Immigrants have higher rates of psychosis. A Dutch care facility believes culture should be part of treatment.

Utrecht, Netherlands – When he was 20 years old, Tofik Boughrini became what he called “a bit disconnected from reality”.

He said for the two years prior he didn’t take good care of himself, sleeping in the day and staying up at night. He was a heavy cannabis user. It evened out his moods and calmed him down.

Then his first psychotic episode began.

“Looking back, what stands out is the incoherent talking and a strong sense that the world is not right,” he told Al Jazeera in his native Utrecht, the Netherlands.

“I felt I could do something about that – there was a bit of megalomania.”

In the years that followed, Boughrini was admitted into a psychiatric hospital five times as he alternated between recovery and slipping back into psychosis.

Until finally he had enough.

Now 31, Boughrini uses his own experience with psychosis to help others.

He was diagnosed with bipolar disorder, a mental illness also known as manic depression, characterised by extreme shifts in moods. Psychosis, a condition with symptoms including delusions, hallucinations and incoherent thoughts, can happen during manic or depressive phases.

Boughrini works as an “experience expert”, coaching people with psychotic disorders at assisted living facilities, including Daar-na, the only assisted living facility in the Netherlands specifically for Muslim men.

All eight men currently living in Daar-na have been diagnosed with schizophrenia, a chronic psychotic disorder.

Most of the men were living with their parents before coming here. They’re here voluntarily, though most of them do have a court order to follow treatment.

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Among the group is Karim*. His mother, Hanan, who asked Al Jazeera to withhold her last name, became increasingly worried about her son when he was 16 years old. The Karim she knew to be a sweet, sensitive star student had become withdrawn and his performance at school had dropped.

“His lust for life kept getting less, he’d sleep more and live at nighttime,” Hanan told Al Jazeera.

He became increasingly aggressive, too, breaking a pen, a phone, a keyboard. When he was 19 years old, Karim picked up his TV, smashed it on the floor and started talking to seemingly no one.

Hanan walked into his room. “These people want me,” Karim told her.

In the months that followed, he would often talk erratically about cameras in the house and people wanting him dead, Hanan said.

The fact that the coaches are of Moroccan descent, the food is halal and there's space for religion is important to me. Hanan

“It was chaos, absolute chaos.”

Hanan sought help after Karim jumped out of his bedroom window during an argument with his father. Doctors diagnosed him with psychosis. After a holiday in Morocco, and with the medication prescribed, Karim started doing better. But then Hanan and Karim’s father announced they were getting a divorce and the symptoms started to come back.

When Hanan took him to see a psychiatrist again, he walked out of the room. Minutes later, he came back and attacked his mother, pulling at her hijab and calling her names.

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The next day, Karim was admitted to a psychiatric hospital. Not long after, he moved into Daar-na.

“Living with someone from the same culture is important,” Hanan said. “Nothing to do with racism, but we don’t understand each other. [Native Dutch people] have a different lifestyle.

“The fact that the coaches are of Moroccan descent, the food is halal and there’s space for religion is important to me.”

Steps towards recovery

Life at Daar-na is not much different from what it would be like at other assisted living residences for psychotic disorders.

But the cultural focus at the facility comes into play in a few practical ways: Islamic holidays such as Ramadan are observed and alcohol is prohibited. Once a week, an imam joins the men for dinner to answer any questions they may have about faith.

For the most part, the culturally sensitive approach serves to make the men feel more at ease.

“We try to connect to people’s identity,” said Alex Roomer. The manager of Daar-na is sitting in the small office joined by Ahmed Salama, who played a leading role in founding the facility, and recovery coach Sabah Nhass.

There's a lot of resistance, a lot of denials. Sabah Nhass

“Providing care in an environment where people feel at home means you can take bigger steps towards recovery,” Roomer added.

The main goals of the residence are to help the men accept their condition, find a way to manage it as a long-term feature of their lives and enhance basic life skills such as cooking dinner and maintaining their living space.

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The men who live here have been diagnosed relatively recently, said Sabah Nhass. Many of them are not aware they have schizophrenia, she added, or they deny it – something that is prevalent in this condition.

“They’re struggling with that a lot. Who am I? What role does this vulnerability play in my life? Do they even want it to play a role? There’s a lot of resistance, a lot of denials,” Nhass said.

Heightened risk

Research has long suggested that people belonging to immigrant groups have a heightened risk of developing psychotic disorders.

One study by researchers from Parnassia Psychiatric Institute in The Hague found that men born in the Netherlands to parents who had immigrated from Morocco had a risk of developing a psychotic disorder up to seven times greater than the native Dutch population.

Wim Veling, now a psychiatrist at the University Medical Centre Groningen was one of the researchers in the study. “In my view, it’s undisputed that there’s a higher risk and we’ve moved on to looking into what could explain this,” he said.

That's quite something - that your address determines whether you're going to have such a serious illness. Wim Veling, University Medical Centre Groningen

Veling has focused on social exclusion as a trigger for developing the disorders in people with a genetic predisposition. In one study, he found that people who lived in neighbourhoods where their ethnic group was relatively underrepresented appeared to have a higher risk of developing a psychotic disorder.

“That’s quite something – that your address determines whether you’re going to have such a serious illness,” he said.

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Another study conducted by Veling suggested that how people of ethnic minorities relate to the native Dutch population made a difference.

“If you are part of a society where your ethnic group is negatively perceived, there are two strategies of dealing with that,” Veling said.

“You can either try to become a part of the dominant culture as much as you can, or you can emphasise that it’s a positive thing to be part of a minority and derive your identity from that.”

People who chose the first strategy, Veling found, had a higher incidence of psychotic disorders in part because they experienced more rejection.

“The constant feeling of ‘I’m being judged and there’s nothing I can change about that’ gives enormous pressure,” he said. “It’s a poisonous mix.”

Psychiatrist Tekleh Zandi, however, believes the heightened risk at developing a psychotic disorder for Dutch-Moroccans is overstated. Her research found that some symptoms which in the Netherlands are associated with schizophrenia, like hearing voices, have a different meaning in Moroccan culture and are not necessarily seen as an indication of mental illness. Culturally insensitive diagnosing methods may have led to overdiagnosis, Zandi believes.

Inclusive environment

To those running Daar-na, creating an environment where all men are included is seen as an important tool in helping the men recover.

“Some of the men recite the Quran together. At a different facility, some of the others might say ‘Hey knock that off’. Here it’s just normal,” Roomer said.

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“If parents come to visit and they want to pray, nobody thinks anything of it,” Nhass added.

“They feel free to do that here.”

Daar-na is also a place where Western and non-Western treatment can coexist. The symptoms of schizophrenia and psychosis resemble those that many in the Dutch-Moroccan community may associate with jinn.

Many of the parents of the men living at Daar-na, including Hanan, have taken their sons to Morocco seeking treatment from an imam.

“I think it’s important they try that trajectory as well, to learn to see the difference between what is schizophrenia and psychotic vulnerability and what is possession by jinn,” Nhass said.

Managing mental illness

Back in Daar-na, Karim has his ups and downs, Hanan said. There have been a few incidents at the facility, including one where he got into a fight.

But he feels at home in the residence now, she added.

Boughrini helps men like Karim get ready to live on their own, informally coaching them in and around the house. He hasn’t experienced a psychotic episode in years. He rents his own flat, works four days a week and plays football at a local club.

You have to imagine that I feel ready to run a marathon but instead, I have to tell myself 'No Tofik, you need to get to bed'. Tofik Boughrini

Someone helps him with his finances, formerly a big source of stress which could push his moods out of balance.

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He also knows how to recognise symptoms of his condition at an early stage, and knows what to do about them.

“Extra medication, extra rest. You have to imagine that I feel ready to run a marathon but instead, I have to tell myself ‘No Tofik, you need to get to bed’. That’s very difficult, but I got better at it,” he said.

“That I’m chronically ill is something I can’t change. But I’ve worked hard on learning how to manage it and have a reasonable quality of life.”

*The name has been changed at the request of the interviewee.