasised, while the listener’s signi cance is fide ned relationally to the speaking subject. The individual asfiactive agent within relationships was often considered in reference to adopting particular behaviours, such as ‘‘seekinghelp’’.

Many respondents located the entire process of recovery withininternal change, citing the importance of the willpower to ‘‘help yourself’’. The centrality of one’s own psyche in managing depression emerged predominantly, with many respondents outlining cognitive approaches. Acknowledging the ‘existence’ of depression—locating and defining the experience—was also mentioned. This acknowledgement invariably involved identifying ‘depression’ as a personal abnormality, as is illustrated by this response:

Realising what’s causing the particular problem right from day one is an extremely large part of it in my opinion, you must really realise that you have a problem.If you don’t acknowledge that you have a problem, then the problem’s just not going to go away (Peter—emphasis added).

The involvement of medical professionals was important to a number of respondents, to facilitate a greater understanding of the depressed person’s mental state:

I suppose you have to recognise the problem rst, someonefihas to recognise the problem for you, and professional help, whatever it may be, professional help (Marion).

Medication was mentioned by several respondents, but this was often quali ed. It seemed that medication may cause a speci c fi fikind of rupture to self-identity:

21

When I was on the tablets I was partly on track, but the tablets are stronger than you are … and I’d rather be in a bit of pain than not think straight (Mark).

Therefore, the intervention of medical professionals or biomedical treatment was continually referred back to understandings of self and self-identity.

What helps people to recover from depression?— Somali and Ethiopian accounts

Ethiopian and Somali respondents focused on socially based solutions, with an emphasis on community and culture. Ethiopian men in particular articulated their pride in their traditional culture which they de ned against the fi‘‘mainstream’’, as illustrated in this response:

I think our community is not as exposed as the mainstreamto such moods. Because we are still continuing with our social life as dictated by our tradition and custom. (Tamirat, Ethiopian man)

Others suggested that community building was important to provide protection from the danger of children drifting away from desirable cultural norms. This distancing from the ‘‘mainstream’’ was also re ected in an emphasis on community flin resolving feelings of distress and unhappiness. Respondentsexpressed a desire for culturally relevant guidance on issues of mental health, in particular being able to communicate about feelings of distress in their rst language:fi

It is in such cases [of distress] and situations that we need a community support. There is nothing more comforting than talking to a fellow compatriot in one’s own language. (Jahzara, Ethiopian woman)

22

Thus, in Ethiopian and Somali interviews there was a strong emphasis on community support, and, in turn, giving back to the community:

We should do social integration with the wider community,to me Somalis have to start the rst step to socialise fiwith the wider community … In Australia people have same rights, so we, Somalis, should use this opportunity and be part of the wider community. If you don’t make any contribution to this country, people won’t like you because they don’t know you. (Malik, Somali man)

‘‘Community’’ in these discourses refers both to a community of Somali and Ethiopian nationals living in Australia, and to the wider society. This re ects a desire for connection, not flonly within the individual’s immediate circle but on a broaderlevel, as respected and valued members of Australian society.

Religious belief was also considered centrally important in dealing with distress, particularly for Somali respondents:

If I get sick my Somali friends will visit me and pray for me, if we are Somalis we strongly believe that Quran is the best treatment and if you believe it, other modernmedicine will work. (Dalmar, Somali man)

The emphasis on psychological resilience emerged in Anglo-Australian accounts also, though as described above these respondents tended to locate this within the personal responsibility of the individual.

In Somali and Ethiopian responses, professional help was considered in so far as it could be made culturally appropriate. The most frequent pattern of responses favoured community-based solutions to problems of distress. Some respondents advocated training members of the Somali and Ethiopian communities so they could take on the role of

23

professional support. This suggests recognition of government initiatives to create structural solutions to social problems.The need to formally train community members indicates a reinvention of these strategies in a way that is meaningful toEthiopian and Somali culture, as well as a desire for greater social capital within the wider Australian society. Help-seeking pathways proved to be, at least partly determined by people’s social network:

The best way [to deal with mental health issues] is to gothrough bi-cultural community educators who have been trained. (Asad, Somali man)

Some respondents questioned the appropriateness of some forms of professional support, such as counselling, as avenues for managing distress. The Somali community worker commented that:‘‘ … we had no such health facilities especially you know, counselling and all that business, this is something foreign to us’’ (Iman, Somali man).

Participants highlighted a discrepancy between what is offeredby ‘helping professionals’ and welfare organisations and what is expected and desired by community members who want general life needs to be addressed. Instead, they often felt trapped into a system of dependent relationships where ‘help’ reinforces their status as refugees rather than addresses systemic issues. Ethiopian and Somali respondents advocated professional support as an extension of broader enhancement ofcommunity agency:

Eh! I also want to tell you that their contribution is minimal and in fact, there is a lot of misunderstanding because what our women expect from the organizations and what the organisations can deliver, can provide, are totally different things. Really! (Tamirat, Ethiopian man)

24

Discussion

Limitations

These two sets of accounts emerged from different contexts. The Anglo-Australian accounts come from people who have been in contact with general medical practitioners, and were identi ed as experiencing ‘symptoms of depression’, although fialmost half had never received a diagnosis of depression from a health professional. The Ethiopian and Somali accounts are drawn from refugee community samples where no formal diagnostic status has been assigned, and from people who have limited contact with primary healthcare services. It is not our intention, however, to make comprehensive claims regarding‘Somali’, ‘Ethiopian’ or ‘Australian’ beliefs about depression. We are aiming rather to give voice to a group of participants in particular but instructive circumstances.

The accounts were also presented in different forms. The Anglo-Australian participants provided responses in the relative anonymity of a telephone interview, while the Somalisand Ethiopians took part in either face-to-face interviews or focus groups. The former spoke in English; the latter mostly in their own languages through the medium of interpreters and translators, and the texts on which the analyses were undertaken were themselves translations from the original.

Implications

We nd an underlying commonality of views across all firespondents, in identifying and acknowledging the reality of emotional distress as an essentially alienating experience. But the understanding of what this distress means, its antecedents and the best means of resolving it, is far from common—either within or between these communities.

The distinction between individuated Anglo-Australian accountsand collectively-based Ethiopian and Somali accounts of

25

depression appears to indicate not entirely different experience of distress, but differences in the way distress isinterpreted and categorised. Both samples often identi ed the ficause of depression in traumatic or distressing external events, but whereas Anglo-Australian participants then locatedthe ‘blame’ for their emotional response internally, East African participants refused to take the blame for their emotional response. For Somali and Ethiopian respondents, ‘depression’ is the result of clearly identi able structural fiand social events and situations. Their centrality to participants in framing the discussion of depression is associated with the traumatic experience of being a refugee migrant, and the consequent social circumstances. The ‘depressed’ person is inextricable from the community as a whole—the ‘health’ of the community is directly related to thewell-being of individuals. Thus, in respondents’ accounts of their home countries, in which their experience of community features as a vital aspect, they question the very existence of ‘depression’. After arrival within Australia however, wherecommunity ties are more unstable, they perceive ‘depression’ as becoming a social reality. In this sense, ‘depression’ is acommunity issue, that ‘exists’ in relation to the stability orotherwise of social networks, and should be dealt with throughinitiatives that strengthen the community as a whole. Previouswork on Somali and Ethiopian refugees has also acknowledged the prevalence of structure in their accounts of distress (Tilbury & Rapley, 2004). Similarly to Karasz’ (2005) comparative study on depression in South Asian and European American women, our Somali and Ethiopian respondents focused primarily on the worlds of the family and community (Kokanovic, Peterson, & Klimidis, 2006), while Anglo-Australian accounts of depression were formulated more often around discrete life events such as abuse in childhood, death in the family, loss of status and loss of nancial security.fi

We found a high degree of uniformity in Somali and Ethiopian participants’ accounts of ‘depression’ and between our ndingsfiand similar studies from other countries concerning Somalis (Elmi, 1999). ‘Depression’ is primarily seen as a contextualised response to dif culties of life in Australia: fi

26

not being pro cient in English, disruptions in family ties, fiimmigration policy creating great dif culties for family fireunion, loss of status, changes in gender roles, changes in dynamics between parents and children, unemployment, lack of social integration, racism and discrimination, and concerns about events in Ethiopia and Somalia.

Our research indicates that ‘depression’ is de ned ficontextually; Ethiopian and Somali respondents, while acknowledging cross-cultural similarities in the experience ofdistress, use ‘depression’ as a metaphor with which to critique their current social, economic and political situation. In their accounts, ‘depression’ appears both as an ‘affect’, and as a descriptive term with which to paint a morefundamental portrait of life as a refugee migrant. Thus, when respondents said they had no concept of ‘depression’ in their country of origin, this not only indicates a cross-cultural distinction in explanatory models, but also points to altered ways in which they represent their lives and relationships in Australia. When long-standing community ties and social identities have been disrupted through the migration process, this calls for a re-evaluation of the conceptual borders of the individual and their social environment. Thus, utilising the terminology of ‘depression’ becomes a way of signifying this change in status and identity. Fundamentally, respondentsused ‘depression’ as a means to describe ruptures in social relations and social selves. In these accounts, ‘depression’ positions the individual in their social context, and is thus tied to other discourses of community such as those of power and inequality. Similarly, Patel (1995) argues that describingpsychological distress within the context of interpersonal andsocial frameworks may be relatively common in ethno-cultural minorities living in Western societies. Further, there were considerable similarities among Ethiopian and Somali respondents across both samples and both genders, despite cultural heterogeneity, which extended our understanding of the ways in which ‘depression’ is socially situated.

In Anglo-Australian accounts, depression was depicted as primarily the affair of the individual, and was best dealt

27

with through personal or internal/cognitive means. Despite itsamorphous conceptual nature, respondents knew they had an understanding of ‘something’ that is de ned as depression, andfithis is portrayed as an affliction. It is not a controllable part of the self (in fact it is rei ed beyond the self (Helman, fi1988))—yet it is also inherent, seemingly unavoidable and ready to emerge at any time. In this way, it uncontrollably alters the very structure of the self, and this may be why medical interventions are deemed useful: they ‘take control’ of rogue parts of the self and, most importantly, they are engaged withaltering and xing internal and integral parts of our being. fi‘Depression’ is represented as both outside conscious control and altering the structure of consciousness. As ‘depression’ is represented as beyond rational mastery, its representation is relegated to the realm of the body over which we have no conscious control—except when we place ourselves in the hands of the doctor, who alone has attained the ability for rationalintervention.

Kwok (2003) argues that the dominant explanatory model in Australian society places responsibility for depression at thelevel of individuals, who are in turn treated through the individuated lens of clinical practice. By focussing on the ‘distressed subject’ as the object of abnormality, broader systemic and social issues that may contribute to the incidence of depression may be overlooked. Therefore, distressis treated through palliative means whilst obscuring the need for more complex social change. Shaw (2002) has previously argued that ‘lay’ beliefs are problematic, due to the prevalence of medical discourses throughout Western society. In this paper, however, we demonstrate that medical models arein constant tension with the subjective experience of depression-like feelings, rendering ambivalence towards the wholesale adoption of biomedical concepts. In Anglo-Australianaccounts of depression, objectivist models are certainly utilised, but there is an inability to encompass subjective experience within this biomedical framework.

Thus, this points to one broad commonality between the samples: the embedding of conceptual categories within

28

personal narratives of social misfortune. This suggests that what we term ‘lay concepts’ of depression are signi cantly ficontextual. We suggest that ‘depression’ as an analytical concept needs to be reconsidered. Lay people use it to describe divergent and highly contextualised experiences and personal circumstances, and there is little consensus over theamorphous nature of the experience itself. It may be more appropriate therefore, while not denying the profound nature of the affective experience, to reframe its analysis within particular structural and social contexts, rather than througha universalising lens.

Acknowledgements

The study re-order from which Anglo-Australian interview data was sourced was funded by the Australian Primary Health Care Research Institute (APHCRI), which is supported by the Australian Government Department of Health and Ageing and National Health Medical Research Council (NHMRC) Project Grant(ID 299869). We thank the re-order team. The study ‘Listening to Diverse Voices’, from which Ethiopian and Somali interview and focus group data is described, was funded by a Healthway research grant. Chief investigators on this grant were: Ilse O’Farrell, Mark Rapley, Renata Kokanovic and Alan Peterson. The authors would like to acknowledge the signi cant ficontribution of all research assistants who assisted in data collection. We would especially like to thank all participantsfor taking part in the research and allowing us to get a better insight into their worlds and experiences. Finally, ourthanks goes to the reviewers of the manuscript for their valuable feedback.

29

References

Alem, A., Jacobsson, L., Araya, M., Kebede, D., & Kullgren, G.(1999). How are mental disorders seen and where is help soughtin a a rural Ethiopian community? Acta Psychiatrica Scandinavica, 100,40–47.

Angel, R., & Thoits, P. (1987). The impact of culture on the cognitive structure of illness. Culture, Medicine & Psychiatry, 11, 465–494.

Carroll, J. K. (2004). Murung, Waali, and Gini: Expressions ofdistress in refugees from Somalia. Primary Care Companion Journal of Clinical Psychiatry, 6, 119–125.

Coker, E. M. (2004). ‘‘Traveling pains’’: Embodied metaphors of suffering among Southern Sudanese refugees in Cairo. Culture, Medicine & Psychiatry, 28(1), 15–39.

Dowrick, C. (2004). Beyond depression: A new approach to understanding and management. Oxford: Oxford University Press.

Elmi, A. S. (1999). A study on the mental health needs of the Somali community in Toronto. New York: Community Services & Rexdale Community Health Centre.

Gray, D. (1995). Lay concepts of autism: The parents’ explanatory models. Medical Anthropology, 16, 99–118.

Greg, J., & Curry, R. (1994). Explanatory models of cancer among African-American women at two Atlanta neighbourhood health centres. The implications for cancer screening programs. Social Science & Medicine, 39(4), 519–526.

Gunn, J. (2006). Depression as a chronic and disabling experience. The DIAMOND study: A longitudinal naturalistic study of depression in primary care in Victoria, Australia. Journal of Affective Disorders, 91(Supplement 1), S21–S22.

Helman, C. G. (1988). Psyche, soma and society: The social construction of psychosomatic disorders. In M. Lock, & D.

R. Gordon (Eds.), Biomedicine examined. Dordrecht, Boston & London: Kluwer Academic Publishers.

30

Jadhav, S., Weiss, M. G., & Littlewood, R. (2001). Cultural experience of depression among white Britons in London. Anthropology and Medicine, 8(1), 47–69.

Jorm, A. F., Medway, J., Christensen, H., Korten, A. E., Jacomb, P. A., & Rodgers, B. (2000). Public beliefs about the helpfulness of interventions for depression: Effects on actions taken when experiencing anxiety and depression symptoms. Australian and New Zealand Journal of Psychiatry, 34, 619–626.

Kangas, I. S. (2001). Making sense of depression: Perceptions of melancholia in lay narratives. Health, 5(1), 76–92.

Karasz, A. (2005). Cultural differences in conceptual models of depression. Social Science & Medicine, 60, 1625–1635.

Kirmayer, L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 62(Suppl 13), 22–28.

Kleinman, A. (1980). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine and psychiatry. Berkeley: University of California Press.

Kleinman, A. (1998). The illness narrative: Suffering, healing and the human condition. New York: Basic Books.

Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258.

Kokanovic, R., Peterson, A., & Klimidis, S. (2006). ‘‘Nobody can help me … I am living through it alone’’: Experiences of caring for people diagnosed with mental illness in ethno-cultural and linguistic minority communities. Journal of Immigrant and Minority Health, 8(2), 125–132.

Kwok, W. L. (2003). Postnatal depression in Whittlesea: A discussion paper. Melbourne: North Central Metro Primary Care Partnership.

Lauber, C., Falcato, L., Nordt, C., & Rossler, W. (2003). Lay beliefs about causes of depression. Acta Psychiatrica Scandinavica, 108(s418), 96–99.

31

Mays, N., & Pope, C. (1995). Qualitative research: Rigour and qualitative research. British Medical Journal, 311, 109–112.

Okello, E. S., & Ekblad, S. (2006). Lay concepts of depressionamong the Baganda of Uganda: A pilot study. Transcultural Psychiatry, 43(2), 287–313.

Papadopolis, I., Lees, S., Lay, M., & Gebrehiwot, A. (2004). Ethiopian refugees in the UK: Migration, adaptation and settlement experiences and their relevance to health. Ethnicity & Health, 9(1), 55–73.

Patel, V. (1995). Explanatory models of mental illness in sub-Saharan Africa. Social Science & Medicine, 40(9), 1291–1298.

Pope, C. (1995). Qualitative research: Reaching the parts other methods cannot reach: An introduction to qualitative methods in health and health services research. British Medical Journal, 311, 42–45.

Prior, L., Wood, F., Lewis, G., & Pill, R. (2003). Stigma revisited, disclosure of emotional problems in primary care consultations in Wales. Social Science & Medicine, 56, 2191–2200.

Radley, A., & Billig, M. (1996). Accounts of health and illness: Dilemmas and representations. Sociology of Health and Illness,18(2), 220–240.

Shaw, I. (2002). How lay are lay beliefs? Health, 6(3), 287–299.

Silveira, E., & Allebeck, P. (2001). Migration, ageing and mental health: An ethnographic study on perceptions of life satisfaction, anxiety and depression in older Somali men in east London. International Journal of Social Welfare, 10(4), 309–320.

Skultans, V. (2003). From damaged nerves to masked depression:Inevitability and hope in Latvian psychiatric narratives. SocialScience & Medicine, 56, 2421–2431.

Smaje, C. (1996). The ethnic patterning of health: New directions for theory and research. Sociology of Health and Illness, 18(2), 139–171.

32

Tilbury, F., & Rapley, M. (2004). ‘‘There are orphans in Africa still looking for my hands’’: African women refugees and the sources of emotional distress. Health Sociology Review, 13(1), 54–64.

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.

Yardley, L. (2000). Dilemmas in qualitative health research. Psychology & Health, 15, 215–228.

33