Mental Health, Mental Illness and Migration (Mental Health and Illness Worldwide) 9811023646, 9789811023644

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Mental Health and Illness Worldwide Series Editors: Norman Sartorius · Ee Heok Kua

Driss Moussaoui · Dinesh Bhugra Rachel Tribe · Antonio Ventriglio Editors

Mental Health, Mental Illness and Migration

Mental Health and Illness Worldwide Series Editors Norman Sartorius Association for the Improvement of Mental Health Programmes (AMH) Geneva, Switzerland Ee Heok Kua Department of Psychological Medicine National University of Singapore Singapore, Singapore

Most books on mental health and illness are published for readers in North America and Europe, and not much is known about psychiatric practice, services and research in Asia, Africa, and South America. This series includes contributions of clinicians and researchers from all over the world. Each volume covers broad issues including epidemiology, cross-cultural comparison, clinical research, stigma of mental illness, cultural issues in mental healthcare, health economics, innovative services, preventive programs and health service outcome research. It is expected that the volumes are finding readership among psychiatrists, psychologists, sociologists, health policy makers, social workers, health economists, anthropologists and philosophers. More information about this series at http://www.springer.com/series/14178

Driss Moussaoui • Dinesh Bhugra • Rachel Tribe • Antonio Ventriglio Editors

Mental Health, Mental Illness and Migration With 6 Figures and 22 Tables

Editors Driss Moussaoui Department of Psychiatry Ibn Rushd University Psychiatric Centre Casablanca, Morocco Rachel Tribe School of Psychology University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London London, UK

Dinesh Bhugra Centre for Affective Disorders IoPPN, Kings College London, UK Antonio Ventriglio Department of Clinical and Experimental Medicine University of Foggia Foggia, Italy

ISSN 2511-8323 ISSN 2511-8315 (electronic) ISBN 978-981-10-2364-4 ISBN 978-981-10-2366-8 (eBook) ISBN 978-981-10-2365-1 (print and electronic bundle) https://doi.org/10.1007/978-981-10-2366-8 © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Series Preface

Psychiatry lives exciting and challenging times. Advances of knowledge stemming from basic sciences and epidemiological and clinical research have provided a better understanding of the etiopathogenesis, psychopathology, and development of mental disorders. Improved methods of treatment have changed clinical practice and prolonged the life of people with mental illness. Economic consideration and the emphasis on human rights of people with mental illness made a profound impact on the way in which psychiatry is to be practiced. Regrettably, however, psychiatry is not practiced in the same manner around the world. Undergraduate and postgraduate education in psychiatry varies in content and duration from country to country. Psychiatrists use different doses of medication for the same disorders. The systems of care for people with mental illnesses differ in the organization and content of their interventions. Support to scientific investigations of matters related to psychiatry fluctuates and in many countries amounts to very little. Information about the function of psychiatric services varies in quantity and quality. The series of seven books on Mental Health and Illness Worldwide aims to help in reducing these differences and to facilitate international collaboration in psychiatry. We have invited top experts from different countries to edit the volumes, and they have in turn selected authors from different parts of the world. We have also decided to approach the body of psychiatry from a public health and epidemiological perspective rather than have books dealing with different groups of diseases. The series thus includes books examining and presenting knowledge assembled according to social and public health variables – gender, urbanicity, migratory status, age, and education. Each of the volumes has adopted a wide perspective and included chapters based on knowledge stemming from epidemiology, on results of the investigation of cultural issues, on the best of psychopathology, on the results of the investigation of biological factors, mental health care and its innovations, health economics, and experience gained in preventive programs. The volume editors have agreed to aim at producing volumes marked by the balance of information and knowledge from basic social and behavioral sciences and from clinical practice. The seven volumes of this opus are: 1. Mental Health and Illness of the Elderly Editors: Helen Chiu (Hong Kong) and Ken Shulman (Canada) v

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2. Mental Health and Illness in the City Editors (Denmark): Povl Munk-Jorgensen, Niels Okkels, and Christina Kristiansen 3. Mental Health and Illness of Women Editors: Prabha S. Chandra (India), Helen Herrman (Australia), Jane Fisher (Australia) and Anita Riecher-Rössler (Switzerland) 4. Mental Health and Illness in the Rural World Editor: S. K. Chaturvedi (India) 5. Education About Mental Health and Illness Editors: Marc H.M. Hermans (Belgium), Tan Chay-Hoon (Singapore), and Edmond Pi (USA) 6. Mental Health and Illness of Children and Adolescents Editors: Eric Taylor (United Kingdom), Frank Verhulst (Netherlands), John Chee Meng Wong (Singapore), and Keiko Yoshida (Japan) 7. Mental Health, Mental Illness and Migration Editors: Driss Moussaoui (Morocco), Dinesh Bhugra (United Kingdom), Rachel Tribe (United Kingdom) and Antonio Ventriglio (Italy) We were delighted to see that the volume editors have succeeded in recruiting outstandingly knowledgeable authors for the chapters of their books. Most of them have received worldwide recognition for their contributions in their fields of specialization, and all of them have written their texts with authority and excellent judgment concerning the materials to be included. We believe that this series of books demonstrates the importance and value of interdisciplinary and international collaboration and that it will provide readers a global perspective of mental health and mental illness. We also hope that it will help to make our discipline more homogenous and bring its practitioners worldwide closer together in the pursuit of helping people with mental illness worldwide. We wish to express our profound gratitude to Professors Driss Moussaoui, Dinesh Bhugra, Rachel Tribe, and Antonio Ventriglio the editors of this volume on Mental Health, Mental Illness and Migration for their dedication and commitment in the production of this excellent work. September 2021

Norman Sartorius Ee Heok Kua

Volume Preface

Since World War II, humankind was progressing on the path of a rapid globalization, until it stopped abruptly with the COVID-19 pandemic, which has been the most impactful phenomenon in recent memory in the entire world. It has immediately raised barriers between countries, regions, and neighborhoods and sometimes between family members. Lockdowns and prohibition to circulate created a sense of depersonalization and isolation in many people who did no more recognize themselves nor their environment. This generalized anomie has inevitably paved the way for all kinds of illnesses, including mental illnesses, and putting migrants and refugees in an even more fragile position. The poor, the underprivileged, and the socially disadvantaged have suffered disproportionate deaths and morbidity due to the pandemic. During this period as pandemic continues to rage and in spite of some success due to vaccination, freedom to move is no longer the norm, but the exact opposite. This lack of freedom of movement is good to experience if we think that we share this with a group of human beings: migrants and refugees. Many of them, on a daily basis, suffer from political instability, physical and mental insecurity, financial shortages, administrative difficulties, isolation, and most of all stigma and discrimination. The more the environment is disturbed, the more it impacts socio-economically the migrants, leading to more poverty and social vulnerability. This in turn produces more suffering, and the vicious circle continues. Mental health impact on women and men who decide and/or are forced to migrate is tremendous. Every single moment of the day comes with its barriers, difficulties, and pain. Depressive and anxiety disorders are often seen in them, as well as posttraumatic stress disorder and increased levels of substance abuse, the latter representing a desperate effort to relieve their suffering. Needless to say health services, including mental health, are not easily available or accessible and geographical and social instability does not help either. The sometimes huge frustration and anger seen in people impacted by the pandemic should be taken as a good model to explore and explain how migrants and refugees live and how they can hardly reach a decent level of life. Despite all difficulties and problems, including the pandemic, most migrants and refugees make it through, showing an extraordinary talent for resilience. Not all traumas kill. Our role as mental health professionals is not only to help overcome the vii

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suffering but as citizens and human beings to advocate for more openness and humanity in this matter. This is why this book was designed to present the case of migrants with recent research and reflections in this field. Thirty-eight chapters were written by authors from four continents reviewing literature and presenting their experience. Our hope is that readers will find this book useful both from the clinical practice and the research points of view and more widely, to stimulate interest in this extremely important field and also to influence policymakers. Morocco United Kingdom United Kingdom Italy September 2021

Driss Moussaoui Dinesh Bhugra Rachel Tribe Antonio Ventriglio

Contents

Part I

Framework

........................................

1

1

Introduction: Migration and Health . . . . . . . . . . . . . . . . . . . . . . . . Dinesh Bhugra, Antonio Ventriglio, Driss Moussaoui, and Rachel Tribe

3

2

Migration, Globalization, and Mental Health . . . . . . . . . . . . . . . . . Driss Moussaoui

15

3

Internal and International Migration and its Impact on the Mental Health of Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Guglielmo Schininá and Thomas Eliyahu Zanghellini

27

4

Micro-identities and Acculturation in Migrants . . . . . . . . . . . . . . . Antonio Ventriglio and Dinesh Bhugra

47

5

Cultural Capital and Acculturation in Migrants . . . . . . . . . . . . . . Dinesh Bhugra, Cameron Watson, Rajiv Wijesuriya, and Antonio Ventriglio

55

6

Migrants, Racism, and Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . Dinesh Bhugra, Cameron Watson, Elliot Clissold, and Antonio Ventriglio

65

Part II

Special Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75

7

Mental Illness and Migrants in Europe Rachid Bennegadi

.....................

77

8

Mental Health Among Latin American Migrants in the USA . . . . Renato D. Alarcón

99

9

The Mental Health of South Asians in the UK . . . . . . . . . . . . . . . . Vishal Bhavsar, Antonio Ventriglio, and Dinesh Bhugra

121

10

Mental Health in Multicultural Australia . . . . . . . . . . . . . . . . . . . . Harry Minas

135

ix

x

11

Contents

The Acculturation Experiences of First-Wave Kosovan Women Migrants Living in the United Kingdom . . . . . . . . . . . . . . . . . . . . . Yllka Krasniqi Morina and Rachel Tribe

165

12

Canadian Immigrant Mental Health Kenneth Fung and Jaswant Guzder

.......................

187

13

Transcultural Aspects of Psychiatry and Mental Health in Migrant Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . Rahmeth Radjack, Sarah Lévesque-Daniel, and Marie Rose Moro

209

14

Migration, Aging, and Mental Health . . . . . . . . . . . . . . . . . . . . . . . Ee Heok Kua and Rathi Mahendran

227

15

Mental Health in Refugees and Asylum Seekers Meryam Schouler-Ocak and Marianne C. Kastrup

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237

16

The Untold Story of Mental Health and Resilience of Internal Migrants in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Raghu Raghavan, Jonathan Coope, Brian Brown, Muthusamy Sivakami, Saba Jamwal, and Tejasi Pendse

247

17

Mental Health of Irish Travellers . . . . . . . . . . . . . . . . . . . . . . . . . . Finola Cullenbrooke and Susham Gupta

261

18

Migration and Mental Health of Arabic-Speaking Communities Jeyda Hammad and Aseel Hamid

...

271

19

Palestinian Mental Health Under Military Occupation and Chronic Warlike Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jeyda Hammad, Zaynab Hammad, and Rachel Tribe

303

Part III

Special Categories

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319

20

Migration and Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Samuel O. Okpaku, Ademola B. Adeponle, and Robert Kohn

321

21

Migration History and Psychopathology . . . . . . . . . . . . . . . . . . . . Mauro Braca, Domenico Berardi, Giuseppe D’Andrea, and Ilaria Tarricone

347

22

Mental Health Morbidity Among Rural-to-Urban Migrant Workers in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bao-Liang Zhong and Helen Fung-Kum Chiu

357

Help Seeking Views Relating to Depression Among Older Black Caribbean Adults Living in the UK . . . . . . . . . . . . . . . . . . . . . . . . Natalie Victoria Bailey and Rachel Tribe

369

23

Contents

Part IV 24

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Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Designing Mental Health Services for Vulnerable Migrants and Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. Ananyeva, N. Gionakis, N. K. Movsisyan, Adil Qureshi, Meryam Schouler-Ocak, and N. Serre-Delcor

391

393

25

Access to Health Care in the Migrant Population Julio Torales and Israel Gonzalez-Urbieta

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407

26

Resilience, Mental Health, and Migrations . . . . . . . . . . . . . . . . . . . Boris Cyrulnik

419

27

Therapy and Therapeutic Considerations with Refugees and Asylum Seekers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Farkhondeh Farsimadan

427

28

How to Best Help Mental Patients Among Migrants . . . . . . . . . . . Tom K. J. Craig

443

29

The Intercultural Psychiatric Program Daniel Towns and Paul Leung

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457

30

Community Engagement and Social Justice . . . . . . . . . . . . . . . . . . Rachel Tribe, Aneta Tunariu, and Dung Jidong

477

31

Working with Interpreters in Mental Health . . . . . . . . . . . . . . . . . Rachel Tribe and Kate Thompson

489

32

Mental Health of Black and Minority Ethnic Communities in the UK and the Utilization of the Mental Health Legislation . . . . . . . . Susham Gupta, Dharangini Dinakaran, and Elaine Athanas

513

33

Minority Women’s Mental Health Lillian Shundi

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523

34

Humanitarian Intervention Training Programs . . . . . . . . . . . . . . . Jeeda Alhakim, Lucia Berdondini, and Claire Marshall

541

35

The Psychological Impact of Residing in a Refugee Camp Claire Marshall

......

561

36

Social and Political Agendas: The Securitization of Migration and Detention as a Spectacle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claire Marshall

583

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Contents

Part V 37

Postface: The Path Toward the Future . . . . . . . . . . . . . . . . . . . . . . Driss Moussaoui, Dinesh Bhugra, Rachel Tribe, and Antonio Ventriglio

Part VI 38

Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Annex

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WPA Guidance on Mental Health and Mental Health Care in Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dinesh Bhugra, Susham Gupta, Kamaldeep Bhui, Tom K. J. Craig, Nisha Dogra, J. David Ingleby, James Kirkbride, Driss Moussaoui, James Nazroo, Adil Qureshi, Thomas Stompe, and Rachel Tribe

603 605

611

613

Correction to: Mental Health, Mental Illness and Migration . . . . . . . . Driss Moussaoui, Dinesh Bhugra, Rachel Tribe, and Antonio Ventriglio

C1

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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About the Series Editors

Professor Norman Sartorius obtained his M.D. in Zagreb (Croatia). He specialized in neurology and psychiatry and subsequently obtained a master’s degree and a doctorate in psychology (Ph.D.). He carried out clinical work and research and taught at graduate and postgraduate levels at the University of Zagreb, at the Institute of Psychiatry in London, at the University of Geneva, and elsewhere. Professor Sartorius joined the World Health Organization (WHO) in 1967 and soon assumed charge of the program of epidemiology and social psychiatry. In 1977, Professor Sartorius was appointed director of the Division of Mental Health of WHO. He was the principal investigator of several major international studies on schizophrenia, depression, and other neurological disorders. In 1993, Professor Sartorius was elected president of the World Psychiatric Association (WPA) and served as president-elect and then president until August 1999, after which he was elected president of the European Psychiatric Association. Professor Sartorius is currently the president of the Association for the Improvement of Mental Health Programmes, and a member of the Geneva Prize Foundation, having been its president from 2004 to 2008. Professor Sartorius holds professorial appointments at universities in different countries including China, the UK, and the USA. Professor Sartorius has published more than 500 articles in scientific journals, authored or co-authored 12 books, and edited more than 100 others. He is the co-editor of two scientific journals and a member of editorial and advisory boards of many others. Professor Sartorius is also a corresponding member and fellow of a large number of international organizations and xiii

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About the Series Editors

advisory boards. He has several honorary doctorates and is a member of academies of science and of medicine in different countries. He speaks Croatian, English, French, German, Russian, and Spanish. Dr. Ee Heok Kua is the Tan Geok Yin professor of psychiatry and neuroscience at the National University of Singapore (NUS) and Emeritus consultant psychiatrist at the National University Hospital, Singapore. He was trained as a doctor at the University of Malaya and received postgraduate training in psychiatry at Oxford University and geriatric psychiatry at Harvard University. Dr. Kua is member of the World Health Organization team for the global study of dementia; previous head of the Department of Psychological Medicine and vice dean, Faculty of Medicine, at NUS; and chief executive officer and medical director at the Institute of Mental Health, Singapore. His research interest includes depression, dementia, and alcoholism, and he has written 23 books on psychiatry, aging, and addiction. A novel he wrote, Listening to Letter from America, is used in a module on anthropology at Harvard University. The former president of the Pacific-Rim College of Psychiatrists and president of the Gerontological Society of Singapore, he was editor of the Singapore Medical Journal and Asia-Pacific Psychiatry journal.

About the Volume Editors

Driss Moussaoui Professor Emeritus, Faculty of Medicine, Casablanca, Morocco. Driss Moussaoui was the founder and chairman of the Ibn Rushd University Psychiatric Centre in Casablanca from 1979 to 2013. He was also director of the Casablanca WHO Collaborating Centre in Mental Health from 1992 to 2013. Driss was president of the Moroccan Society of Psychiatry and of the Arab Federation of Psychiatrists. He edited or co-edited 10 books and published more than 150 papers in international journals. He founded with the World Psychiatric Association (WPA) Executive Committee the Jean Delay Prize (1999) and is the scientific director of the WPA series International Anthologies of Classic Psychiatric Texts (French, German, Spanish, Italian, Greek, and Russian versions are under preparation). Driss Moussaoui is past president of the World Association of Social Psychiatry (WASP, 2010–2013) and member of the French Academy of Medicine. He is an honorary member of the World Psychiatric Association and WASP. He is currently president of the International Federation for Psychotherapy (2018–2022)

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About the Volume Editors

Professor Dinesh Bhugra CBE, M.A., M.Sc., M.B. B.S., Ph.D., FRCP, FRCPE, FRCPsych, FFPHM, FRCPsych (Hon), FHKCPsych (Hon), FACPsych (Hon), FAMS (Singapore), FKCL, M.Phil., FAcadME, FRSA, DIFAPA Professor Dinesh Bhugra is emeritus professor of Mental Health and Cultural Diversity at King’s College, London. He was dean (lead educational officer) of the Royal College of Psychiatrists (2003–2008) and then president of the Royal College (2008–2011). Professor Bhugra was vice chair of the Academy of Medical Royal Colleges with remit for education for doctors of all grades and specialties. During this period, he led on the Colleges’ campaign for fair deal for people with mental illness. He established strategy for public mental health. As president of the World Psychiatric Association, he led the development of 20 Position statements and various other initiatives, including bill of rights for people with mental illness (signed by 60 organizations) and a campaign for social justice for people with mental illness to support this. As President of the BMA (2018– 2019), he led on a large survey of mental health and well-being of medical students globally, a campaign for equity between physical and mental health and medicine’s social contract. So far, he is the only British Asian for having been president of the Royal College of Psychiatrists and of the World Psychiatric Association. He chaired the board of trustees of Mental Health Foundation (2011–2014) and is on the boards of Psychiatry Research Trust and Sane charities. He is currently non-executive director and deputy chair of the Tavistock and Portman NHS Foundation Trust since 2014. In 2017, he was placed #1 in public sector professionals in FT-Outstanding Awards. In 2018, he was voted international Global Champion on mental health in an international poll. He has published widely with over 500 papers; 175 chapters; edited and written 37 books, three of which have been translated into Japanese and Chinese; and two have won awards. In 2019, two of his books were shortlisted in the BMA psychiatry book of the year award. Appointed CBE, he has been awarded 10 honorary degrees from international universities. He continues to champion the cause of people with mental illness.

About the Volume Editors

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Professor Rachel Tribe is an active clinician, researcher, consultant, and trainer. She is a trustee of two international mental health charities. Professor Tribe has published extensively in the area of migration and mental health. With colleagues she developed a mental health and well-being portal for refugees, asylum-seekers, and health and social care professionals, https://www.uel.ac.uk/Schools/Psychology/ Research/Refugee-Mental-Health-and-Wellbeing-Por tal. Her clinical interests focus on all aspects of trauma, culture and mental health, professional and ethical practice, working with interpreters and bicultural workers in mental health, migration and mental health, older adults, social justice, and organizational development. She has consulted to and worked with a range of humanitarian organizations in a number of countries. Her work has global reach and has had an impact in a number of countries. Antonio Ventriglio Based in Foggia, Italy, Dr. Ventriglio is a psychiatrist and psychotherapist at “Riuniti” Hospital in Foggia, Italy. He is professor of psychopharmacology and social psychiatry at the School of Psychiatry in Foggia, Department of Clinical and Experimental Medicine, University of Foggia. He has been research fellow in the Department of Schizophrenia and Bipolar Disorder, Harvard University, Cambridge, MA, USA; completed two Ph.D. programs on medical, clinical, and experimental sciences at the University of Foggia. He is currently member of the Italian Society of Psychiatry, Italian Society for Social Psychiatry, and honorary member of World Psychiatry Association. Dr. Ventriglio is editor for letters for the International Journal of Social Psychiatry; editorial board member of the International Review of Psychiatry, Open Journal of Psychiatry and Allied Sciences, Current Drug Research Review, Frontiers in Psychiatry, and Neurosciences; and editor of books for Oxford University Press and Springer Nature.

Contributors

Ademola B. Adeponle Department of Psychiatry, McGill University, Montreal, QC, Canada Culture and Mental Health Research Unit, Jewish General Hospital, Montreal, QC, Canada Renato D. Alarcón Mayo Clinic College of Medicine, Rochester, MN, USA Universidad Peruana Cayetano Heredia, Lima, Peru Jeeda Alhakim Psychology, University of East London, London, UK O. Ananyeva Tilburg University, Tilburg, The Netherlands Elaine Athanas Psychiatry, East London NHS Foundation Trust, London, UK Natalie Victoria Bailey School of Psychology, University of East London, London, UK Rachid Bennegadi Minkowska Centre, The World Association of Social Psychiatry (WASP), Paris, France Domenico Berardi Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy Lucia Berdondini School of Psychology, University of East London (Stratford Campus), London, UK

The original version of this book was revised. The handbook was inadvertently published with an incorrect spelling of the author’s name in Chapters 1, 4, 39, 41, 9, 15 as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. In addition to this, he is also one of the editors and therefore, his name has now been amended throughout the book as Antonio Ventriglio. The correction is available at https://doi.org/10.1007/978-981-10-2366-8_45 xix

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Contributors

Vishal Bhavsar Department of Psychosis Studies, King’s College London, London, UK Section of Women’s Mental Health. Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK Dinesh Bhugra Centre for Affective Disorders, IoPPN, Kings College, London, UK Kamaldeep Bhui Queen Mary School of Medicine and Dentistry, London, UK Mauro Braca Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy Brian Brown Mary Seacole Research Centre, De Montfort University, Leicester, UK Helen Fung-Kum Chiu Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, SAR, China Elliot Clissold Barts Health NHS Trust, London, UK Jonathan Coope Mary Seacole Research Centre, De Montfort University, Leicester, UK Tom K. J. Craig Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK Finola Cullenbrooke City and Hackney Rehabilitation and Recovery Service, London, UK Boris Cyrulnik Education, University of Toulon, Toulon, France Giuseppe D’Andrea Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy Dharangini Dinakaran Consultant Psychiatrist, Priory Healthcare, London, UK Nisha Dogra Greenwood Institute of Child Health, University of Leicester, Leicester, UK Farkhondeh Farsimadan UEL Refugee Mental Health and Wellbeing Portal, London, UK Kenneth Fung Department of Psychiatry, University of Toronto, Toronto, Canada

Contributors

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N. Gionakis Babel Day Centre, Athens, Greece Israel Gonzalez-Urbieta Psychiatry, National University of Asunción, School of Medical Sciences, San Lorenzo, Paraguay Susham Gupta Early Intervention of Psychosis, East London NHS Foundation Trust, London, UK City and Hackney Early Intervention Service, Donald Winnicott Centre, London, UK Jaswant Guzder Psychiatry, McGill University, Montreal, QC, Canada Aseel Hamid Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Jeyda Hammad School of Psychology, University of East London, London, UK Zaynab Hammad Faculty of Life Sciences and Medicine, King’s College London, London, UK J. David Ingleby European Research Centre on Migration and Ethnic Relations, University of Utrecht, Utrecht, The Netherlands Saba Jamwal Asoka University, Haryana, India Dung Jidong School of Psychology, University of East London, London, UK Marianne C. Kastrup Speciallæge i psykiatri, Frederiksberg, Denmark James Kirkbride University Department of Psychiatry, Addenbrooke’s Hospital, Cambridge, UK Robert Kohn Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI, USA Ee Heok Kua Department of Psychological Medicine, National University of Singapore, Singapore, Singapore Paul Leung Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA Sarah Lévesque-Daniel CIUSSS du Nord-de-l’Île-de-Montréal, University of Montreal, Montreal, QC, Canada Cochin Hospital, Paris, France Rathi Mahendran Department of Psychological Medicine, National University of Singapore, Singapore, Singapore Claire Marshall Psychology, University of East London, London, UK Harry Minas Global and Cultural Mental Health Unit, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia

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Contributors

Yllka Krasniqi Morina Department of Psychology, University of East London, London, UK Marie Rose Moro Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Paris, France INSERM CESP, Paris, France Driss Moussaoui Department of Psychiatry, Ibn Rushd University Psychiatric Centre, Casablanca, Morocco N. K. Movsisyan International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic James Nazroo University of Manchester, Manchester, UK Samuel O. Okpaku Center for Health, Culture and Society, South Nashville, TN, USA Tejasi Pendse Centre for Health and Social Science, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India Adil Qureshi Servei de Psiquiatria, University Hospital Vall d’Hebron, Barcelona, Spain Rahmeth Radjack Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Paris, France INSERM CESP, Paris, France Raghu Raghavan Mary Seacole Research Centre, De Montfort University, Leicester, UK Guglielmo Schininá International Organization for Migration (IOM), Geneva, Switzerland Meryam Schouler-Ocak Psychiatry and Psychotherapy, University Psychiatric Clinic of Charité at St. Hedwig’s Hospital, Berlin, Germany N. Serre-Delcor Tropical Medicine and International Health Unit Vall d’HebronDrassanes, PROSICS, Catalan Health Institute, Barcelona, Spain Lillian Shundi School of Psychology, University of East London, London, UK Muthusamy Sivakami Centre for Health and Social Science, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India Thomas Stompe Psychiatric University Clinic, Vienna, Austria Ilaria Tarricone Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

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Kate Thompson Rakuba, London, UK Julio Torales Psychiatry, National University of Asunción, School of Medical Sciences, San Lorenzo, Paraguay Daniel Towns Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA Rachel Tribe School of Psychology, University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London, London, UK Aneta Tunariu School of Psychology, University of East London, London, UK Antonio Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy Cameron Watson Barts Health NHS Trust, London, UK Rajiv Wijesuriya London, UK Thomas Eliyahu Zanghellini International Organization for Migration – Regional Office for the EEA, the EU and NATO, Brussels, Belgium Bao-Liang Zhong Department of Social Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong Province, China

Part I Framework

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Introduction: Migration and Health Dinesh Bhugra, Antonio Ventriglio, Driss Moussaoui, and Rachel Tribe

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Migration and Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Abstract

Migration is a major social phenomenon in many parts of the world. It can have an impact on the mental health of individuals, families, and communities, and mental health workers cannot ignore it. Most of the time, migration is accompanied by difficulties such as cultural differences to understand and overcome, as The original version of this chapter was revised. The chapter was inadvertently published with an incorrect spelling of the author’s name as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. The correction to this chapter is available at https://doi.org/10.1007/978-981-10-23668_45 D. Bhugra (*) Centre for Affective Disorders, IoPPN, Kings College, London, UK e-mail: [email protected] A. Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy e-mail: [email protected] D. Moussaoui Department of Psychiatry, Ibn Rushd University Psychiatric Centre, Casablanca, Morocco e-mail: [email protected] R. Tribe School of Psychology, University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_1

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well as hardships relating to housing, employment, the schooling of children, and the difficulties of crossing borders. For some migrants, this might express itself through psychopathology such as depression, anxiety disorders, substance use, and abuse. Relationships between migratory status and psychosis are also seen. Special training for mental health workers, the appropriate and accessible design of services, and the adaptation of psychotherapeutic sessions are all needed for the best possible response to the mental suffering of some migrants. Keywords

Migration · Migrants · Schizophrenia · Refugees · Asylum seekers · Culture conflict

Introduction Ever since human beings emerged, we have always moved around migrating from one place to another for a number of reasons. In past centuries the migration was probably slower and took longer. With increased globalization and the interconnectedness it has been relatively easier for people to move migrate. In these days of globalization and rapid urbanization and industrialization in some parts of the world, it is inevitable that people will migrate within the country and across national boundaries. Stressors for the move between rural and urban areas or urban to rural areas will have similarities and differences with migration across countries and societies. Globalization also means that it is about the movement of people and resources. Manufacturing of the goods is in one part of the world, whereas the consumption is in another, and resources and raw materials for the manufacture are shipped from one part of the world to another. Furthermore with the spread of and increasing reach of social media globally has meant that people are even more connected and events in one part of the world affect other parts of the world much more rapidly and encourages fast responses. This has also contributed to a sense of restlessness. As communications are moving faster, the news does too, and there is very likelihood that all serious incidents get reported rapidly and exaggerated. Reasons for primary migration are many and include political, economic, and educational reasons. It is also possible that push and pull factors play a role. Moreover, people may move singly or in groups. It is important to make a clear distinction between migration, refugee, and asylum seeker status and experiences. It is also worth remembering that not all migrants move for the same reason or go through the same experiences; thus the actual process of migration is not a homogeneous one. It is inevitable that some migration experiences may be seen as adventurous and in a more positive way compared with others. Individual responses will be affected by a number of factors including individual’s personality, motivation for migration, and resilience as well as social support available to them in the new country. The actual reasons for migration and time available and used for preparation could work toward both as stressor and as support. It is highly likely that those who have migrated for personal educational or economic advancement may well be better

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motivated to succeed and thus make every attempt to adjust and settle down. On the other hand, those who may have been expelled or chose to leave due to political or persecutory reasons may not have any time to prepare for the purpose and may feel abandoned and hurt, thus feeling alienated in the new country especially if they are waiting for their asylum applications to be dealt with which may take years in certain circumstances. Thus they may find it difficult to adjust. The actual process of migration can be arbitrarily divided into three stages: premigration, migration, and post-migration. Inevitably they are not very clear or very discreet stages, and there is always a degree of overlap. The reason for clarifying these stages is to ascertain that there will be both common and variable stressors at each stage that clinicians need to be aware of. Premigration may be a stage where the individual has limited time to prepare for the departure and adjust and learn about the new culture and society. In cases of educational or economic migration, this will include applying for admissions or jobs and being prepared. In cases of political persecution or wars and disasters, there will not be enough time to prepare and migrate. The second stage of migration is the actual physical process of moving to the new culture, society or country, and environment. The third stage is that of post-migration which could be forever as the individual may take a long period of adjustment and acculturation. The number of migrants runs into millions around the globe as discussed in detail in subsequent chapters. It is difficult to get an accurate picture of internal migrants in a country as many people move in search of employment and a result of urbanization and industrialization.

Epidemiology There is considerable research evidence that migrant groups are more prone to certain psychiatric disorders. From the classic work of Odegaard (1932), studies across countries have demonstrated that some migrant groups are more prone to psychiatric disorders. Of these, schizophrenia has been studied most extensively, although recently rates of common mental disorders (CMD) have been reported (Kirkbride and Jones 2011). Although the association between common mental disorders and immigrant status is less clear than that for psychotic disorders (Lloyd 2006), some migrant groups do show higher rates of CMD when compared with other groups. For example, in the UK, a sample of Bangladeshi women in the UK reported lower rates of CMD when compared with Pakistani women who show much higher rates even if they were from the same subcontinent (Weich et al. 2004; also see Kirkbride and Jones 2011).

Migration and Schizophrenia As mentioned above, there have been a series of studies from the UK, the Netherlands, and elsewhere showing that rates of schizophrenia among migrants are 3–14 times higher among certain groups of migrants. These differences become even starker in younger generations. Various hypotheses for such huge variations have been put forward, and the commonest ones are social causation and social

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explanations (Bhugra and Bhui 2010). Selection and stress have been suggested as potential explanations. Cultural congruity has been put forward as a potential explanation too. One of the hypotheses is focusing on the discrepancy between achievement and aspiration which may make individuals feel let down by the system and add to the sense of alienation. This acculturation process can carry on across generations but needs to be examined further. Migrants and depression: The word depression carries means different things across cultures, but also in many languages, there are no words to explain depression, thus making cross-cultural comparisons somewhat distorted. In addition the actual question being asked and the research methodology being followed must be explored while making sense of the epidemiological data (Liu and Cheng 2011). Not surprisingly rates of trauma and consequent psychiatric disorders have been reported to be much higher than expected in refugees and asylum seekers (Fazel et al. 2005, Lindert et al. 2009). The duration of waiting period while asylum claims are being assessed has been shown to be related to levels of stress and resulting psychiatric morbidity especially CMD (Hallas et al. 2007). Stress of migration: In addition to the migration itself and its nature, it is also important that personality characteristics, healthcare systems, ideologies, commitments, aspirations, and role performance are taken into account because these may add to the stress (Shaw 1975). Also internal migration within the same country may carry with it some kinds of stress, especially when it is from a rural to an urban area. As in across countries migration, the changes in family structures, changes in support, and financial factors will all play a role. Moussaoui and Agoub (2011) emphasize that psychological resources may themselves in any given individual provide protection in all phases of migration. Furnham and Bochner (1986) have described eight theoretical constructs related to migration which are worth remembering. These include loss, fatalism (embedded in a sense of control), expectations of and from the new society, negative life events, and social support, along with the loss of or clash of values and skills deficit. All of these deserve to be assessed using various existing assessment tool so that the support systems and stressors can be worked out. Acculturative stress has been attributed to the experiences of acculturation (Ruiz et al. 2011). Acculturative stress can lead to decompensation and produce psychopathology in vulnerable individuals. This stress often goes under-recognized and may be misdiagnosed as clinical depression, whereas problems may simply be in adjustment. It is likely that some migrants may feel lost in the new culture but may also experience a sense of loss of all that was important to them, e.g., relationships, social networks, and specific objects, thus leading to a sense of bereavement and possible depression. These responses will depend upon support systems in the new country as well as individual personality traits. The ideas of self vary across cultures. This will affect cognitive schema as well as their world view. For example, refugees and asylum seekers may carry with them experiences of persecution and further alienation and isolation. A sense of entrapment may further contribute to depression (Gilbert and Allan 1998). Gender and gender roles: For women, migration may have specific impact. Trafficking is becoming an increasing problem. It is estimated 55% of trafficking victims around the world are women and girls. Women may well be a primary

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migrant, or they may follow male members of the family as dependents; thus the experiences of the three stages of migration mentioned above will be very different. After migration, they may feel isolated in the new culture more so if they are not allowed to move around or that the family control is so strong that they are not allowed to have an independent existence. As depression generally is more common in women across cultures, their vulnerability may be exaggerated further following migration. Gender role performance and gender role expectations may vary, and this discrepancy may well make women more vulnerable to depression and acts of selfharm. Chandra (2011) points out that the feminization of migration is increasing with globalization and work opportunities (especially in urban areas) and that women face additional stressors on their mental health. In addition, biological and endocrinal factors may also play a role. Responses to acculturation are also likely to vary across genders changing micro-identities. Poor economic security, lack of social networks and support leading to alienation and isolation, and lack of language skills may lead to women becoming more vulnerable to social stresses. Gender and gender role expectations will also affect children and adolescents as well as on child rearing. Female adolescents may feel additional pressure to conform getting caught in the culture conflict. Like their male counterparts but perhaps more likely, female migrants may get stuck in low-status low-paid jobs in spite of their skills again contributing to the discrepancy between aspirations and achievements contributing to psychiatric disorders. Women may get caught in the culture conflict. There are three types of reactions to migration which include culture shock, cultural bereavement, and culture conflict. Culture shock: Culture shock was used as a term to explain the shock experienced by some migrants after their move to the new culture (Oberg 1960) and looks at a number of areas of an individual’s functioning. Bock (1970) uses the term culture shock to describe an emotional reaction related to a lack of familiarity, which produces a stress reaction. It may have both negative and positive aspects to it. Culture shock may produce anxiety and feelings of helplessness and impotence which will affect the migrant’s settling as they may well see the new culture as not only remarkably different but also unwelcoming and alien. This alienation may produce further anxiety. In an unusual study from London, Pantelidou and Craig (2006) reported on 133 Greek students that the experience of culture shock was related to gender and quality (and degree) of support available. Culture shock did disappear over time. Not surprisingly high levels of culture shock were associated with high levels of dysphoria. Thus longitudinal studies are needed to explore the outcomes. As mentioned earlier, degree and availability of social support are critical in managing culture shock. Females tended to experience higher levels of culture shock, which may be related to gender and gender roles, both of which are social constructs likely to be affected by social and cultural factors. Individuals may manage culture shock through various factors such as educational, social, and economic ones. Individuals from higher social class may also experience shock when trying to deal with poverty or strange habits of individuals in the new country. Those who have high levels of education and may have high expectations of the new culture may experience low self-esteem and possible depression if these are not met. Culture shock may equally apply to the whole migrant group as well as at an individual level.

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Cultural bereavement: Like other types of bereavement related to loss, cultural bereavement is related to a series of losses experienced by the migrant individual as a result of migration. Eisenbruch (1990, 1991) described cultural bereavement as occurring in refugees as a result of loss of social structures, cultural values, and (cultural) identity. A key feature of cultural bereavement was described as strong and almost unnatural attachment to the past. It is possible that individuals may be idealizing and hankering after their past which never was and may also see the culture they had left behind as perfect and ideal when compared with the current and new culture. Eisenbruch (1990, 1991) reported that the “odd” experiences described by refugees included feeling guilty (at their own survival, at their abandonment of other loved ones or families), intrusive thoughts and images of their elders (ancestors) and their own past, and morbid thoughts along with anger. It is likely that refugees and those who have been forced to leave for political reasons or as a result of human disasters may experience and report cultural bereavement rather than those who choose to migrate for economic and educational reasons. An individual’s personality and whether they migrated alone will also play a role in the genesis and coping with cultural bereavement as well as with its consequences. Managing this grief will be important in clinical settings. It is important to recognize that Western constructs on bereavement may have only a limited value while trying to explaining expressions of grief and its management in non-Western cultures (Bhugra and Becker 2005). The migrant may experience physical losses and but also losses related to skills, social status, etc. which may produce a delayed reaction (Wojcik and Bhugra 2010). Culture conflict: Culture conflict is defined as tension and conflict related to cultural values between two members of the same culture and perhaps across generations but also between the migrant group and new culture. Some aspects of an individual’s cultural identity may become more rigid in the context of the migration experiences, whereas those who are born and brought up in the new culture may hold values of the new society. This tension between the two individuals with specific cultural values can lead to further altercations, leading to culture conflict. Of course, culture conflict can also occur between migrants’ (minority) culture and the broader culture. Holding traditional values in a more modern and less traditional society may contribute to alienation and conflict, especially if others hold less traditional values, leading to an element of culture conflict. Culture conflict is seen as a result of an affective and cognitive dissonance resulting from attempts to assimilate values of the new culture and reflects dilemmas experienced by the individual in trying to integrate two cultures which may hold extreme and differing views on a specific issue (Inman et al. 2001). Such conflicts will lead to emotional and psychological distress in both parties. Culture conflict has been shown to be related to deliberate self-harm among South Asian females in the UK (Bhugra 2004). Acculturation and culture conflict deserves better attention especially in third and fourth generations which may feel further alienated. Thus managing culture conflict in the context of family therapy takes on an important dimension. It can be challenging for the therapist’s world view and cultural values as well. Understanding acculturation and managing the acculturative processes and stress can be critical in

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managing culture conflict but also with cultural bereavement and culture shock. The conflict may produce a sense of isolation, alienation, and a sense of abandonment, producing depression.

Vulnerable Groups Other vulnerable groups who may show higher than expected rates of psychiatric disorders post-migration include: older adults, children and adolescents, and lesbian, gay, and transgender (LGBT) individuals. Each of these groups carries with them additional vulnerability factors. These include attitudes to aging and seeing older people differently across cultures and seeing certain sexual behaviors as illegal further contributing to stress. Refugees and asylum seekers may experience further wait, uncertainty, and alienation making them further vulnerable to stress and resulting psychiatric disorders. On the other hand, businessmen, film stars, and industrialists who migrate only for short periods but have material resources with them helping them to deal with certain kinds of stress but they may face other types of stressors and may have different responses. The typology and classification of migrants on the one hand and that of psychiatric disorders on the other make for a very complex interaction; and the heterogeneity of experiences and presentations must be remembered (see Fig. 1). Social factors: As already alluded to, social and economic factors are likely to play a significant role in the genesis of psychiatric disorders among migrants especially those which impact upon the individual’s functioning soon after arrival. Others may emerge after a period of stay in the new country. And it is at the latter stage that social and economic inequalities may come to play a bigger role in the genesis of psychiatric disorders. In the early stages of the migration phase, fundamental factors such as access to and success with housing, employment, and social support networks will influence acculturation and psychopathology. Housing: Poor housing in inner city areas and overcrowding with material poverty may contribute to the development of psychiatric disorders. Uncertainty of tenancy and the inability to purchase or rent suitable properties will place an additional burden on individuals, once again contributing to a discrepancy between aspiration and achievement. Employment: Migrants often end up in underpaid, difficult-to-fill jobs in unpopular areas and types which may well carry low status in spite of their superior educational attainments and skills. This discrepancy may further add to feelings of underachievement, thereby affecting self-esteem and leading to depression. Life events (especially negative ones) can lead to various psychiatric disorders. The act of migration itself can contribute as a life event and also contribute to other life events of loss and separation, thereby having a cumulative effect on the genesis of psychiatric disorders. Other social factors, especially perceived or real prejudice, discrimination, and racism in the new society, may well add to a sense of alienation and isolation as well as feelings of persecution, thereby contributing to the onset of psychiatric distress and disorders.

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Risk Factors

Personality

Protective Factors

Pre-Migration

Preparation

Genetic

Group support

Biological

Planned migration

Social skills deficit

Stable cultural identity

Negative events

Migration

Realistic expectations

Post-Migration

Social acceptance

Racism

Cultural bereavement Culture shock Culture conflict Discrepancy in

Psychiatric disorders

Aspiration/achievement Fig. 1 Interrelationship of factors leading to depression in migrants. (Modified after Bhugra 2003)

Migrants may not seek help from the professional healthcare sector for a number of reasons. They may have nonmedical explanatory models and may not understand the new healthcare system, thereby delaying help-seeking. They may be misdiagnosed, for example, because they do not see depression as a medical condition, even though they recognize its symptoms (Bhugra et al. 1997) or because they present with somatic symptoms. Cultural identity: Social and cultural identity is a crucial aspect of the individual’s functioning no matter what the surroundings are. All of us carry a cultural identity which may not be clear as often skin color gets confused with cultural being and values. Embedded within the whole cultural identity are factors related to a person’s unique cultural framework which makes one cultural group distinct from another. These factors include what has been described as micro-identities (Wachter et al. 2015) such as gender, religion, ethnicity, race, cultural attitudes, etc. Attempts at preserving these in the face of threat of integration and assimilation,

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perceived or real discrimination, and an unwelcoming environment in the new country or expectations of the new country may lead either to withdrawal or to an assertive or aggressive response. Cultural identity may work at both individual and group levels, thereby creating tensions which could contribute to culture conflict. As part of the acculturation, the individual may shed some aspects of their cultural identity with greater ease than others. It is entirely possible that the group identity may well prove to be more resilient and difficult to change. Acculturation is a complex period of adjustment to the new culture through direct or indirect contact and may lead to the individual giving up some parts of their cultural values or attitudes. These include what can be described as cultural expansion and cultural contraction which are discussed further in the chapter on microidentities. It is worth remembering that members of the same group and even of the same family may well undergo the process of acculturation at different speeds and varying levels, thereby creating tensions within the group and the family. Cultural identities can be misunderstood on both sides. Many psychiatric disorders are not well studied among migrants. It is worth recognizing that migration itself can be a major stressor and may contribute to mental illness, although it may appear years later as Odegaard (1932) reported. Clinicians must take into account the potential impact of migratory experiences related to cultural bereavement, culture shock, and culture conflict, which may also occur in such a longitudinal order. Furthermore, explanatory models and knowledge of the new healthcare system will determine when and how help is sought from and what sources are used for this purpose. In this volume, authors show that rates of mental illness among migrants and refugees vary. From high rates of psychosis shown among certain but by no means all groups indicate that there may be social factors which may explain some of the variations. Using detailed examples of Hispanic migrants to the USA and other migrant groups in Canada, Australia, and Europe, the authors suggest the role cultural formulation may play and also propose specific interventions related to these vulnerable groups.

References Bhugra D (2003) Migration and depression. Acta Psychiatr Scand 418(Suppl):67–72 Bhugra D (2004) Culture and self-harm: attempted suicide in South Asians in London, Maudsley monographs, vol 46. Psychology Press, London Bhugra D, Ayonrinde O (2001) Racism, racial life events and mental ill health. Adv Psychiatr Treat 7(5):343–349 Bhugra D, Ayonrinde O (2004) Depression in migrants and ethnic minorities. Adv Psychiatr Treat 10(1):13–17 Bhugra D, Becker M (2005) Migration, cultural bereavement and cultural identity. World Psychiatry 4(1):18–24 Bhugra D, Bhui K (2010) Schizophrenia in African-caribbeans; contributing factors. In: Bhattacharya R, Cross S, Bhugra D (eds) Clinical topics in cultural psychiatry. RCPsych Publications, London, pp 103–118

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Bhugra D, Baldwin D, Desai M (1997) Focus groups: implications for primary and cross-cultural psychiatry. Prim Care Psychiatry 3(1):45–50 Bock P (ed) (1970) Culture shock. New York, Alfred Knopf Chandra P (2011) Mental health issues related to migration in women. In: Bhugra D, Gupta S (eds) Migration and mental health. Cambridge University Press, Cambridge, pp 209–219 Eisenbruch M (1990) The cultural bereavement interview: a new clinical research approach for refugees. Psychiatr Clin N Am 13:715–735 Eisenbruch M (1991) From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med 33:673–680 Fazel M, Wheeler J, Danesh J (2005) Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet 365:1309–1314 Furnham A, Bochner S (1986) Culture shock. Routledge, London Gilbert P, Allan S (1998) The role of defeat and entrapment (arrested flight) in depression. Psychol Med 28:585–595 Hallas P, Hansen A, Staeher M et al (2007) Length of stay in asylum centres and mental health in asylum seekers: a retrospective study from Denmark. BMC Public Health 7:288 Inman A, Ladany N, Constantine MG, Morano CK (2001) Development and preliminary validation of the cultural values conflict scale for South Asian women. J Couns Psyc 48:17–27 Kirkbride J, Jones P (2011) Epidemiological aspects of migration and mental illness. In: Bhugra D, Gupta S (eds) Migration and mental health. Cambridge University Press, Cambridge, pp 15–43 Lindert J, Ehrenstein O, Priebe S, Mielck A, Brähler E (2009) Depression and anxiety in labour migrants and refugees. Soc Sci Med 69:246–257 Liu I-C, Cheng ATA (2011) Migration and mental health – an epidemiological perspective. In: Bhugra D, Gupta S (eds) Migration and mental health. Cambridge University Press, Cambridge, pp 44–55 Lloyd K (2006) Common mental disorders among black and minority ethnic groups in the UK. Psychiatry 5:388–391 Moussaoui D, Agoub M (2011) Risk and protective factors in mental health among migrants. In: Bhugra D, Gupta S (eds) Migration and mental health. Cambridge University Press, Cambridge, pp 98–106 Oberg K (1960) Culture shock, adjustment to new culture environments. Pract Anthropol 7:177–182 Odegaard O (1932) Emigration and insanity. Acta Psychiatr Neurol 4(Supp 1):1–206 Pantelidou S, Craig TK (2006) Culture shock and social support: a survey of Green migrant students. Soc Psychiatry Psychiatr Epidemiol 41:771–781 Ruiz P, Maggi IC, Yusim A (2011) The impact of acculturative stress on the mental health of migrants. In: Bhugra D, Gupta S (eds) Migration and mental health. Cambridge University Press, Cambridge, pp 159–171 Shaw RP (1975) Migration theory and fact: a review and bibliography of current literature. RSSI, Philadelphia Weich S, Nazroo J, Sproston K, McManus S, Blanchard M, Erens B, Karlsen S, King M, Lloyd K, Stansfeld S, Tyrer P (2004) Common mental disorders and ethnicity in England. Psychol Med 34:1543–1551 Wojcik W, Bhugra D (2010) Loss and cultural bereavement. In: Bhugra D, Craig T, Bhui K (eds) Mental health of refugees and asylum seekers. Oxford University Press, Oxford, pp 211–223 Wachter M, Ventriglio A, Bhugra D (2015) Micro-identities, adjustment and stigma. Int J Soc Psychiat 61:436–437

Further Reading Bhugra D, Bhui K (eds) (2018) Textbook of cultural psychiatry. Cambridge University Press, Cambridge Bhugra D, Craig T, Bhui K (2010) Mental health of refugees and asylum seekers. OUP, Oxford

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Bhugra D, Gupta S (2010) Migration and mental health. CUP, Cambridge Bhugra D, Ventriglio A, Bhui K (2019) Practical Cultural Psychiatry Oxford: OUP Bhui K, Bhugra D (eds) (2007) Culture and mental health: a comprehensive textbook. Hodder Arnold, London Helman C (2007) Culture, health and illness. Hodder Arnold, London Tseng W-S (2001) Handbook of cultural psychiatry. Academic, San Diego

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Migration, Globalization, and Mental Health Driss Moussaoui

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Migrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial Impact of Globalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Can Mental Health Workers Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Migration and globalization always existed and will always exist. Acceleration makes all phenomena take a path which is exponential. This means that the speed of change is speeding up. The “accelerated globalization” must be decelerated, because more power needs more responsibility and more ethics, individually and globally. The psychosocial consequences of this acceleration are good in some aspects (sense of being citizen of the world, better governance and democracy), but it clearly has bad aspects for almost all of us, especially the most vulnerable, leading to mental health problems, especially mood disorders. More research is needed in this field that is just at its beginning. Keywords

Migration · Globalization · Mental Health

D. Moussaoui (*) Department of Psychiatry, Ibn Rushd University Psychiatric Centre, Casablanca, Morocco e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_2

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Introduction A number of concepts are considered to be recent, such as stress or modernity. Stress always existed and will always exist, and modernity becomes rapidly a tradition, time going by. The same thing happens to globalization; most people think that it started in the second half of the twentieth century, while it existed in fact from the very beginning of human existence on earth. The core phenomenon of globalization is migration. It is well-known that all living beings migrate, including trees and plants through their seeds with wind and water. Animals are no exception, adapting themselves to various climates in order to live and prosper in as many ecological niches as possible. Homo species (Homo erectus, Homo faber, and Australopithecus) did the same, migrating millions of years ago inside Africa, where they appeared for the first time but also toward the rest of the planet (Meredith 2011). Genetic studies of various populations in the world confirm that the cradle of Homo sapiens lies with the Bushmen (San people) in South Africa, about 200,000 years ago. They migrated in waves toward the north, reaching the rift region of the Big Lakes. They then stopped in Ethiopia before continuing toward Egypt and the Middle East but also toward other North African Morocco and the Gibraltar straits. They after that expanded toward Europe, Asia/Pacific region, and the Americas. Aterian sites, dating back to 80,000 years, were found in North Africa, especially in Morocco (Balter 2011). Similarities in tools in the various sites in South and North Africa were particularly striking for paleoanthropologists. This means that migrating Homo sapiens transported in their voyage know-how, craftsmanship, and way of living from the southern part of Africa to the extreme north of the continent. It seems that the seven billion human beings on earth come all from a small group that lived in Ethiopia about 50,000 years ago who efficiently migrated to the rest of the planet. All other migrations before were less successful. We may then consider that successful migration is a survival component of life. In the midst of xenophobic campaigns all over the world, especially in Europe and now in the USA, it is of interest to remember that the first Homo sapiens who inhabited the Middle East but also Europe had dark skin, as opposed to the Neanderthal in Europe who lived at the same time and who was white; the Neanderthal disappeared about 40,000 years ago. To sum up, globalization concept, as used today, started very early in the history of mankind through physical migration but also through techniques and beliefs that accompanied the migrating persons. In this respect, studying trade routes and processes allows to better understand that the concept of globalization existed thousands of years ago. Silk Road is the most famous, going from China to the Mediterranean region. Other kinds of trade are less well-known: ivory, gold, and amber between Pharaonic Egypt and the Baltic region, for example. In the sixteenth and seventeenth centuries, imperial China built ships for trade that were ten times bigger than the Columbus caravels that “discovered” Central America. It goes without saying that religions, cultures, beliefs, myths, and manuscripts travelled with human groups from one part of the world to the other.

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The Christianization of the Native Americans is a good example of this. In another part of the world, in the eleventh century, a copy of book written by Avicenna or Razes in Central Asia/Persia could be found in Marrakech, Morocco, a few months later because of the importance of exchanges in the Muslim region, especially through Mecca pilgrimage. Again, this means that migration of persons was consubstantially accompanied by migration of goods and ideas. Migration must have two ingredients: survival need or curiosity on the one hand and courage on the other. As a matter of fact, individuals or groups of human beings had to confront very difficult routes and situations in order to find a better place to live, to trade, or to conquer. Often, it was a mixture of motivations that pushed migrants to travel: tough situation at home, desire to show one’s courage to family and society, hope of a better life, and desire to learn by travelling. The Troy war and the trip of Odyssey and his companions are a good illustration of such phenomenon, as well as the multiple trips of Vikings in the Atlantic and Mediterranean regions. The extraordinary maritime trips of the Maori from the Marquesas islands, conquering the entire Pacific islands, are also a good example. This is to say that migration transports also with it the image of heroes and continues to do so. Only the most courageous, smart, and able of the base community dare to start a journey into the unknown; hence, to come back without success is not an alternative and is synonymous of shame and social disqualification. This explains, to some extent, the reason candidates to migration are ready to die in the desert or in the sea in order to succeed in their migratory project. We can also say that military migrations and colonizations, that started at the end of the fifteenth century and peaked at the end of the nineteenth century, are definitely part of the process of globalization.

New Migrations The last two centuries have witnessed an extraordinary change, that is, acceleration of migrations, including goods, resources, ideas, and technologies. In the nineteenth century, colonization of Africa, Australia, India, and the Americas was boosted by the construction of big steam boats. For the USA, most migrants came from poor socioeconomic strata of Northern and Central Europe. In this respect, it is rarely mentioned that, at the beginning of the twentieth century, about a third of the population of Sweden migrated to other parts of the world, because it was one of the poorest places of Europe. Great Britain and France, as well as other countries in Europe, created huge empires by colonizing big portions of other continents. They also used and abused natives for their own interest (African slaves, soldiers during the two world wars, Maghrebian miners, etc.). The remarkable development of means of transportation (trains, ships, airplanes, cars, trucks, etc.) helped tremendously in achieving these purposes. Transportation machines became much bigger, much faster, and much cheaper over time, thereby contributing to rapid transit. The positive aspect of this is that travel became much more easy and more democratic, expanding horizons for all citizens of developed countries. At present, the

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number of persons who travel worldwide had never reached such magnitude in the history of mankind. The acceleration of the migration phenomenon is also shown through the switch from rural to urban areas. The estimate of United Nations is that 200,000 persons move each day from countryside to cities, 73 million every year. In other words, 54% of the world population lived in 2014 in cities, while this figure reached hardly 30% in the middle of last century. This increase will continue and will reach 66% in 2050 (United Nations, Department of Economic and Social Affairs, Population Division 2014). This is how megacities (Tokyo 38 million, Delhi 25 million, Shanghai 23 million, and Mexico City, Mumbai, and São Paulo, each with around 21 million inhabitants) became less and less of an exception. The existence of cities is a blessing and a curse at the same time. The positive aspect of big cities is the availability of more services (education, health, transport, culture, etc.) and anonymity. Their negative side is anomie, crowdedness, slums, pollutions of all kinds, infectious diseases, etc. impacting negatively on mental health of people. United Nations reported in its 2013 (United Nations, Department of Economic and Social Affairs, Population Division 2013) that there are 232 million migrants who settled in other countries, 41% of them living in developing countries. From 1990 to 2013, this represented a 50% increase, and the rhythm of growth of this phenomenon is steadily increasing. In other words, one person in seven of the total world population is, one way or another, a migration situation, and one out of three lives and works in a different place than the one of birth. It is also of interest to watch carefully the seasonal migrations, especially tourism. In 2014, some 1.18 billion tourists were touring the world (United Nations World Tourism Organization 2015). The religious tourism is a major sector of economic activity: Mecca receives 18 million tourists every year, and the Maha Kumbh Mela in Allahabad, India, on the Ganges river, gathered 120 million people in 2013 over. The most striking figure is given by the International Civil Aviation Organization which reported that 3.5 billion passengers took a plane in 2015, and the International Air Transport Association (IATA) expects that number to be 3.8 billion in 2016 (http://www.airspacemag.com/daily-planet/how-much-worlds-population-has-flownairplane). Travelling by plane was an 8-week period only, exceptional till the 1970s century, but became usual and even the rule nowadays. It is expected that the number of persons who would fly, if the growth continues as it is, will reach 18 billion people per year by 2050. We witnessed a huge increase of physical geographical movements, but the most important change happened with shared information. In a major city such as Casablanca, Morocco (five million inhabitants), one needed to ask directly the governor in order to obtain a regular phone line at the end of the 1980s. At present, there are 58 million phone subscriptions for a population of 34 million inhabitants in the country, half of the devices being smartphones with access to Internet. In the second half of the twentieth century, another major development was the extraordinary increase in the number of radio and TV stations; this allows everybody in the world, even in the remotest places, to listen to or to watch these channels through satellite dishes with rapid and ready access to news from around the globe.

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As a matter of fact, small villages in the mountains, which had no electricity, used car batteries to switch on their TV sets and satellite modems. Information starts to move at light speed from one part of the world to the other. Leguillant (1960), a French psychiatrist, adopted in 1960 the concept of “still migration” (transplantation immobile) to describe this new way of life. Still migration means that a person can travel by image or sound in other parts of the world without passport, without visa, without moving from one’s own home, and for very small amount of money equivalent to the electrical consumption of a TV or a radio set. This remarkable change became even more important with the creation and development of Internet in the 1990s of last century, especially through smartphones with their multiple applications. These computers are much more powerful than the very big and expensive ones of the 1970s. Not only they are powerful at computing, but they also allow each owner of a mobile phone to become a social actor, photographing an event and putting it instantly on social media networks which can then go around the world rapidly. Such kind of mass communication channels were decisive in throwing out a number of dictators in North Africa and the Middle East in 2011–2012 in the so-called Arab Spring. This promoted democracy, even if some revolutions led to tragic outcomes. This is why, still today, nondemocratic countries in the Middle East and Asia try to ban satellite dishes and to put Internet under strict control. On the other hand, some powerful democratic countries gather huge data on individuals and groups on Internet both overtly and covertly, with the pretext of fighting terrorism; the real aim of such big data collection is in fact economic, political, and military spying on friends and foes alike, inside and outside the country. The best example of acceleration is represented by YouTube (Fortune 2013). It was created in 2005, and 5 years later, the number of viewed videos was 62 billion; in 2013, this figure became 130 billion, with more than 100 h of videos uploaded each minute. To summarize, exponential growth is becoming the rule for all technologies, and it has necessarily an impact on mental and social functioning of individuals and communities.

Psychosocial Impact of Globalization The impact of globalization and “still migrations” on the minds of people is huge. It changed profoundly the way persons and communities perceive themselves, the way they work and interact in families and societies, and the way they deal with the world at large. There are a number of positive aspects to globalization. The first one is an increasing sense of being a citizen of the world beyond country borders. This is the case for ecological awareness, such as climate change, due to the swift information on what happens in the world in real time. More and more people think, rightly, that what happens in one part of the world impacts directly or indirectly on them and on the rest of the globe. The idea that we have only one earth, and that if we abuse it

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and make it sick, which will threaten the immediate future of mankind, is quite new. The trend is that the identity of human beings is still national but more and more global as well. Another positive aspect of globalization is availability of more goods for the neediest in the poorest countries, because of the steady decrease in prices. This allows better nutrition and health and better access to care. Life expectancy is increasing almost everywhere in the world. A number of impacts of globalization on mental aspects of individuals and communities can be described as follows: – Acceleration, cognitive functioning, mood, traditions, and technologies: with the invention of electricity and cars at the end of the nineteenth century, it changed the perception of time and space. Days became much longer than nights, and security improved with electric lighting in the streets. In a traditional Muslim society, an old lady stated: “With introduction of electric bulbs in houses, ‘jinn’ (spirits) were frightened and fled away.” Light in the middle of the nights chased away the fear of darkness and gave more sense of security. This is how one type of technology may change significantly traditional beliefs. For cars, distances shortened tremendously. Historically, a trip of King Louis XIV from Versailles to Paris necessitated a whole day at the beginning of the eighteenth century! In 1920, a car driven at 17 km/hour was considered to have a crazy speed. It is very clear that it is impossible to drive the same way one rides a donkey or a mule. The cognitive demand for the car driver is much higher, and the more a car is sophisticated, the more attention, vigilance, and concentration it needs to drive it safely. This is also the case for all other aspects of life, transport, information, shopping (more and more on Internet with virtual shops and markets), money management, work, etc., leading to an exponential growth of cognitive demand. And here, we are addressing social and mental acceleration. A remarkable work on the phenomenon of psychosocial acceleration was carried out recently by the German sociologist, Hartmut Rosa from Jena University (Rosa 2013). He described the speeding up of all social processes. Consumption is on the rise everywhere in the world. Even the poorest in the world ingest more food than ever before and even suffer more and more from obesity. For richer economic classes, the consumption of goods has increased and diversified in such a way that a significant part of what is bought (including food) will rarely or not be used at all. In order to buy more, people have to work more and are asked to be more efficient and more productive. This leaves less time to be with family and friends, to eat quietly (fast food is almost the rule), or to read. Everything must go faster and faster. People expect to receive replies to e-mails, SMS, or WhatsApp messages minutes later, and if not, they may call to know if something is wrong. The number of trips per year and per person, including international ones, is also on the increase. For example, half of the US population took a plane in 2015. This speed transformation affects even the language; instead of letters and long sentences, young people prefer onomatopoeia or emoticons sent through

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social media networks. In this respect, the impact of social media on the political life, including elections, is becoming a major trend as seen recently in the US presidential elections. Another aspect of globalization is the amazing development of international finance. In the 1980s, the Prime Minister of Italy visited the New York Stock Exchange and was appalled to notice that the equivalent of the annual budget of his country was traded in less than 10 min. At present, this same amount is traded by computers in a fraction of second. Worldwide, the amount of money invested by hedge funds is 750 trillion US$, representing three times the GDP of all countries in the world. This extraordinary amount of money, representing a huge power, is in the hands of few people only. Moreover, the equivalent of 5,000 billion US dollars switches daily from one currency to another in the world exchange market! All this creates a huge problem of governance; no government, including the USA and China, has enough financial clout to counteract the hedge funds whose aim is mostly speculative: money producing money. The consequence of that is fluctuation of prices of essential goods, such as food, energy, and other commodities, that is not necessarily in the best interest for the vast majority of human beings, especially the most vulnerable. The main aim of this acceleration process is to obtain more for less: more goods for less money, more information in less time, more trips in less days, more food with less exercise, more “friends” on social media instead of fewer friends in real life, etc. And human beings become more and more addicted to speed; they don’t even have time to think that another way of life is possible. The mental and social cost of this for individuals and communities is much more than anecdotal. The accelerated way of life, from the psychopathological point of view, looks like a hypomanic one. In mania, time flies, and on the opposite, perceived flow of time is very slow in depression/melancholia. This approach was well documented by the German and French phenomenologists in psychiatry (Ludwig Binswanger, Eugène Minkowski, Hubertus Tellenbach), especially in the book Le temps vécu by Minkowski (1995) or in the Melancholy by Tellenbach (1980). I remember that one of my severely depressed patients told me that, for her, 1 min lasted 40 h. According to the World Health Organization, burden of depression and other mental health conditions are on the rise globally (World Health Organization). The epidemiological surveys on the prevalence of depression in the general population conducted in the USA for three decades (Epidemiological Catchment Area, National Comorbidity Survey, National Comorbidity Survey Replication) show clearly a steady increase of the prevalence of depression (Robins and Regier 1991; Kessler et al. 2005). A reasonable question to ask then is: Is there a role of acceleration in the increase of occurrence of depression in the general population? On the same subject, what is the role of decrease of duration of sleep in almost all societies (about 1 h and a half in one generation)? The answer may come as a metaphor to help understand the dynamics of this situation: if a group of persons are asked to walk more and more quickly, day

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after day (look at the people going to their work in the morning in the metro/tube), than obliged to run more and more quickly, exhaustion will happen without the slightest doubt. With exhaustion, increasing number of walkers/runners will stop on the side of the road and will refuse even to walk. The acceleration we see in motion every day is most probably a risk factor for depression and even for other mental disorders. A subsidiary question is worth asking: all epidemiological surveys show a decrease in sleep hours worldwide, due in part to introduction of electricity in houses, especially the rural ones, and the multiplication of screens, especially TV and telephone sets. In the USA, a Gallup survey (http://www.gallup.com/poll/166553/ less-recommended-amount-sleep.aspx) showed a loss of more than an hour night sleep time from 1942 to 2013; it went down from 7.9 to 6.8 h sleep per 24 h. What is the relationship between this fact and the steady increase of prevalence of bipolar disorders in the general population as found in many countries of the world? – Cultural changes and technologies: another major psychosocial transformation in individuals and communities is the introduction of new cultural schemes through TV channels. It is interesting to see how US American, Mexican, Brazilian, Indian, or Turkish soap operas impact profoundly on the spectators in other countries, especially when translated into local languages. For members of a traditional conservative family, watching an episode where a girl refuses to marry a boy chosen by her parents or, as it happened recently in a Mexican series, two homosexuals kiss amorously each other, these behaviors are equivalent to a cultural earthquake. This kind of phenomena accelerates the process toward modernization of families and societies and leads to the emergence of an individually marked thinking, discourse, and behavior. A beautiful example of that is the story of the Afghani Nobel Prize (the youngest ever) winner Malala Yousafzai. Malala was very severely wounded by Taliban because she fought in Northern Pakistan for girls’ education. A female adolescent who dares to act against aggressive patriarchal misogynistic society is a complete cultural revolution in a traditional Muslim country. The evolution of status of women, children, and aged people is greatly impacted by the flux of images broadcasted through satellite TV channels, and this transforms in depth the way traditional families and societies function. – Political implications of globalization: globalization induces strong reactions, most of them leading to adaptation and sometimes to rejection. The use of social media for more democratization by toppling dictators has already been mentioned above. Another aspect of the interface between politics and globalization is reluctance and rejection. The more globalized culture conquers the world, with its sodas, jeans, fast food, malls, and arrogant stock exchanges, the more reluctance it encounters, and not only in poor countries. One of the examples is the strong emergence of Islamic fundamentalism in rich and poor Muslim countries alike. Another example is the recent Brexit that occurred, despite the economic loss for British people that may accompany the exit of the UK from the European Union (EU). This vote happened because the low and middle class in the UK considered that the EU (interestingly represented by the immigrants from the EU) is responsible for their economic hardship and rejected at the same time the dilution of British identity in the bigger

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landscape of Europe. Another example is the recent race for US presidency that shows how conservative white people think, in a very populist way; for them, the only manner to fight globalized invasion, including migration/terrorism and loss of jobs because of deindustrialization, is to bring back old specificities, including racism and contempt toward other nations. This is how President Donald Trump proposed to bar access of the country to 1.5 billion Muslims of the world and to build a wall of more than 3,000 km on the US-Mexican border. Another example, in the same direction, is the tremendous rise of extreme right parties in Western and Central Europe. All of them are against EU and aggressively nationalistic. Globalization highlights always the same equation: legitimacy of the specific, local, and national as opposed to global and universal. Another political aspect of globalization is about the perception of terrorism, especially in its new form Daech or ISIS. This terrorist organization uses very well new communication technologies to recruit fighters and to give its murderous activities maximum visibility all over the world. This leads to governments and people worldwide became deeply obsessed with this menace. For example, all governments put heavy constraints on visa acquisition and on travellers by plane in the world (3.5 billion people!), while most attacks are likely to happen in streets and public places, sometimes with limited means. Let us compare two figures: 13,286 people were killed in the USA by firearms in 2015, according to the Gun Violence Archive, and 26,819 people were injured (http://www.bbc.com/ news/world-us-canada-34996604). This is the equivalent of deaths by September 11, 2001, attack on the twin center every trimester of 2015! In comparison, in July 2016, CNN stated: “Since declaring its caliphate in June 2014, the selfproclaimed Islamic State has conducted or inspired more than 140 terrorist attacks in 29 countries other than Iraq and Syria, where its carnage has taken a much deadlier toll. Those attacks have killed at least 2,043 people and injured thousands more” (http://www.cnn.com/2015/12/17/world/mapping-isis-attacksaround-the-world). Needless to say, most of ISIS victims are Muslims. Henry Kissinger wrote in 2016 a book World Order (Kissinger 2016), showing that, in the USA, there were more persons killed due to allergy to peanuts than those who died due to Islamic terrorist attacks during the last decade. At the same time, 35,000 people died because of traffic accidents in the USA in 2015. Still, the universal perception today is that the main threat facing mankind is religious (mostly Muslim) terrorism, and this is due to the continuous highlighting of terrorist attacks on all TV networks. This threat, as Henry Kissinger stated, is “grossly exaggerated.” Needless to say, this list of psychosocial effects of globalization is by no means complete. The phenomenon of big data; the extraordinary developments in molecular biology, including nanotechnologies and interface between machines and brain; the environmental challenges; the greater place of robots in the future, including the “singularity” phenomenon; and the growing importance of virtual and augmented reality, and not only as a game, are all important to consider. The consequences of globalization are certainly interesting to study, but why would we, psychiatrists and other mental health workers, be in need of addressing

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such issue? What can we do practically to decrease the negative impact of globalization on individuals and communities?

What Can Mental Health Workers Do? (a) The first necessity is to recognize that globalization has indeed an impact on mental health of all of us, especially the most vulnerable. Globalization is not only for economists or politicians to lecture on. It has to be addressed by mental health professionals. The examples given above are illustrative of this fact. (b) A simple message is “slow down” whenever possible. It is extremely important for the mental health of all not to put oneself in danger because “time is money.” Speed kills, definitely, and not only with cars and traffic accidents. What is the real cost of lost health if all the time is spent to earn money? And what is the value of money without health? It is of essence not to be a slave of technologies and to master their effect. Replying to e-mails until late at night and when awakening early morning, having numerous “friends” on multiple social media, and being a multitask/ multifunction person permanently are all detrimental to health and mental health. Time can be a precious ally or a terrible foe. To take time for leisure and for significant others is a protecting factor for mental health. The slow attitude should become a motto for a better life, even if it is considered by others as laziness. (c) Migration from rural to urban areas is huge, especially in low- and middleincome countries. It is hence essential to strengthen family and social ties in all neighborhoods, especially the most vulnerable; this is the way to apply prevention from mental disorders. Social workers and other mental health workers can do their best to fight anomie that is known to be a risk factor for depression and suicide (Durkheim 1897), especially through community psychiatry. Another aspect of mental health is noise, which is detrimental when it is excessive, and this is the case in cities, especially the poorest ones. Having more silence in cities is good for mental health. In 1983, Herbert von Karajan stated in a speech given at UNESCO “One day, silence will become one of Human rights.” (d) Work mental health: having time for one self in workplaces is best understood by successful international companies. Well-being of employees leads to better productivity. Some of these companies have even gyms, playing rooms, or a place to nap during working hours. The possibility of working at a distance should also be considered for some employees. This list of suggestions is in no way complete. Globalization is changing dramatically our lives, and mental health workers need to do their best to dampen its bad effects. Each situation must be analyzed and solutions found together with those concerned.

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Concluding Remarks Migration and globalization always existed and will always exist. It is a very old reality that gains momentum year after year. Acceleration makes all phenomena take a path which is exponential. This means that the speed of change is speeding up. The best metaphor of this situation is like driving a car that has an increasingly powerful engine without upgrading the brakes; the accident is inevitable if we do not change the terms of the equation. The “accelerated globalization must be decelerated, because more power needs more responsibility and more ethics, individually and globally. The psychosocial consequences of this acceleration are good in some aspects (sense of being citizen of the world, better governance and democracy), but it clearly has bad aspects for almost all of us, especially the most vulnerable. The question is on the table to know whether accelerated migration/globalization is or is not a major risk factor for mental health, especially mood disorders. More research is needed in this field that is just at its beginning.

References Balter M (2011) Was North Africa the launch pad for modern human migrations? Science 331:20–23 Dastugue J (1962) Paléopathologie. In: Ferembach D, Dastugue J, Poitrat Targowla MJ (ed) La Nécropole Épipaléolithique de Taforalt (Maroc oriental). Edita-Casablanca, Rabat. Éditions du CNRS, Paris, pp 133–158 Durkheim E (1897) Le suicide. P.U.F, Paris Fortune, European edition, August 12, 2013 Kessler RC, Chiu WT, Demler O, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:617–627 Kissinger H (2016) World order. Penguin Press, London Leguillant L (1960) Psychopathologie de la transplantation. Concours Med 82:3429–3440 Meredith M (2011) Born in Africa, the quest for the origins of human life. Jonathan Ball Publishers, Johannesburg. 230 p Eugène Minkowski (1995) Le Temps vécu. Étude phénoménologique et psychopathologique, 1933, Delachaux. PUF-Quadrige, Paris. ISBN https://fr.wikipedia.org/wiki/Sp%C3%A9cial:Ouvrages_ de_r%C3%A9f%C3%A9rence/2-13-046991-4 Robins LN, Regier DA (eds) (1991) Psychiatric disorders in America: the epidemiologic catchment area study. The Free Press, New York Rosa H (2013) Social acceleration: a new theory of modernity. Columbia University Press, New York. 496 p Tellenbach H (1980) Melancholy; History of the problem: endogeneity, typology, and clinical features. Duquesne University Press, Pittsburgh United Nations, Department of Economic and Social Affairs, Population Division (2013) International migration report 2013 United Nations, Department of Economic and Social Affairs, Population Division (2014) World urbanization prospects: the 2014 revision, highlights (ST/ESA/SER.A/352) United Nations World Tourism Organization (2015) World tourism rankings World Health Organization. http://www.who.int/mediacentre/factsheets/fs369/en/

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Internal and International Migration and its Impact on the Mental Health of Migrants Guglielmo Schininá and Thomas Eliyahu Zanghellini

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration: Definitions and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration and Vulnerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration and Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Right-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some Effective Actions to Promote Migrants’ Access to Mental Health Care . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter describes the facts and figures of today’s migration patterns and briefly presents the limits and findings of the existing research on the impact of different forms of migration on the mental health of migrants. The article aims at promoting a right-based approach to migrants’ access to mental health care, as supported by international legal instruments. Since this right is at times disregarded due to the legal unavailability and factual inaccessibility for migrants of the existing mental health services, the article proposes a series of actions that could facilitate migrants’ access to mental health care across health systems and countries.

G. Schininá (*) International Organization for Migration (IOM), Geneva, Switzerland e-mail: [email protected] T. E. Zanghellini International Organization for Migration – Regional Office for the EEA, the EU and NATO, Brussels, Belgium e-mail: [email protected]; [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_3

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Keywords

Mental health · Migration · Migrants · Refugees · Mental illnes · Psychosocial support

Introduction An estimated one billion migrants live in the world today, including those who migrate within their county or internal migrants and those who migrate between countries or international migrants (IOM 2016a). This figure makes populations’ mobility one of the defining issues of today’s global anthropology. Certain migration paths provoke extraordinary vulnerabilities and stressors to the migrants, as it is the case for minors who travel unaccompanied (Jensen et al. 2014); refugees and internally displaced people (IDP) (Salah et al. 2013) escaping from wars, conflicts, natural disasters, and famine; forced migrants (Siriwardhana and Stewart 2013); and those who end up in exploitative situations (Zimmermann et al. 2006) or in detention (Robjant et al. 2009). Most migratory paths, however, are not as obviously vulnerable, as it is for foreign students, migrant workers, transnational families, domestic workers with regular contracts, and most of those who move inspired by an upward social mobility objective. Migration in general and vulnerable migration in particular are considered a determinant of poor mental health. This general assumption is rooted in the “unhealthy migrant myth” (Cattacin 2010) and in the global tendency to manage migration as a “risk,” but it is not consistently supported by the evidence. The research’s reliability in the domain of mental health of migrants is hampered by many factors including the different definitions of a migrant in various countries, which make comparative analysis nearly impossible, methodological biases, and the unrepresentativeness of samples (Knipper and Bilgin 2009). The existing research, however, seems to support the fact that victims of trafficking (Oram et al. 2012), migrant detainees (Robjant et al. 2009), and asylum seekers and refugees (Mann and Fazil 2006) are more at risk than the general population to certain mental disorders, including depression, anxiety, and psychotic disorders but the variance between the results of the different studies does not allow to draw definitive conclusions and regards a comparatively small number of people. In any instance, the supposed higher or lower vulnerability of migrants to mental disorder is not substantial in validating the need to promote migrants’ access to mental health care. According to the Constitution of the World Health Organization (WHO 2006) and the International Covenant on Economic, Social and Cultural Rights 1966 (OHCHR 2016), health, including mental health, is a fundamental human right, irrespective of race, gender, age, religion, political views, and socioeconomic conditions. Mental health care is therefore a fundamental right of all migrants, and yet migrants, especially the ones in irregular situations, are often excluded from mental health care, either because the relevant services are not legally available to certain categories of migrants or because language and cultural barriers, lack of outreach and information, and stigmatization of mental health problems make the available mental health

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services factually not accessible for migrants (Devillé et al. 2011). The exclusion of migrants from mental health care hampers one of their fundamental rights, and this alone should suffice to promote all migrants’ inclusion in mental health systems. This chapter will describe some of the key facts and figures of today’s migration patterns and briefly present the research on psychopathology of migration, with its limits and its findings. It will then recommend a series of actions that irrespective of the type of health care and migrants’ inclusion systems applied in a country can facilitate migrants’ access to mental health care. The article will do so mindful of the importance to consider the mental health needs of migrants in the organization of the health, social, and educational systems of origin and return, transit, and destination countries but conscious that a default association between migration and mental illness not only is not consistently supported by evidence but would also risk to validate biased policies and narratives that look at migrants as “risks,” “problems,” and “burdens” for the social care and health-care systems of the host countries (Schininá et al. 2011), which are unmotivated and often unethical.

Migration: Definitions and Figures Consistently with the International Organization for Migration’s (IOM) relevant definition, in this chapter a migrant is considered as “any person who is moving or has moved across an international border or within a State, away from his or her habitual place of residence, regardless of the person’s legal status, whether the movement is voluntary or involuntary, what the causes for the movement are, or what the length of the stay is” (IOM 2016b). This umbrella definition includes individuals that enjoy different sets of rights and have different life paths and is in line with definitions proposed by the International Federation of the Red Cross and Red Crescent Societies (IFRC) (IFRC 2016) and the United Nations High Commissioner for Human Rights (UNHCHR) (Al Hussein 2014), but it has been criticized by the United Nations High Commissioner for Refugees (UNHCR), since it includes asylum seekers and refugees under the definition of a migrant. According to UNHCR, this can risk to associate refugees to the mainstream negative perception of migrants and to put into question the special set of rights that refugees are entitled to (UNHCR 2015). If this definition does not find consensus among all intergovernmental organizations (IO), the situation becomes even more fragmented at the national level. A universal definition of migration that is consistently adopted in all countries worldwide does not exist (OHCHR 2012). Quite to the contrary, the definition of a migrant varies between countries, institutions within the same country (Devillé et al. 2011), and international and national laws (Blinder 2013). This has tremendous implications on the rights of migrants, their access to health and mental health services, and on the more specific domain of the research on mental health of migrants. The populations included in research on migrants differ from a study to another, complicating analysis and comparisons (Anderson and Blinder 2015). In addition, it is not universally clarified when a migrant ends to be a migrant (Devillé et al. 2011). From one side, the protracted identification as migrants of people who are residing in a new country or location can be stigmatizing. On the

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other side, for some, the definition of migrants should be extended to look beyond the generation that has moved from one residence to another. Although the term “second-generation migrant” is for many a contradiction in terms (Kobayashi 2008), the health and integration challenges of the direct descendants of migrants are sometimes greater than those of the people, who migrated (Ingleby 2011; Gushulak et al. 2009; WHO Regional Office 2018). The IOM estimates that roughly one billion individuals in the world are migrants, which correspond to the 14% of the global population and include both internal and international migrants (IOM 2016a). Data on international migrants are generally more available and reliable than data on internal migrants, which has to do with the fact that regular international movements are easier to trace than those within a country. According to international statistics, the number of international migrants reached 244 million in 2015, up from 222 million in 2010, and 173 million in 2000, demonstrating a progressive increase in populations’ mobility (UNDESA 2015). This number, however, does not include all those that migrated irregularly and have not been identified and is, as such, underestimated. Nearly two thirds of all international migrants live in Europe or Asia, and women comprise slightly less than 50% of them. Female migrants outnumber male migrants in Europe and Northern America, while in Africa and Asia, particularly Western Asia, migrants are predominantly men. The median age of international migrants worldwide was 39 years in 2015, and it has remained almost the same for over two decades (IOM 2016a). The majority of international migrants live in so called high-income countries, and 65% of them originate from middle-income countries. The 10% only comes from low-income countries, suggesting that most international migration is the result of an upward social mobility objective rather than driven by severe vulnerability. In many parts of the globe, migration occurs primarily between countries that are located within the same region-area, with the exception of migrants coming from South and North America and the Caribbean (IOM 2016a). Particularly vulnerable international migration paths are the ones of refugees and asylum seekers, and a direct correlation exists between migrants’ well-being and their experiences of detention. A refugee as defined by the UNHCR would be a person “who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it” (UNCHR 1967 p. 14). In 2015, there were 20 million refugees in the world (UNDESA 2016). An asylum seeker is an individual who has claimed refugee status but has not been granted this status yet. In many countries in the world, irregular international migration is criminalized, and large numbers of international migrants spend time in prison or detention due to their irregular status only (COE 2010). In some countries, even asylum seekers and refugees have to spend some time in detention, before being regularized (Nakache 2011; Amnesty International 2012).

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Detaining migrants based on an irregular status only is questionable for ethical, human rights, political, and financial reasons (IRIN 2015). In 2015, an estimated 5,400 international migrants died or went missing during their movement. About 3,770 of these casualties occurred in the Mediterranean. This figure is however likely to represent a small, dramatically evident proportion of the number of migrants that die during their trip in search for a better life on land, at borders, and in deserts (IOM 2016a). The data about internal migrants are less elaborated because internal migration is not consistently surveilled. The estimated 740 million internal migrants in the world (UNDP 2009) encompass a variety of populations including seasonal workers, those who move from the countryside to the urban centers, those who move from the province to the big towns, students, and many others (ILO 2010). Urbanization is constantly rising and will be a global challenge in the coming years (ILO 2015). In 2015, 27.8 million individuals were internally displaced (IDMC 2016), roughly the equivalent of the populations of New York City, London, Paris, and Cairo combined. Of those, 8.6 million had to flee conflict and violence in 28 countries, and 19.2 million were displaced due to natural disasters in 113 countries, in the same year (IDMC 2016). The most-affected country was Yemen, where 2.2 million individuals – or 8% of the population – had to flee their homes (IDMC 2016). As in previous years, the South and East Asia and the Pacific regions faced the largest internal displacement associated with natural disasters. Low- and middleincome countries were most affected across the world as a whole (Bilak et al. 2016). Particularly vulnerable migration paths, both in terms of internal or international migration, are those of victims of trafficking and of children who migrate without their parents or caregivers, usually called unaccompanied or separated minors. A victim of trafficking is an individual, who has been convinced to migrate either internally or externally with false information, kidnapping, through the use of force or threat, or the abuse of his/her state of vulnerability for the purpose of being exploited sexually, in domestic servitude or as a workforce in different industries. In the most concerning situations, people can be trafficked for organ removal and trade (OHCHR 2000). A rough estimate reports that around 700,000 people are trafficked every year (IOM 2016c), but data are not conclusive. Only a small percentage of victims of trafficking is identified and assisted every year. In 2015, the victims assisted through IOM were nearly 7,000 in 115 countries (IOM 2016). Unaccompanied minors are understood to be children, who have been separated from both parents and other relatives and are not being taken care of by an adult who would be responsible to do so by law or custom (IOM 2011). “Separated children’ are children, who have been separated from both parents, or from their previous legal or customary primary caregiver, but not necessarily from other relatives. These may, therefore, include children accompanied by other adult family members” (IOM 2011 p. 2). In 2014, more than 23,000 asylum applicants in the European Union alone were registered as unaccompanied and separated children (IOM 2015). These statistics and numbers give an idea of the scope of today’s migration trends but are not fully able to describe the variety and diversity of migration paths and populations. Under the same figures, a constellation of individuals with different

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legal and life course patterns endures, including refugees and asylum seekers but also labor migrants, cyclic or seasonal workers, foreign students, foreign domestic workers, intercontinental and interregional migrants, mobile and travelling populations, victims of trafficking, unaccompanied and separated children but also irregular migrants, transnational families, and maritime workers, among others (OECD 2015). Nowadays, the diversification of migrant populations is immense, fed by the general increase of the world population, the spread of mass communication and the consequent easier access to information (GCIM 2005), an increased access to cheaper means of long-distance transportation, the global transformations of the labor market, and inequalities that mass communication makes more blatant (Calhoun et al. 2005).

Migration and Vulnerability Especially after the 1980s, at least in Europe, certain factors of the new migration, including an increase in flows from other continents and regions, the increase in arrivals from developing countries or countries in distress, as it was for migrants from East to West Europe after the Berlin Wall fall (Fiddian-Qasmiyeh et al. 2014), and finally the impossibility to control movements with the consequent increase in irregular movements, have brought to a default association between migration and vulnerability. The perceived vulnerability of migrants encompasses the perception that migrants are less healthy than the resident populations and even a potential threat to the public health systems of the receiving countries (Neumann 2014). According to Cattacin et al. (2006), this has not always been the case. Until the 1980s, migration in Europe was mainly characterized by movements of low-skilled laborers from the south to the north within and between countries. In that period, migrants were widely perceived as strong and emotionally stable, due to their willingness to take risks and face challenges for an upscale social mobility objective. Their health was assessed at the borders, and, in many countries, being diagnosed with certain disorders lead to an immediate expulsion. This contributed to the formation of the “healthy migrant” myth (Chimienti and Achermann 2007). During and increasingly after the 1980s, however, the “healthy migrant” myth has evolved into the “unhealthy migrant” myth, whereas migrants are considered not only vulnerable to health problems but also a public health threat as carriers of diseases (Kaya and Efionayi-Mäder 2007). In the field of mental health, since the 1990s, the general discourse on vulnerability of migrants has been semantically characterized by “trauma” narratives, whose pertinence is clinically and sociologically questioned by many critics (Papadopoulos 2002; Summerfield 2001). In reality, nowadays safe and vulnerable migration processes coexist, but the latter only monopolize the political and social discourse on migration. In terms of health vulnerabilities, it is difficult and probably wrong to draw a direct cause and effect relation between migration and specific pathologies (Conféderation suisse 2006). According to the WHO, the exposure of refugees and migrants to the risks associated with population movements increases their vulnerability to some noncommunicable diseases, including psychological disorders, reproductive health

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problems, higher newborn mortality, drug abuse, nutrition-related disorders, and alcoholism (WHO 2016). For most experts, however, being a migrant is not to be considered as a health-risk factor in itself, and each migrant’s vulnerability to a disorder has to be considered as the result of a combination of genetic, social, economic, political, and administrative factors (Kaya 2007) and individual and family lifestyles (Lindert and Schininá 2011). Looking at systems, evident are the negative effects that the hazards of unsafe travels and the conditions of life and work of certain categories of migrants, as well as the administrative procedures related with immigration in transit and receiving countries can have on the health of a migrant (Kaya 2007), which has brought some to advocate for the consideration of migration as a social determinant of health. Davis et al. (2006) state that migrants are affected by social inequalities, which increases the likeability for them to experience risks to their physical, mental, and social well-being, in countries of destination and transit (Davis et al. 2006).

Migration and Mental Illness Migration in the last two decades has been often associated with psychological and emotional vulnerabilities, either resulting from the “trauma” experienced by the migrants in the past (Kaya and Efionayi-Mäder 2007) or their difficulties in adapting to a new culture and way of living in absence of preexisting support networks and significant relational ties in the new country (Loue and Sajatovic 2009). According to the WHO, mental health is a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO 2014). Looking at this definition, it is true that migration can pose serious threats to the mental health of migrants. Migrants are indeed facing stressors that are at times abnormal, which regard the reasons that brought them to decide to leave, the conditions of travel and reception in the new countries, and the adaptation to the new situation (Bhugra and Becker 2005). Migrant’s conditions of work in many instances risk to be exploitative and unethical (ILO 2009), especially for irregular migrants, who work under the table and do not enjoy regular contracts and workers’ rights (ILO 2009). Migrants’ contribution to their community is made difficult by the proliferation of communities to contribute to, which include the community back home, the host one, and the migrant community in the host country, with their different expectations, functioning, and set of values (Bhugra and Becker 2005). Moreover, some host communities do not enable all migrants to fully contribute and at times proactively exclude them, due to stigma, prejudice, and punitive administrative procedures (Merritt 2015). Finally, despite their best intentions, migrants may not be in a position to demonstrate their full potential, due to administrative limitations, stigma, and brain drain and de-professionalization (OECD 2016). These factors are political, administrative, sociocultural, and sociorelational in nature and can build on preexisting socioeconomic and psychological vulnerabilities. These various stressors can bring to negative psychological outcomes, including anxieties, toxic stress, sadness, a sense of rebound, anger,

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maladaptation (Potochnick and Perreira 2010; Kirmayer et al. 2011), or what Renos Papadopoulos calls nostalgic disorientation (Papadopoulos 2015). The answer to the question whether these negative psychosocial factors and related emotional outcomes make migrants more vulnerable to mental disorders is still inconclusive. First, the heterogeneity within results of the existing research is wide (Kaya and Efionayi-Mäder 2007), which highlights how evidence is hampered by the quality of sample size and selection and the reliability of the tools adopted. The populations included in research on mental health of migrants vary from study to study, making it difficult to derive comparative or generalizable data and to conduct comparative reviews (Lindert and Schininá 2011). Most of the research is not longitudinal; it is based on self-reports or checklists rather than clinical interviews and focusses on the same set of disorders (anxiety, depression, PTSD, and psychotic disorders) (Selten and Hoek 2008). A part from the lack of exploration of other possible clinical outcomes, some critics envisage problems with the pathological categories used, as they are based mainly on a western understanding of mental illnesses and mental health (Knipper and Bilgin 2009). Finally, the way studies are designed makes it difficult to correlate specific pathologies with forms of migration, socioeconomic conditions of migrants, and contextual factors and sectors of employment (Carta et al. 2005). The limitations of conducting mental health epidemiological research on migration are, however, objective. Migration is a global phenomenon, and the definition of migration encompasses often incomparable life paths, causes, destinations, populations, industries, genders, and age groups. Analyzing all these correlations can provide a structured vision of the mental health problems at stake, but statistical cross-analysis of these data is nearly impossible and not central in the design of efficacious response programs. Moreover, being able to derive differential epidemiological data on migrants from national surveillance systems becomes impossible as soon as a migrant enjoys the same set of health rights of the resident population and is therefore not registered separately (Devillé et al. 2011) – something that, regardless of its impact on epidemiologic research, is nevertheless to be advocated. These limits in research withholding, existing studies tend to confirm that certain categories of migrants are more likely to develop certain mental disorders than the resident population, but generally speaking, migrants are not that different from the general population. PTSD is mainly studied in the context of asylum seekers and refugees (Gojer and Ellis 2014). Most studies confirm a higher prevalence of PTSD among these two categories than in the resident population and the other migrant populations, excluding victims of trafficking. PTSD as a syndrome has been however under scrutiny for many years, and some scholars and professionals arrive to consider it a clinical invention without validity (Summerfield 2001 and Eisenbruch 1991). It is certainly true that the variance of prevalence of PTSD across populations and contexts have called in recent years for a revision of the relevant symptomatology in the main diagnostic manuals (APA 2013), which makes most prior research obsolete. There has been some debate about overdiagnosis of PTSD, especially in crisis settings (Brunet et al. 2007). The results of most research however confirm a direct link

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between disruptive events experienced in the past and limitations to the functionality of a minority of affected individuals in the present moment, to various degrees of severity (Lindert and Schininá 2011). A significant correlation between different forms of migration and depressive disorder is confirmed by various studies with different migrant populations, conducted in different host countries in various periods of time, such as Mexican migrants in the USA (Breslau et al. 2011), over 50 years old migrants in Germany (Aichberger et al. 2012), different migrant populations in Central Asia (Ismayilova et al. 2014), and in Turkish, Portuguese, Somalian, and Tamil migrants in Switzerland (Schweizerische Eidgenossenschaft, Department des Inneren 2010). Moreover, relatives left behind by migrants were found more likely to develop depression than other populations in China (Lu et al. 2013) as well. Most studies correlate or associate depression in migrants to stresses related with the adaptation to the new context, lack of social supports, and marginalization. Bhugra and Goldberg (2003) attribute the causes for depression in migrants to a combination of biological, psychological, social, cultural, and environmental factors (Bhugra and Goldberg 2003). Even if less present in the general discourse on migration and vulnerability, a consistent and more valid body of research confirms a higher risk for psychotic disorders in migrants than in the resident populations. In their meta-analysis and review of relevant studies (1973–2003) on prevalence of psychotic disorders in various migrant populations in Denmark, the Netherlands, and the UK, CantorGraae and Selten (2005) conclude that a personal or family history of migration is an important risk factor for those. Tortelli et al. (2014) confirm these results for Sub-Saharan populations in France and refer to studies reaching similar results in England, Italy, Norway, and Sweden for other migrant populations. Hollander et al. (2016) studied the prevalence of psychotic disorders and other non-affective psychoses among refugees and non-refugee migrants from the Middle East and North Africa, Sub-Saharan Africa, Asia, and Eastern Europe in Sweden. In the study, refugees result more at risk of psychotic disorders: (126.4/100,000), than non-refugee migrants (80.4/100,000) and resident populations (38.5/100,000) This is a study with 1,300,000 participants compared with non-refugee migrants from the same regions of origin and the native-born Swedish population and using a sound research and statistical model (Hollander et al. 2016). Bhugra and Jones (2001) identify few possible causes for migrants’ vulnerability to this disorder, including (1) higher rates of psychotic disorders in the countries of origin, (2) more predisposition to migrate in people with psychotic disorders, (3) the fact that migration brings to stressors that can facilitate the manifestation of psychotic disorders, and (4) misdiagnoses due to cultural misunderstandings (Bhugra and Jones 2001). These hypotheses need to be unfolded. It is not true that sending countries have always higher rates of psychotic disorders, even though sometimes they enjoy very poor mental health surveillance systems in general, which make baseline data unreliable. Moreover, results do not hold for the same populations across different host countries, hinting that the most relevant determinant is the process of integration in the new country, and not provenience, nor the act of migrating in itself (Tortelli et al. 2014; Cantor-Graee and Selten 2005). The results

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of studies (van der Ven et al. 2014; Cannon et al. 2010) on the selective migration hypothesis (Ødegaard 1932), according to which people predisposed psychotic disorders are more predisposed to migrate, disconfirm this hypothesis and again hints at the stress of adaptation as the determining factor (van Os et al. 2010). As for misdiagnoses, the seminal studies on the case of Caribbean migrants in the UK (Selten and Hoek 2008; Morgan et al. 2010) and other relevant studies (Cantor-Graae and Selten 2005; Bourque et al. 2010) tend to confirm that some migrant populations in determined contexts are more prone to peculiar manifestations of psychotic disorders, which may be related with cultural norms, religious elements, and the different value given in different cultures to the concept of possession, and can remain a challenge for the western diagnostic system and defined psychopathologies (Hollander et al. 2016; Bhugra et al. 2011; VersolaRusso 2006). These differences can indeed bring to misdiagnoses. It is worth noting that while the rates of psychotic disorders in migrants are higher in statistical terms than the ones in the general population in some studies, in general terms this problem regards an extremely small part of the surveyed migrant populations. In the study from Hollander et al. (2016) that was already presented, the difference in prevalence of psychotic disorders was of less than 50 persons every 100,000 migrants, that is, the 0.005% of the population. There are specific categories of migrants that are more prone to develop mental disorders than other migrants and the general population, including victims of trafficking and migrant detainees. Ottisova et al. (2016) conducted an updated systematic review of 37 studies on prevalence and risk of violence and physical, mental, and sexual health problems among victims of trafficking. The researches included in the review focus primarily on female victims of trafficking trafficked for sexual exploitation, with very few studies including men and children or victims exploited in other industries. All studies, irrespective of gender and profile of the population and geographical region, confirm a very high prevalence of symptoms suggestive of anxiety, depression, and post-traumatic stress disorder (PTSD) and of psychotic disorders in men. While it is true that the wide heterogeneity within results for each mental disorder between studies puts into question investigation methods and in particular quality of sample size and selection, thematic focus, and reliability of the tools adopted, the general trend is quite clear (Ottisova et al. 2016). Studies looking at causal correlations found that sexual abuse and physical violence, longer duration of trafficking, and post-trafficking stressors (poor social support and greater unmet needs) independently predict mental disorder post-trafficking (Abas et al. 2013; Kiss et al. 2014; Oram et al. 2012). Another group at risk are unaccompanied and separated minors. Even though this is a highly diverse group (ethics, upbringing, etc.), studies show that they are prone to develop symptoms of PTSD (Huemer et al. 2013) and for emotional and behavioral problems (Bronstein et al. 2012) higher than in normal population and accompanied minors. In addition, several studies show that detention has a negative effect on migrant’s mental health. Robjant et al. (2009) in a systematic review of 10 studies with different detained migrant populations found that anxiety, depression, PTSD, selfharm, and suicidal ideation were commonly reported in all studies and time spent in

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detention was positively associated with severity of distress. Steel et al. (2005), in a study aiming to investigate the longer-term mental health effects of mandatory detention on refugees concluded that past immigration detention contributed to risk of PTSD, depression, and mental health-related disability. Also in this study, longer detention was associated with higher prevalence of mental disorders, which persisted for an average of 3 years after release. Kotsioni et al. (2013) and Bacon et al. (2010) all found a direct correlation between detention of migrants, refugees, and asylum seekers and worsened mental health state.

A Right-Based Approach In synthesis, research on migrants and mental illness is technically weak and probably not entirely ameliorable due to objective difficulties. The existing research hints to a higher vulnerability of certain categories of migrants to certain mental disorders, but it is not conclusive, and the analyzed difference regards, in any case, a very small part of the population, for severe mental disorders. Moreover, the same research seems to confirm that the determining factors of migrants’ vulnerability to these disorders are linked with the process of integration and its social aspects, including unnecessary and often arbitrary detention. Certain migratory experiences which expose migrants to sexual and political violence, exploitation, and detention are associated with a higher vulnerability to mental disorders. Those experiences, in fact, equally affect the mental health of migrants and nonmigrants but are likely to be more frequent among migrants. In all cases, nothing in research substantiates that migrants are less vulnerable than residents to mental disorders. Mental health is a need of migrants as much as it is a need of nonmigrant populations. More importantly, mental health, as any forms of health, is a right of migrants as well as it is a right of nonmigrant populations. A consistent body of international legal instruments supports all migrants’ right to mental health care, starting from the International Covenant on Economic, Social and Cultural Rights (WHO 2008). Other instruments enunciate the right of specific categories of migrants to mental health care and psychosocial support, as it is for VoT (UN-GA 2000) and separated and unaccompanied minors (UNHCR 1997). More recently, the UN Human Rights Council readdressed the issue of mental health needs and care within a human rights framework, promoting legal access for everyone (UN-GA 2016). Prevalence studies, in this framework, are useful if they aim at improving quality and diversity of services and facilitate access. However, the very design of most studies is not really conducive to this objective and is actually aimed at justifying the need to offer mental health care to migrants. It is true that this research may be used to promote the application of the right, substantiating it with a need. On the other side, it risks to become functional to the current public discourse and national social and access policies on migration that, from the 1980s on, have progressively transformed migrants from subjects to objects and from objects to “abjects.”

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The transformation of migrants from subjects to objects is embedded in what Vanessa Pupavac calls the “therapeutic governance of societies” (Pupavac 2001). She posits that in the last decades, representative democratic societies and ruling political classes have understood governance in terms of risk management rather than participation and strategy. This approach would seem to question or at least minimize the value of democracy, and it has been hampered by ideological presumptions and vested interests in the identification and prioritization of the risks that “need” to be managed, but it has gone largely unquestioned. Pupavac does not link the therapeutic governance of societies to migration governance. Yet since therapeutic governance is strictly linked with the act of defining categories based on vulnerabilities and manage them in terms of risk, it is all too easy to see how this connects to the way migration governance has been approached in the last decades and how this approach is connected with prevalence studies on mental disorders in migrants. In addition and progressively, migrants have been transformed from objects to “abjects.” Bulgarian philosopher Julia Kristeva defined the abject as neither an object nor a subject but as an entity that was radically excluded by our symbolic order of meaning to allow the intersubjective community to persist – the opposite of the object of desire (Kristeva 1982). In this sense the abject has to do, in her words, with “what disturbs identity, system, order. What does not respect borders, positions, rules” what highlights the “fragility of the law” and marks the eruption of the “real” into our lives (Kristeva 1982). We are attracted and repelled by the abject because we are attracted and repelled by “death’s insistent materiality” and from being confronted with concrete images and events that traumatically show us our own temporal and symbolic limits as individuals and as a society (Kristeva 1982). Because of their abjectization, migrants lately have become significant for us only if they are dead or if they suffer in the act of migrating. The suffering of the “abject” tends to be understood in terms of trauma and mental disorder. In reality vulnerable migrant’s presence makes us question our very symbolic and social order because migration displays all the horror that, as a society, we have tried to exclude, in order for us to persist, such as poverty, war, injustice, and pandemics. The migrant traumatizes us by reminding us that this horror still is, and therefore we call the migrant traumatized, because the migrant is indeed the carrier of the trauma he/she provoke to us and our ordered society with the testimony of the persistence of the abject and of our own temporal and symbolic limits. This paradox lies at the center of the ongoing migration debate; the very suffering of the migrant is the only reason that makes us finally look at a migrant as more than a category, more than an object, but also the main reason why we reject him or her. Prevalence studies, even when they are done to support migrants’ right to mental health care, risk to reinforce these narratives, especially when services are then not available or accessible to migrants or they are generally stigmatized. To be effective and ethically sound, the general focus on mental illness of migrants should switch from a need-based to a right-based approach. This right for migrants is often overlooked. In many countries not all migrants have right to health care, with mobile populations and irregular migrants always falling out of the existing system (EYD 2015). Even in those countries where primary health care is

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available for all, migrants’ legal right to access secondary and tertiary health-care services is not granted or complicated by specific administrative procedures, and this is where most mental health services are located (Keith and van Ginneken 2015). Even when the legal right is granted, problems of outreach, information, language, cultural relevance, stigma, and education make those services often inaccessible for migrants (Morris et al. 2009). Switching to a right-based approach would mean to look at these obstacles to create diversity oriented and inclusive systems, and research at this point would be population and service specific, looking at ways to operationalize migrants’ right to mental health care rather than aiming at substantiating the need of it, which should be given for granted.

Some Effective Actions to Promote Migrants’ Access to Mental Health Care A right-based approach to the provision of mental health care for migrants brings to the search for modalities that can make mental health services legally available, factually accessible, and technically efficacious for migrants. A series of recommendations that could facilitate availability, accessibility, and efficaciousness of those services are presented below to conclude this chapter. Since mental health care in countries of origin is mainly offered at the secondary and tertiary care level, it is important to promote or advocate for policies and procedures that grant to all migrants access to primary, secondary, and tertiary health services and not only to primary one. As migration and integration can create major stressors and most mental disorders in migrants are correlated with social problems in the integration phase, mental health and mobility considerations should be mainstreamed in all the concerned systems: the educational, the social care, the health care, the religious, the security and law enforcement, and the community services ones. This can take the form of capacity building of different professionals and of integrated models of service. There is no doubt that migration is a feature of today’s citizenship, and since the psychopathology of migrants does not differ substantially from the psychopathology of nonmigrant populations, segregated mental health-care services for migrants are not to be advocated, while the existing services need to be potentiated for all and be made migrant friendly. Often migrants have problems in accessing existing services due to a number of reasons including a lack of information and understanding of mental distress, using different idioms of distress, and stigma; it is important that outreach to different migrant communities should be envisaged in forms that are linguistically and culturally appropriate and efficacious. This can include the creation of capacity among volunteers from the various migrant and host communities. Since talking therapies dominate western therapeutic models, language barrier creates an obstacle in providing psychotherapy to migrants. Mental health services should always consider interpretation and training for interpreters among their core functions, especially those services in high migration areas. Moreover, mental health

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has to do with what is acceptable or unacceptable behavior in a culture and a community, and as such the understanding of cultural differences is essential to achieve good therapeutic results and avoid misdiagnoses when therapists and clients come from different cultures. In this respect, the formation of cultural or mental health mediators coming from migrant communities and capacitated in absolving this function has proved efficacious in many countries. In contrast, since migrant communities are multiple, the cultural mediator model may become unsustainable in many cultures. In addition, due to multiple subcultures in a culture, cultural mediation can at times in itself lead to stigmatizing. The management of cultural diversity in the help and therapeutic relation should in any case be made part of the training curricula for psychiatrists, clinical psychologists, clinical social workers, and nurses, especially in countries of high immigration. In this respect, research should switch from a purely and generic focus on prevalence, to the “systematic enquiry into (. . .) culturally appropriate indicators of social, vocational and family functioning, which will allow clinicians to recognize problems in adaptation and undertake mental health promotion, prevention or treatment interventions in a timely fashion” (Kirmayer et al. 2011) and in research that help defining different understanding of psychosocial functioning in different cultures ad contexts to tailor appropriate responses. All this could help operationalizing migrants’ right to mental health care, avoiding coincidentally, that migrant’s mental health needs are used to “objectify” them in terms of risk and to concur to their progressive objectification.

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Micro-identities and Acculturation in Migrants Antonio Ventriglio and Dinesh Bhugra

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Micro-identities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Cultural identity is a core aspect of individual’s personality. These identities ensure that cultural factors are carried wherever migrants go, and as part of acculturation, some of the aspects may well change and alter for both positive and negative purposes. The individual identity affects interactions with others. Group and individual identities may well interact with each other. However, often the micro-identities embedded in the cultural identity are ignored. These micro-identities are related to gender, religion, sexual orientation, etc. Some of

The original version of this chapter was revised. The chapter was inadvertently published with an incorrect spelling of the author’s name as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. The correction to this chapter is available at https://doi.org/10.1007/978-981-10-23668_45 A. Ventriglio (*) Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy e-mail: [email protected] D. Bhugra Centre for Affective Disorders, IoPPN, Kings College, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_4

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these identities such as sexual orientation can be hidden when required, whereas others such as gender cannot generally be hidden. An interaction between the micro-identities held by the clinician will interact with those of the person who is seeking help contributing to therapeutic alliance or making it difficult to do so. Clinicians need to learn as part of cultural competence the importance of micro-identities in interactions. Cultural identity changes in response to acculturation which is defined as the process by which one individual from one culture changes his/her attitudes and subsequently his/her behavior in response to coming into direct or indirect contact with another culture. Some of these characteristics in identity are easy to change, e.g., dress, language, and food, whereas others such as religious taboos and religious rituals are perhaps more difficult. In this chapter the authors present concepts related to microidentities. Keywords

Micro-identities · Acculturation · Migration

Introduction As human beings we all carry our cultural identities no matter where we go. The identity is important for a number of reasons. The identity allows us a degree of belonging whether it is in kinship or in group. There are various components of identity. The individual self is at the core of human existence. This self is very strongly influenced by the culture we grow up in and also how different factors play a role in helping us develop as individuals. It is well-known that the concepts of the self and the way it is identified are very strongly influenced by the culture within which an individual is born and they grow up in and where they live and work. Two rather primitive concepts of the self are egocentric or sociocentric. It is likely that these aspects of the self will have at their core a major identity which probably is less susceptible to change and shift. People’s concepts of others depend upon cultural factors. However, it is worth noting that the perceptions of one’s self by the others may also differ. In this chapter we highlight the development and existence of micro-identities which get influenced by external cultural factors. The identity of the individual is both self-defined and externally validated. And this identity depends upon a number of factors such as gender, religion, sexual orientation, profession, and other factors. “Who am I?” defines an individual that is a result of complex thoughts, patterns of behavior, and actions. Equally importantly the identity of the individual is influenced by how others see the individual. Individuals respond to how the others see them and them seeing the other in a complex interaction, thereby creating a valid identity and consequent relationships. The development of the identity occurs across one’s life span and does not stop at any given point. The changes in micro-identities thus carry on across the age of the individual.

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Identity The way individuals identify themselves depends upon a number of factors. Berry (1990, 2007) highlights that cultural identity is at both an individual and a group level in the context of acculturation. Identity often has been seen in the context of race, ethnicity, social group, or nationality. Cochrane (2001), while talking of ethnic identity, highlights that no one is born with an intact sense of self and who they are. At an individual level, using models developed in studying large companies, Hofstede (2001) describes egocentric/sociocentric, masculine/ feminine, uncertainty avoidance, distance from power center, and long-term orientation as dimensions of cultures. However, it must be emphasized that not all members of the same culture are alike and are not likely to have the same characteristics. Individual identity is the cultural concept of the self. The psychological concepts of the self may be influenced by psychoanalytic, behavioral, or cognitive aspects, and the cultural or anthropological self is affected by culturally determined worldview. There is a distinction between the person and the self (Harre 1983; see Morris 1994 for detailed discussion). Western philosophers since ancient times have developed and described these concepts. Mauss (1979) describes that forms of the self vary across times and places and goes on to suggest that a concept of the self is evident across all communities. However, he draws a distinction between the sense of self, the conscious personality, and the concept of the self, and the latter he attributes to social categories. All human beings have an awareness of their self, their bodies, and the spiritual or metaphysical aspects of their being even if it is not related to organized religion. Interestingly Mauss (1979) points out that over the centuries human beings have moved from sociocentric concept of the person to a more egocentric one. In the sociocentric times, the membership of the clans was important. This shifts from sociocentric being or persona to the notion of the person as an autonomous human subject. Mauss concludes that the concept of the individualized self is a notion that has developed historically. This becomes relevant both in the ideas of cultural expansion/contraction as well as development of micro-identities in response to social factors.

Acculturation Acculturation is the process by which one individual from one culture changes his/her attitudes and subsequently his/her behavior in response to coming into contact with another culture. Berry (2007) points out that as part of the acculturation process, individuals have to deal with the question: “Who am I?” There is no doubt that this question has many dimensions (such as age, gender, social class, religion); acculturation relates to cultural dimensions of the question. Considerable research (e.g., Berry 1999; Liebkind et al. 2016; Phinney et al. 1992, Phinney and Baldelomar 2011) has demonstrated a complex pattern of thoughts, attitudes, feelings, and social

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interactions that make up a person’s cultural identity. This complexity is particularly evident during the course of development (Beiser et al. 2015; Motti-Stefanidi et al. 2012; Umaña-Taylor et.al. 2014), and it can be argued that the process of acculturation has fairly similar parameters although often it may not take as long to change cultural identity. Within the process of acculturation, it is one’s cultural identity that is influenced and altered as a result of exposure to values of another culture. The process of acculturation in a way brings two cultures, their values, attitudes, beliefs, and practices. These two views may be similar or very different, and previous knowledge of the new culture may indeed hamper or facilitate the process. Furthermore during intercultural contact which may be direct or indirect, the individual adapts certain norms and may abandon others, thus creating a space which is largely comfortable so that individuals move in and out of two cultures. Cultural identity involves, at its core, a sense of attachment or commitment to a cultural group. This commitment is social, cultural, and psychological. These interactions with microidentities produce an interesting mix which can be ascertained and analyzed and explain the cultural levels of variations. It must be recognized that cultural identity is not static and is not rigid responding to situations and other external influences in different ways. Berry (2007) points out that acculturation requires the existence of a cultural group, which can be actual and viable at present, remembered from one’s past, or imagined in one’s future. Thus relativist values of two cultures as well as universalist values will produce some aspects which will be easily malleable, whereas others will not. In this context we suggest that two types of responses may occur. These are cultural expansion and cultural contraction. Cultural expansion means that the individual will pick up values, attitudes, and behaviors from another culture whether it is at a psychological and social level or at cultural level. Similarly cultural contraction means that the individual may give up some parts of their own cultural identity which may not be very deep-rooted and may not be seen as essential in defining their identity.

Micro-identities Each individual has a cultural identity, but embedded within the broad notion are several micro-identities. For example, an individual may have Punjabi identity (whether it is from the Indian Punjab or Pakistani Punjab, both of which will have same language and diet but different scripts and religions), but they would have an identity related to their gender, their religion (Hindu, Sikh, Muslim, or Christian), their sexual identity and sexual orientation, and their professions and jobs. These will also include identities of where they trained and where they were educated and where they work. For example, studying in Punjab University and working in Lahore will have some distinct differences in studying in Punjab

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University and working in Ludhiana. Thus these identities may well vary in spite of commonality of geographical origin and broad cultural identity. Social identity is a person’s acknowledgment of belonging to a social group or category where its members possess a common social identification and observe their surroundings with an identical perspective (Hogg and Abrams 1988, p. 7). Social identities are linked to social structures (Burke 2004, p. 6). Often in clinical and research settings, micro-identities such as gender or religion are used in epidemiological bases, and micro-identities which may also be locality based are ignored completely. However, micro-identities embedded within the self and actually forming part of the self will be more amenable to change. We believe that the importance of microidentities and the role these may play in adjustment and acculturation have been neglected and deserve further consideration in research questions. We feel that a debate is needed in psychiatric circles to understand individual variation in spite of common diagnoses in psychiatric disorders but also to put down a marker for psychotherapeutic as well as psychopharmacological interventions in the context of these micro-identities. Another reason for studying micro-identities is that often people choose to hide one part of their identity and “pass off” as someone else. This could be reflected in hiding sexual orientation in some settings whereas exaggerating this in others or not emphasizing their religious affiliations. Passing off as “the other” also allows individuals to deal with potential stigma they may face in other microidentities. For example, it has been shown that male sex workers when faced with stigma use (micro-) identity management in managing stigma related to prostitution (Browne and Minichiello 1996). These men may select “sex as work” option which can separate their male/masculine identity from sex to work. They may define themselves as professionals and entrepreneurs who offer a valuable and welcome service (Browne and Minichiello 1996; McLean 2012). They may thus create boundaries between personal sex and work sex. As mentioned above, individuals may choose “passing” to hide their work or may choose to tell some friends as “covering” and/or use other options of hiding or exposing parts of their identity (Koken and Bimbi 2014). Therefore, different aspects of the same identity are divulged or shared with selected individuals (perhaps too carefully) with selective information. Such an approach in other walks of life is also well-known and well described. These actions and these identities therefore have a role to play in the individual’s social functioning and social identity. Micro-identities may also be a part of locality living. Thus a particular street or small geographical area may have an impact on individual facets of social identity. Identity is not static and can change in response to a number of factors, varying from education, growing up, or migration. These changes may be temporary, such as changing hairstyle, or permanent, such as tattooing. Clearly the most obvious facet of identity is physical, but it is the internal world which plays a key role. Not all women will have a feminist view of the world, and not all will have short hair or

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piercings. After migration, as part of acculturation, individuals may choose to expose some micro-identities but not others, and this may allow them to find a level of comfort in the new society which enables them to settle down. Often a major reason for such “passing off” is about dealing with stigma and discrimination. It is well recognized that stigma against an individual based on their mental state, religion, gender, or sexual orientation can probably cause more damage, especially as religion and orientation may not always be too obvious. Thus one way of managing and dealing with perceived stigma is either to hide those aspects of individual identity completely or expose them to confidants and people one can trust (Wachter et al. 2015). The role of micro-identities in mental health and psychiatric fields needs to be explored and developed further and understood in the individual cultural context especially among migrants. For example, an individual who has a homosexual orientation and has sexual dysfunction and is also a migrant may internally feel stigmatized and may choose to hide his/her sexual orientation, whereas it may be difficult to hide the migrant status or other way. They may not be experiencing the same level of stigma as a physically disabled and obviously hallucinating mentally ill individual will. Therefore micro-identities become important in our understanding of what the individual may be experiencing and what they may be hiding and what parts of their identity they may choose to show. Thus it is relevant that any stigma-busting programs take these into account and perhaps become more sophisticated in dealing with micro-variations and how different levels of stigma affect these micro-identities and how these micro-identities contribute to stigma. For example, homophobia or Islamophobia will need to be seen in that specific context. Morris (1994) very eloquently describes the perceived distinction between Western concepts of the person (with Cartesian mind-body dualism) or stereotypically egocentric, advanced, and superior and the Eastern concepts of holistic, sociocentric, and traditional (perhaps inferior). The focus of the identity is in the body, but other aspects of micro-identities need to be explored and understood and dealt with. Another complicating factor in the identity formation is that in the end Western notions may be more materialistic and rationalistic. The self-structure within Western culture (assuming it is all homogenous) has been widely described as individuated, detached, separate, and self-sufficient (Morris 1994, p. 16) and, as noted above, may well have emerged as a result of social changes. A dualism between the mind and the body and between the self and the other leading to a sense of autonomy emerges in this context. Micro-identities may thus affect certain aspects of the individual and not others. The demonstrated evidence that the rates of deliberate self-harm in South Asian women are nearly three times those of their white British counterparts have been suggested to reflect gender roles and gender role expectations as well as culture conflict (Bhugra et al. 1999a, b, Bhugra 2004). Within this context, what these women understand as their real self and their micro-identities become important in our understanding of their experiences which psychiatry and psychiatrists have often ignored.

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Conclusions We all carry multiple identities, and at different times, places, and occasions, we use these identities to affirm as well as confirm who we are and our existence. It is important that in clinical settings when faced with patients whether they have migrated or not, clinicians must focus on specific micro-identities to engage with them, especially in the context of psychotherapy, self-assertion, and self-esteem. There is no doubt that self-management of identity is a crucial part of psychotherapy, whether it is part of the pharmacological management or individual psychotherapy. We need to develop better research tools to identify and measure micro-identities, especially in the context of mental illness across different cultures so that specific interventions can be put in place.

References Beiser M, Puente-Duran S, Hou F (2015) Cultural distance and emotional problems among immigrant and refugee youth in Canada: findings from the New Canadian child and youth survey. Int J Intercult Relat 49:33–45 Berry J (1990) Psychology of acculturation. In: Brislin RW (ed) Applied cross-cultural psychology. Sage, Newbury Park, pp 232–253 Berry JW (1999) Aboriginal cultural identity. Can J Nativ Stud 19:1–36 Berry J (2007) Acculturation and identity. In: Bhugra D, Bhui KS (eds) Textbook of cultural psychiatry. Cambridge University Press, Cambridge Bhugra D (2004) Culture and self-harm: attempted suicide in south asians in London. Psychology Press, London Bhugra D, Desai M, Baldwin DS (1999a) Attempted suicide in West London, I. Rates across ethnic communities. Psychol Med 29:1125–1130 Bhugra D, Baldwin DS, Desai M, Jacob KS (1999b) Attempted suicide in West London, II. Intergroup comparisons. Psychol Med 29:1131–1139 Browne J, Minichiello V (1996) The social and work context of commercial sex between men: a research note. J Sociol 32:86–92 Burke PJ (2004) Identities and social structures. Soc Psychol Q 67:5–15 Cochrane R (2001) Race, prejudice and ethnic identity. In: Bhugra D, Cochrane R (eds) Psychiatry in multicultural britain. Gaskell, London, pp 75–90 Harre R (1983) Personal being: a theory for individual psychology. Blackwell, Oxford Hofstede G (2001) Culture’s Consequences: Comparing Values, Behaviors, Institutions and Organizations across Nations. Sage, Thousand Oaks Hogg M, Abrams D (1988) Social identification: a social psychology of intergroup relations and group processes. Routledge, London Koken J, Bimbi D (2014) Mental health aspects of male sex work. In: Minichiello V, Scott J (eds) Male sex work and society. Harrington Park Press, New York, pp 223–240 Liebkind K, Mähönen TA, Varjonen S, Jasinskaja-Lahti I (2016) Acculturation and identity. In: Sam DL, Berry JW (eds) Cambridge handbook of acculturation psychology. Cambridge University Press, Cambridge, pp 30–49 Mauss M (1979) Sociology and psychology (trans: Brewster B). Routledge & Kegan Paul, London McLean A (2012) New realms, new problems? Issues and support networks in online male sex work. Gay Lesb Issues Psychol Rev 8:70–81 Morris B (1994) Anthropology of the Self. Pluto, Cambridge

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Motti-Stefanidi F, Berry JW, Chryssochoou X, Sam DL, Phinney J (2012) Positive immigrant youth adaptation in context: Developmental, acculturation, and social psychological perspectives. In: Masten A, Liebkind K, Hernandez D (eds) Capitalizing on migration: The Potential of immigrant youth. Cambridge University Press, Cambridge, pp 117–158 Phinney JS, Baldelomar OA (2011) Identity development in multiple cultural contexts. In: Arnett Jensen L (ed) Bridging cultural and developmental approaches to psychology: new syntheses in theory, research and policy. Oxford University Press, New York, pp 161–186 Phinney J, Chavira V, Williamson L (1992) Acculturation attitudes and self-esteem among school and college students. Youth Soc 23:299–312 Umaña-Taylor AJ, Quintana SM, Lee RM, Cross WE, Rivas-Drake D, Schwartz SJ, Syed M, Yip T, Seaton E, Ethnic and Racial Identity in the 21st Century Study Group (2014) Ethnic and racial identity during adolescence and into young adulthood: an integrated conceptualization. Child Dev 85:21–39 Wachter M, Ventriglio A, Bhugra D (2015) Micro-identities, adjustment and stigma. Int J Soc Psychiatry 61:436–437

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Cultural Capital and Acculturation in Migrants Dinesh Bhugra, Cameron Watson, Rajiv Wijesuriya, and Antonio Ventriglio

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Levels of Cultural Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Cultural capital has been described in the context of education and educational achievements. Every individual, no matter which culture they belong to, carry with them cultural capital which consists of three sources – objective (comprising of books, works of arts, music and cultural goods, etc.); embodied (consisting of language, preferences, etc.); and institutionalized (qualifications, educational, and training credentials). Cultural capital, although different from economic, social, educational, and political capitals, may have a degree of overlap. Migrants after

The original version of this chapter was revised. The chapter was inadvertently published with an incorrect spelling of the author’s name as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. The correction to this chapter is available at https://doi.org/10.1007/978-981-10-23668_45 D. Bhugra (*) Centre for Affective Disorders, IoPPN, Kings College, London, UK e-mail: [email protected] C. Watson Barts Health NHS Trust, London, UK R. Wijesuriya London, UK A. Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_39

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migration tend to adjust to the norms and more of the new culture in what has been described as process of acculturation. Results of acculturation can be assimilation, biculturalism, and deculturation. Cultural capital is an essential component of acculturative processes. In this chapter, we hypothesize that strength of their own culture and cultural capital may contribute to acculturative responses. It is likely that some components of cultural capital are more likely to change than others.

Keywords

Migration · Acculturation · Culture · Cultural capital · Migrants · Social capital

Introduction Migration is one of those human activities which is universal and has been going on for millennia. Migrants move with their cultural values and inherent cultural attitudes. There is no doubt that cultures form us and influence our worldview, thinking, and social development. Cultures influence the way we form relationships and bring children up, our religious upbringing, values, and behaviors. Individuals are born, play, learn, work, and live in a culture thereby acquiring various aspects of their cultural capital. We are not born with a culture, and throughout one’s life, these cultural values form us all. Cultures, whether they are the ones we live in or work in, give us a sense of security and belonging. Having different physical appearances due to ethnicity or race with different colors of skin, hair, and shape of facial characteristics create a sense of identity on the one hand, but also a sense of “the other” especially if one is in a minority. This development of “the other” can question one’s own identity which may have certain specific cultural components. Culture can be seen as a way of life because often that is all we know but in an interconnected world, cultures are changing shape readily. For example, watching American television programs has influenced people in many countries to speak English with an American accent and using American spellings, grammar, and idioms. Culture creates intergenerational continuity through observation of a broad range of behaviors and values which are thus consciously or unconsciously transmitted across generations. Folk tales, fairy tales, arts, music, folk songs, etc. all tend to mold our minds according to the cultural messages they are given. Cultural capital is formed of these values and needs to be differentiated from social capital which is defined as bonds between individuals based on a common identity (immediate family and friends), bridges (formed of connections between acquaintances and distant friends), linkages (related to peers, colleagues, employers, and others), and a sense of belonging and purpose. Economic capital will be associated with economic and work-related assets. Educational capital includes training, qualifications, and skills attributed to educational attainments. Culture in the work place will influence economic capital whereas culture in educational institutions will

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Table 1 Components of cultural capital 1. Objective components

2. Embodied

3. Institutionalized 4. Others

Books Art Music Fairy and folk tales, literature, poetry Language Diet Dress Training Qualifications Subcultural Technical skills Emotional, e.g., empathy National, e.g., stereotypes and caricatures

inculcate values which may be unique to that particular institution. These types of capitals will also contribute to micro-identities of the individual (Wachter et al. 2015). The concept of cultural capital was first described by Bourdieu (1984) in the 1970s based on the notion that cultural capital differs from economic capital in assuring social status to the individual. Cultural capital was described by Bourdieu as an individual being familiar with the legitimate culture within a particular society. According to Bourdieu, cultural capital has three sources – objective (exemplified by books, music, arts, paintings, folk tales, etc.); embodied (which includes language, preferences, mannerisms, etc.); and institutionalized (these comprise of qualifications, educational, and training credentials). These could also be seen as major components of cultural capital, which therefore, has cultural, economic, and educational components. More additions have been made to this concept by including technical (marketable skills); emotional (empathy); national (national characters or stereotypes which may well lead to stigmatizing caricatures) along with subcultural (see Thornton 1995; Bennett et al. 2008; Holden 2010). Cultural capital thus consists of a number of components (see Table 1) and every individual will have these – some to a higher level and others at lower levels. It has been noted that cultural capital in embodied by an individual who is knowledgeable and comfortable about their own culture, but also in being aware of its values and weaknesses (Bhugra et al. 2020). Like cultural values, our contention is that cultural capital is transmitted across generations (vertically) as well as horizontally across members of the family or kinship. Cultural capital facilitates communication (through language and mannerisms) within the culture and across cultures. It also contributes to a sense of purpose as well as belonging, hence stability. Undoubtedly as Bourdieu identified, cultural capital may give status and associated power. Cultural capital also comprises of knowledge, skills, and values which contribute to cultural values and experiences which will be colored by culture. Thus, over a period of time, cultural capital may build up over time. Cultural framework, as described by Bourdieu, uses family and environment within which the child grows up and develops. Through this framework the child gathers values, norms, mores, and ideas which help the child, and such framework is defined as habitus. Cultural capital as mentioned above, contributes to

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one’s social status. For example, in a country like India, due to the caste system the social status is defined by the caste to which an individual belongs. The culture of the institutions contributes to status as seen in studying at Ivy League universities may provide a degree of exclusivity. Cultural capital contributes to our identity and it is quite likely that this will also contribute to social inequalities. Bourdieu (1984) divides society in several sections, for example, law, sports, religion, which can be seen in cultural and social capital. These components are both institutions and organizations which are of course formed of individuals and institutional memory and the cultural capital of these organizations may be more difficult to shift turning these institutions into dysfunctional or even malignant institutions. Cultural capital needs to be differentiated from natural capital, human capital, and physical capital (Throsby 1999). From a migrant’s perspective, they carry their cultural capital with them which allows them to feel confident about their values and it is managing these values in the context of a new culture which may facilitate or obstruct acculturation. Again it is entirely possible that some aspects of cultural capital are so ingrained that they may be difficult to change or modify whereas others are more readily changeable. Language, diet, dress, etc. are easily amended but religion, and its values and rituals may well be more difficult to shift.

Levels of Cultural Capital Although social and cultural capitals are different, they are also interlinked. Whereby social capital is about social networks and cultural capital is about cultural assets. Cultural capital can be seen at three levels. First of these is at individual level. At this level, cultural values and norms, education, skills, training, and knowledge play a role in helping build cultural capital. Folk and fairy tales and arts, music, and literature of a particular culture provide a template at an individual level. Language, although at an individual level, will span across generations and cross-generation. Diet, dress, food taboos will also play a role as will religion and gender roles along with gender role expectations. This works both internally (with values) and externally. Individual levels emerge through child rearing. Group/kinship level of cultural capital includes values embedded in the type of culture people belong to and live in. For example, sociocentric societies are kinship based and values are different than seen in egocentric cultures Hofstede (1980/2000). This is not to say that all individuals in a sociocentric culture will be sociocentric. Institutional cultures will also contribute to cultural capital. Each institution where one trains in or works in has its own culture and values and these form an integral and unconscious part of cultural capital. Although Bourdieu’s (1984) notions of cultural capital have been heavily criticized on a number of grounds (Thorsby 1999; Giroux 1983; Lamont 1992), we believe that cultural capital remains a useful concept if it is seen as a mixture of legacy, learning and lumping together of cultural upbringing, experiences, and values. However, the learning and gathering of cultural capital cannot be confined only to home but also from schools, universities, places of employment, peers, colleagues, extended families, and written and visual sources. The interconnectedness of the world as a result of globalization and social media has made it possible

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for other sources of learning about cultures, making it almost impossible to have pure cultures, although some politicians are using this process as a reason to push through the agenda for nationalism and xenophobia. Human capital is thus, a sum total of education, training, skills, knowledge, and cultural capital. Cultural capital can play a major role in providing resilience and coping strategies. This may lead to better engagement and functioning. Migrants carry with them various levels of cultural capital. Let us look at acculturation now and see how it works.

Acculturation Migration, across countries and even within the same country, requires adjustment and engagement with the new culture. This process of adjustment has to be seen at physical, emotional, and psychological levels. Physical adjustment can be somewhat straightforward in getting used to the physical conditions such as climate, environment, accommodation, diet, etc. Psychological adjustment is at the heart of acculturation and linking this with emotional adjustment can be helpful. Emotional adjustment can mean that the way emotions are expressed in different cultures may need to be learnt. This is where stereotypes related to cultural capital can come into play. Such a process of two cultures coming into contact with each other directly or indirectly leads to a degree of adjustment across both groups and communities. Cultural capital is transmitted at home (Sullivan 2001) but this cannot be the only source as other resources related to education, employment, and social contact come into play. Hence both individual and group acculturation become important. On arriving in a new country or in a new place, migrants bring with them their personal values which are strongly influenced by culture and family values which are also strongly affected by their culture and upbringing. These values may coalesce neatly and provide a degree of support to individuals. It is entirely possible that such values are likely to be in conflict across two cultures leading to a degree of culture conflict. After migration, adjustment is needed at a number of levels in order to survive. A large part of such an adjustment is a physical and psychological levels. Redfield et al. (1936) defined acculturation as such (cultural and psychological) changes resulting from direct or indirect contact between two cultures. Individual beings are carriers of such communication and contact. This contact, in current times, is much more immediate through social media, television, etc. feeding into negative attitudes on part of both the migrant, that is, minority community and majority community. As discussed elsewhere in this volume, xenophobia nationalism sees migrants as a threat thus changing the relationships and it is possible acculturation domains will change too. Berry and Sam (2016) observes that from colonial (acculturation) to more individualized (acculturation) processes influence how various groups and within each group, individuals relate and respond to each other and change their values in the context of moving to, living in and functioning in new cultures. Some aspects of an individual’s cultural identity will change more than others. For example, diet, language, dress are more likely to change than characteristics like religion. The

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actual process of acculturation may even be life-long and the younger generation may be trying to navigate this process across two different cultures. Responses to acculturation: psychological acculturation occurs as a consequence of contact between cultures (minority and majority) and inevitably both cultures change in this context – perhaps one more than the other (Graves 1967). Our hypothesis is that the degree of change will be influenced by cultural capital of both the individual and the group. The degree of change will be strongly influenced by the quality and duration of contact on the one hand and strength of their cultural capital on the other. It is essential to recognize that cultural differences may be maintained by the individuals and their groups in order to pressure their respective identities (Berry et al. 2011). Thus, some cultural capital may need to be exchanged in order to acculturate. Cultural capital and psychological capital are intricately interlinked but need to be seen separately as cultures impact upon psychological upbringing, overview and functioning. Berry and Sam (2016) outline the framework which identifies specific characteristics of the two groups along with degree and duration of contact. The resulting changes can be temporary or permanent, minor or major. Embodied sources of cultural capital (such as language) are more likely to change, whereas objective sources such as books and music may carry a lower degree of importance (Bhugra et al. 2020). Institutionalized sources (such as qualifications, skills) may be brought over with migration and in most cases will be acceptable, perhaps with some minor modification in the new country although some qualifications and professions are more readily acceptable. Some of these characteristics are also much more flexible in that they can be changed easily, for example, qualifications can be changed after further education or training. A key question that often requires an answer by the individual migrant is about identity (Berry 2018). Identity can be defined as not only “who am I” but also “how I see other seeing me.” This reordering of identity will form a part of the acculturation and if cultural capital does not offer a defense the individual may experience acculturative stress. The changes in cultural capital following and during acculturation are more likely in embodied sources rather than institutionalized sources. Such a process can be further complicated by past experiences, actual processes of migration and by micro-identities as described by Wachter et al. (2015). As mentioned elsewhere often an individual’s identity gets trumped by identification as a migrant. For example, a doctor who has migrated in their country is likely to be seen as a doctor whereas after migration they will be migrant doctor. This can create a sense of frustration and low self-image leading to various psychiatric disorders. Outcomes and results of acculturation can be any of the following: assimilation, integration, separation, or marginalization, both a group and individual levels (Berry 1980). At an individual level, these changes may be in attitude, behavior, etc., or in response to the majority culture, these may become more rigid and inflexible creating further sense of alienation. These are all related to how the new or majority culture reacts and responds. The new society may respond positively, negatively, or neutrally thus creating appropriate laws and leading to segregation (as in France), multiculturalism (as in the UK), melting pot (as in the USA), rainbow nation (as in Canada), etc. Within such individual responses, some aspects of cultural capital are

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more prone to change and individuals may choose to change them (e.g., language, diet) in order to communicate and may change others, for example, dress in response to new culture or for practical reasons of climate. As Bhugra et al. (2020) have argued, some components of cultural capital may well change in response to altering hierarchies within cultural capital. One’s own identity depends upon identification with two dimensions – first is the identification with one’s heritage or ethnocultural background (which may well form part of cultural capital) and the second is identification with the majority or the dominant group (Phinney 1990; Phinney and Baldelomar 2011). If the migrant is from a similar culture, it is entirely possible that institutional aspects of cultural capital may be common. For example, even if medical schools are in different countries, their curriculum is likely to be broadly similar and medicine may be taught in a common language, for example, English, the skills and knowledge will be broadly similar. With a recognition of local variations and different emphasis on different aspects. With a recognition of local variations and different emphasis on different aspects, it is likely that subtle nuances in the use of certain words may differ which can then change in line with the acculturation processes. After migration, the migrant may well have to change some aspects of their cultural capital using means such as validating and enacting factors (Erel 2010). The national, human, economic, or other forms of capital will influence cultural capital in a number of ways. Hence the core aspects of cultural capital may change less, but the peripheral ones, for example, language, diet, may change more. However, the migrant individual often feels more at home in their primary language. Most migrants will prefer their own cuisine and are much more likely to miss that, especially in times of stress. The identity of the migrant will comprise of value identity and real identity (Camilleri and Malewska-Peyce 1997). They point out that any discrepancy between the real identity and value identity may create problems in settling down in the new culture. They argue that, as seen among adolescents, this tension, when the adolescent is trying to discover their own real identity and the authority as embedded in parents or teachers, may push them toward a different set of value identity may lead to rebellion. This model, when mapped on to aspiration and achievement, may well explain acculturative stress when applied to migrants. Another key aspect is crossgenerational transmission of values in migrants as second or third generation where various components of cultural capital are likely to change thereby possible alienation. An interlinking of social capital, acculturation, and health, along with life style, has been proposed by Tutu and Busingye (2019). They argue that as social relations affect out wellbeing (especially as loneliness is said to be bad for human beings) through the use of language and other commonalities which impact upon communication, comprehension, and resulting life style which in turn influences health and well-being. This model confirms the hypothesis that cultural capital can contribute to better health and well-being. Acculturative stress can contribute to poor mental and physical health and well-being in general. This stress may be acute or chronically persistent and combined with changes in life style can contribute to a deterioration of health. In an interesting study of Latino migrants in Florida, Concha et al. (2013)

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found that acculturative stress is negatively related to support from friends, but positively related to support from parents. They did not measure cultural capital and did not identify whether their friends were Latino. However, on follow up, they found that acculturative stress was negatively associated with support from their children confirming that cultural capital may be relevant here. Sociocentric individuals from sociocentric societies may find it difficult to adjust and settle down in egocentric cultures especially if they do not have sociocentric individuals around them whereas egocentric individuals moving to egocentric societies may well show better settling down especially if they are not surrounded by sociocentric individuals from their sociocentric society. Thus, our contention is that although they may belong to the same culture, their cultural capital will vary. Under these conditions, settling down by migrants may well become more influenced by the cultural capital they carry with them. Cultural capital must be seen as an aggregate of actual and potential resources in managing new and old relationships, be they personal or institutionalized. Cultural capital teaches individuals to formulate and form relationships. The impact of cultural capital on health and well-being especially among migrants needs urgent attention in research, health delivery, and policy making. It has been shown that as social capital impacts on access to health care of migrants, in this case Hispanic migrants (Rodriguez-Alcala et al. 2019), urgent attention needs to be paid to explore cultural capital perhaps using quantitative methods combined with qualitative methods in longitudinal studies.

Conclusion All individuals carry their cultural capital with them and migrants, irrespective of their reasons to migrate, more so than others. It is because their value identity is influenced by their upbringing and culture as embedded in the cultural capital. They may choose to hang on to their cultural values in order to feel secure and giving up certain aspects of their cultural identity may well be very difficult. Their contact and responses to the majority culture or society will facilitate their settling down in a more productive way. Our worldview is modified by our cultural capital as is our social interaction. This can be a crucial aspect in managing our mental health and well-being. The impact of cultural capital on the well-being of individuals and their communities needs to be explored and understood in an urgent manner. The postmigration adjustment and assimilation or bi-culturalism needs to be explored further in order to help migrants protect from any acculturative stress. It is likely that some aspects of cultural capital are more prone to change than others and psychological and emotional well-being of individual migrants may be influenced by such changes. Further exploratory research is required to clearly understand what the components of cultural capital are and which of these are more prone and ready to change.

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References Bennett T, Savage M, Silva E et al (2008) Culture, class, distinction. Routledge, London Berry J (1980) Acculturation as varieties of adaptation. In: Padilla A (ed) Acculturation, theory, models and findings. Westview, Boulder, pp 9-2585-193 Berry J (2018) Acculturation and identity. In: Bhugra D, Bhui K (eds) Textbook of cultural psychiatry. Cambridge University Press, Cambridge, pp 185–193 Berry J, Sam D (2016) Conceptual Issues In. In: Sam D, Berry J (eds) Cambridge handbook of acculturation. Cambridge University Press, Cambridge, pp 11–29 Berry J, Poortinga Y, Breugelmans S, Chasiotis A, Sam D (2011) Cross-cultural psychology: research and applications, 3rd edn. Cambridge University Press, New York Bhugra D, Watson C, Ventriglio A (2020) Cultural capital. Int Rev Psychiatry. https://doi.org/10. 1080/09540261.2020.1733786. Accessed 5 Apr 2020 Bourdieu P (1984) Distinction. Routledge, London Camilleri C, Malewska-Peyce H (1997) Socialisation and identity strategies. In: Berry J, Dasen F, Saraswathi T (eds) Handbook of cross-cultural psychology, vol 2. Allyn & Bacon, Boston Concha M, Sanchez M, de la Rosa M, Villar ME (2013) A longitudinal study of social capital and acculturation related stress among recent Latino immigrants to South Florida. Hisp J Behav Sci 35:469–485 Erel U (2010) Migrating cultural capital: Bourdieu in migration studies. Sociology 44(4):642–660 Giroux H (1983) Theory and resistance in education. Bergin & Garvey, South Hadley Graves T (1967) Psychological acculturation in a tri-ethnic community. Southwest J Anthropol 23:337–350 Hofstede G (1980/2000) Culture’s consequences. Sage, Sherman Oaks Holden J (2010) Culture and class. Counterpoint, London Lamont M (1992) Money, morals and manners. University of Chicago Press, Chicago Phinney J (1990) Ethnic identity in adolescents and adults. Psyhol Bull 108:499–514 Phinney J, Baldelomar O (2011) Identity development in multiple cultural contexts. In: Jensen LA (ed) Bridging cultural and developmental approaches to psychology. Oxford Univeristy Press, New York, pp 161–186 Redfield R, Linton R, Herskovits M (1936) Memorandum on the study of acculturation. Am Anthropol 38:149–152 Rodriguez-Alcala ME, Oiu H, Jeanetta S (2019) The role of acculturation and social capital in access to healthcare. J Community Health 44:1224–1252 Sullivan A (2001) Cultural capital and educational attainment. Sociology 35:893–912 Thornton S (1995) Clubs, cultures, music, media and subcultural capital. Polity, London Throsby D (1999) Cultural capital. J Cult Econ 23:3–12 Tutu RA, Busingye JD (2019) Social capital and acculturation. In: Tutu RA, Busingye J (eds) Migration, social capital and health. Springer, Cham, pp 113–137 Wachter M, Ventriglio A, Bhugra D (2015) Micro-identities, adjustment and stigma. Int J Soc Psychiatry 61:436–437

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Migrants, Racism, and Healthcare Dinesh Bhugra, Cameron Watson, Elliot Clissold, and Antonio Ventriglio

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of Institutional Racism on Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causes of Institutional Racism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of Institutional Racism on Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Response to Institutional Racism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences of Personal Prejudice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinician’s Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

In recent times, racism against migrants has become much more prominent and visible. A reason for this is likely to be an increase in nationalism and xenophobia. Migrants choose to migrate both voluntarily and involuntarily. The latter group are more likely to do so due to geopolitical disasters and climate change. Voluntary migration may be due to all these reasons, but is also likely to be because of economic or educational advancements. Race is itself a social constrict

The original version of this chapter was revised. The chapter was inadvertently published with an incorrect spelling of the author’s name as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. The correction to this chapter is available at https://doi.org/10.1007/978-981-10-23668_45 D. Bhugra (*) Centre for Affective Disorders, IoPPN, Kings College, London, UK e-mail: [email protected] C. Watson · E. Clissold Barts Health NHS Trust, London, UK A. Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_41

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and racism is applied to retain power related to education, employment, and other resources. There is no doubt that institutionalised racism presents migrants from seeking help and if they do so, they are less likely to remain engaged in services. Keywords

Race · Racism · Xenophobia · Mental health · Mental illnesses · Pathways into care

Introduction Human beings have been migrating in search of adventure and a better life for millennia. A major challenge to the receiving countries has been acculturation and assimilation in the new country. This acculturation occurs at both individual and group levels. However, it is well recognized that new cultures, communities or societies also change in response to coming into contact with new cultures. This process of adjustment can take a long time. There is little doubt that migrants who look different are often treated differently but even the slightest differences in accent, language, clothing, etc. can generate a feeling of otherness by the new community. The obvious distinction has to be physical by virtue of skin color or physical appearance in a number of levels as perceived by the new community. Race is a social construct dating back to the colonial era when the colonial masters and academics differentiated those colonized according to skin color, hair type, shape of the nose, and other external physical characteristics. It is not a biological or scientific fact (Sternberg et al. 2005). The original colonial concept was turned into a genetic one to explain the differences. Spickard (1992) points out that European scientists chose to identify people by virtue of geography as well as physical characteristics. These were subsequently modified according to tribes or clans, languages spoken, etc. (Thomas and Sillen 1972). Often the assumption in many cultures (e.g., in India, Jamaica) is that lighter skin people hold higher roles in the social hierarchy. Colonial powers also saw light-skinned Christians to be superior to the dark-skinned natives (Hayes 2008). Hayes (2008, p. 11) goes on to point out that until relatively recently, in the USA, that “white blood” is not to be tainted by “black blood” was prevalent and inter-racial marriages were looked down upon. Racial distinctions as noted above are not genetically discrete and are not reliable or scientifically useful (Smedley and Smedley 2005, p. 16). There are no pure genes – a misconception that let to atrocities by the Nazis. Many physical characteristics spill over in other cultures and communities. Linking race with IQ is not only erroneous, but racist in itself. The consequences of this creation of race on a genetic basis are real in creating perceptions of similarities as well as differences (Altman 2007, p. 15). Racial identity may or may not be important to the migrant. As described elsewhere in this volume, each individual carries with them multiple micro-identities which may be due to gender, religion, sexual orientation, etc. and racial identity may be seen as a micro-identity. However, it must be recognized that individuals may choose to hide their sexual orientation or religion but skin color and other

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physical characteristics may well be difficult to do that with. The individual thus may be forced to face various challenges. Race needs to be differentiated from ethnicity or ethnic identity. Ethnicity has been described as the group’s concept of “peoplehood” including the “common ancestry through which individuals have evolved shared values and customs” (McGoldrick et al. 2005, p. 2). Ethnicity may have some shared biological or genetic heritage its most important aspects are socially constructed (Hayes 2008, p. 12). These social constructs include beliefs, norms, language, institutions, etc. which all form part of culture and cultural capital as discussed in this volume (also see Bhugra et al. 2020). Ethnic groups are often labelled very broadly and widely. Phinney (1996) cautions us that ethnicity should not be conceptualized as a discrete categorial variable. Culture is often described in this context as consisting of traditions, thoughts, behaviors, and history with language which is acquired, shared, and passed on across generations. Cultures influence child rearing as well as cognitive and social development. Racism is defined as the feelings of prejudice of by a majority group against a minority group on the basis of physical appearances. This is to do with power and a sense of entitlement which the majority community feel that they deserve especially related to education and financial matters. In nineteenth century USA, draeptomania (desire to run away as a slave) was seen as a psychiatric illness confirming that concept of racism has often infiltrated practice of clinical psychiatry. Pinderhughes (1973, pp. 61–64) sees racism as a relatively constant pattern of prejudice and discrimination between one party who is idealized and favored and another who is devalued and exploited in a common relationship. Racism may well be linked with classism. Thomas and Cromer (1973, pp. 166–167) define racism as a belief that race or identifiable physical characteristics related thereto are primary determinants of human behavior and sets the limits for human accomplishment. Thus, “the inherent superiority of certain races to other races is an important part of a racist belief system” (Allport 1954, p. 2). On the other hand, Allport sees prejudice as over categorization based upon misconception and closely related to the human potential for prejudgment (the latter becoming prejudices if they are not reversible in the face of new knowledge). Ethnic prejudice can be seen as being fairly similar to racism. The effect of prejudice and racism is to place the disadvantaged group at considerable disadvantage with advantages geared up to themselves. Such prejudice and racism may be expressed as an individual but it is to be seen as intergroup or institutional phenomenon (Kramer 1973). Racism exists between different ethnic groups too. Racism can apply to any number of outgroups, e.g., anti-Semitism, homophobia, Islamophobia. Individual racism does not occur in a social institutional or psychological vacuum and the social context dictates power and privileges. Racism is also defined by psychocultural traits which are seen as being determined by biological race and inherent perceived superiority of a particular race and its right to domination over others. Kerner (1969, pp. 537–541) sees the attitudes of the white majority towards blacks. American Indians and other as describing racism

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dating back centuries. The key aspect embedded within the definition is that of white superiority and black inferiority. The white population’s attitudes to other whites based on the “within in-groups” attitudes may reflect basing it on discrimination of one kind or another. It has been argued that the history of racism precedes history of races (Bethencourt 2013). The definition of racism is relational and thus keeps changing over time. It is seen as prejudice concerning ethnic descent coupled with discriminatory actions. In his volume, Bethencourt (2013) argues that prejudice has varied in history according to a number of factors. He sees racism as attributing a single set of real or imaginary physical and/or mental features to precise ethnic groups and that these features are transmitted cross-generationally (p. 8). Racism needs to be differentiated from ethnocentrism in that it accepts people from other communities whereas racism confirms that blood affects all members of the affected community who must therefore, be excluded. Ethnocentrism may take pride in their views while racist views will not be seen as pathological views by those who hold them. Institutional racism can be defined as that complex of institutional arrangements that restrict the life choices of a minority or outgroup in comparison with ingroup or a majority group. Thus, it is not an issue for white (majority) or black (minority) groups but as seen in India, the caste system is institutionalized and those in upper castes often see the lower castes with denigration, prejudice and distaste. Originally several centuries ago, the caste system was set up based on skills and businesses and individuals could move across castes but has become racially institutionalized. Institutional racism avidly supports individual racism and vice versa and racist institutions are not necessarily headed by racist individuals (Pettigrew 1973, p. 175). It must be remembered that very often it is extremely difficult to get rid of institutional racism, partly because of complex nature of the institutions which hold the power themselves. Frederickson (2002) argues that institutional racism broke down between 1945 and 1994 (largely in response to Nazism) and notes that in medieval times, religion was the instrument for institutional racism. A major development has been that in many parts of the world, institutional racism, especially in healthcare systems, has raised its ugly head, perhaps as a result of anti-migration feelings provoked by politicians. The institutions themselves can be defined as functional organizations and therefore institutional or institutionalized racisms can develop and persevere.

Impact of Institutional Racism on Healthcare Services It is self-evident that if the services are institutionally racist, they are far less likely to be used by minority groups who may feel less welcome. These types of services may lead to delays in help-seeking and longer the delay worse the long-term outcome. Furthermore, even if they access services, due to institutionalized racism individuals may not collaborate with any therapeutic interventions. Delay in help-seeking can lead to delays in responses. It is essential that services are culturally appropriate,

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culturally competent, and culturally sensitive. Only then migrants can engage with services. If services are not racist, individuals can seek help readily. More racist services may well lead to more compulsory detentions and admissions. A lack of appropriate diet, make up products, etc. in the inpatient services may make individuals feel unwanted and unwelcome. Bhugra et al. (2011) reported that for black patients, working with nongovernmental organizations who could provide more culturally sensitive services, was more acceptable. Services, if they are not welcoming to minority culture individuals, may lead to rejection and non-engagement. In addition, such services may produce high levels of alienation not only from the services but also from rest of the society because they may feel unwelcome and unwanted.

Causes of Institutional Racism Causes of institutional racism are complex and varying. Institutions are organizations formed of individuals and traditions. Institutions are all powerful and may dictate how its staff and others behave. Institutions are difficult to define and understand. These are not the buildings, but people and policies as interlocking of people and of social practice (Harre 1979, p. 98). Schools, universities, shops, post offices, and hospitals are all institutions of one kind. The interaction between people forms the basis of the institution. A commonality of cultural systems is essential and there are different levels of institutions as observed by Guala (2016). In the end, racism is about overt and covert power. Racism and prejudice are likely to affect ethnic identity. Racism is a multidimensional concept and is a negative attribution made by people of one social group towards people of a different group (Bhugra and Bhui 1999). Culture of an institution and unconscious bias of people forming institution constitute racist attitudes and behavior. Unconscious attitudes and behavior, irrespective of knowledge, can be more dangerous. Within an institution this bias is about gaining and retaining power irrespective of what the qualifications of minority group individuals are.

Impact of Institutional Racism on Individuals In addition to industrial racism, minority individuals may experience racial life events which may cause ongoing stress and contribute to poor functioning (Bhugra and Ayonrinde 2001a, b). Social factors and determinants will be affected directly and indirectly. Institutional racism will affect access to housing, employment, etc., thereby leading to poverty. This differential access is partly about power by the majority population and partly about controlling the levers of power and subjugating the other. Poverty is often a result of inadequate employment or unemployment. Studies have repeatedly shown that all things being equal those with foreign sounding names are less likely to be short-listed for job interviews and less likely to be appointed.

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Housing too is controlled by “power” in that often housing which is offered to migrants is of poor quality or overcrowded. There may be differential attainment in schools and in many jobs too. These social determinants are well known to affect mental health. It is likely to have cumulative effect on the mental health and wellbeing of individuals. Littlewood and Lipsedge (1988) and Perera et al. (1991) suggest that institutional racism can lead to schizophrenia and psychosis. What is even more worrying is the observation that often it is the perception of racism which can cause psychiatric disorders.

Response to Institutional Racism Institutional racism affects health directly and indirectly. Individuals faced with institutional discrimination may get isolated and stress-diathesis model suggests that chronic stress due to ongoing racial life events may produce psychiatric disorders. It is quite likely that discriminatory experiences, mistrust and marginalisation may lead to paranoid ideation and alienation. What is worth emphasizing, as mentioned above, is that not only actual discrimination, but its perception can contribute to mental ill health (Jackson et al. 1996). Various mediating factors may play a role in pathological responses to institutional racism. Feeling trapped or loss of focus of control may act as mediating factors. There is every likelihood that racial discrimination may well contribute to changes in racial identity. An additional point that is worth considering is the explanatory models of the illness held by the patients, their carers, and families which may be in contrast with those of the clinician who may see these as inferior and less educated which may delay help-seeking and forming therapeutic alliances. Increased rates of detention, increased dissatisfaction, poor engagement will all affect the outcome of the patients with various mental illnesses.

Consequences of Personal Prejudice Prejudice can be expressed in many ways. Systemic discriminations in institutions can lead to non-engagement, physical assault and lack of access to justice. Disguised discrimination or missionary racism can create additional problems. Missionary racism is when an individual thinks on behalf of minority communities with a major assumption that minority individuals are unable to think for themselves. Such an attitude and behavior causes non-availability of certain therapies such as psychotherapies. Another insidious manifestation of prejudice which can be described as adjectival racism (Cochrane 2001) which is attaching a racial or ethnic identifying adjective to a person or group confirming a stereotype which again in healthcare may lead to exclusion and non-availability of various treatments and therapies increased less of status may follow due to insidious discrimination. It may be that for sociocentric individuals, egocentric therapies may be offered which may be unacceptable. Although psychoanalysis has been described in India, by and large

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sociocentric individuals find it easier to deal with some therapies rather than egocentric psychotherapy. Similarly, often pharmacotherapy is offered using same doses and chemical substances. It is well recognized that many ethnic groups react badly to high doses and yet often they are treated with similar levels of high doses which leads to high levels of side effects and resulting rejection of drugs and non-compliance. It is also well recognized that different cultures see different medications, colors, and mode of administration of medication in different ways (Bhugra and Ventriglio 2015).

Clinician’s Response Clinicians may carry their own prejudices and unconscious bias towards other races and cultures especially if they happen to be unaware of these. With national and international hysteria against migrants may well add to this sense that migrants are not worthy of their attention. Institutional racism can lead to stereotyping and rejection of migrants and ethnocentrism will denigrate other cultures. At an individual level, the clinician may also stereotype other cultures and unwittingly reject the individual. They may feel threatened or under attack or may be seen as threatening by the migrant who may have different expectations of the clinical encounter. Hostility by the in-group towards the out-group is likely to contribute to a sense of marginalization. A sense of inconsistency in status where everything gets reduced to the identity of the individual as a migrant may contribute to a feeling of being devalued and thereby being inferior. Minority migrants may be more visible and therefore prove to be attacked by virtue of being seen as stereotypes and have symbolic meanings. It is worth noting that for migrants, social support and cultural capital may well act as mitigating factors. Socioeconomic and educational status may also contribute to a degree of mitigation whereas stress, entrapment, feeling powerless may exacerbate effects of racism on migrants. Jackson et al. (1996) acknowledge that racism, whether personal or institutionalized (and racial life events), will affect the individual functioning and the cumulative perception may lead to poor mental health. The interaction between stressor stimuli, such as prejudice, hostility, discrimination with external mediating support such as social support and internal mediating factors such as cognitions, past experiences, etc., will be available to manage stress by the migrant. Racism itself, be it individual or institutional, will be a chronic difficulty and a stressor and may put migrants in the position of helplessness and entrapment thus, pushing them towards clinical depression. This may make them feel inadequate and contribute to a sense of poor achievement in spite of higher aspirations. These abstract obstacles may make them feel trapped and bewildered with poor selfesteem, low self-image and diminished self-valuation. This is likely to alienate them further from others and their own ethnic group – more so if their coping mechanisms are different. The rest of their ethnic group and kinship may thus look down upon them as they may be seen to have let the culture down. Such a reaction is more obvious in sociocentric societies. This in itself will further add to their stress

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making recovery perhaps more difficult. Racism may affect primary care physicians and migrant may find it difficult to traverse healthcare pathway especially if they come from a different healthcare system and their explanatory models of their symptom experience are at variance from the larger majority group. WHO (1997) described racism as the belief that there is an inherent connection between perceived, hereditary, and cultural traits and that some groups see themselves as superior to others. Prejudice is the negative attitudinal, behavioral, and emotional set against an individual or group based purely on selected social or cultural characteristics. Ethnocentrism is the overvaluing of one’s own culture in relation to other cultures thereby leading to biased judgments. Bhugra and Ayonrinde (2001a, b) describe various types of racism. Racial life events are those life events which may be influenced by the impact of racism, e.g., not getting a job or house due to discrimination on part of the majority community. Racial life events thus can be directly attributed to racial behavior and may be seen in addition in fields of education, finance, health, bullying or harassment, damage to property, or legal discrimination. Minority communities and migrants may be more reluctant to report crimes against them thinking that this may draw attention to them. They may also face and experience chronic difficulties which may further contribute to stress and alienation. In addition, as mentioned earlier, perception of an event as threatening or racial can contribute to stress and consequent distress. Racism thus creates differential social status with differential health consequences, differential exposure, and impact on individual migrant’s functioning and mental wellbeing.

Conclusion Migrants, especially if they are involuntary and have been expelled due to political, religious, or sexual discrimination, may be subject to further racism at individual or institutional level in the new culture and country. Their interaction with a new culture and social environments can contribute to further stress and their response will provoke a response from the new culture. Actual racism and racial life events or perception itself will contribute to development of various social determinants along with psychiatric disorders. It is crucial that clinicians are cognizant of their own prejudices, biases, including unconscious biases. Matters related to negative attitudes and cultural transference and cultural counter transference must be discussed with the patient and relevant bits with the carers and family where appropriate.

References Allport G (1954) The nature of prejudice. Addison-Wesley, Reading Altman N (2007) Toward the acceptance of human similarity and difference. In: Muran JC (ed) Dialogues on difference: studies of diversity in the therapeutic relationship. American Psychological Association, Washington, DC, pp 15–25 Bethencourt F (2013) Racisms: from the crusades to the twentieth century. Princeton University Press, Princeton

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Bhugra D, Ayonrinde D (2001a) Racial life events and psychiatric morbidity. In: Bhugra D, Cochrane R (eds) Psychiatry in multicultural Britain. Gaskell, London, pp 91–111 Bhugra D, Ayonrinde O (2001b) Racism, racial life events and mental ill health. Adv Psych Treatment 7:343–349 Bhugra D, Bhui K (1999) Racism in psychiatry paradigm lost, paradigm regained. Int Rev Psych 11:236–243 Bhugra D, Ventriglio A (2015) Do cultures affect placebo response? Acta Psych Scand 132:227– 230 Bhugra D, Ayonrinde O, Butler G, Leese M, Thornicroft G (2011) A randomised control trial of assertive outreach versus TAU for black people with sever mental illness. Epidemiol Psychiatr Sci 20:83–89 Bhugra D, Watson C, Ventriglio A (2020) Migration, cultural capital and acculturation. Int Rev Psych Cochrane R (2001) Race, prejudice and ethnic identity. In: Bhugra D, Cochrane R (eds) Psychiatry in multicultural Britain. Gaskell, London, pp 75–90 Frederickson GM (2002) Racism: a short history. Princeton University Press, Princeton Guala F (2016) Understanding institutions, the science and philosophy of living together. Princeton University Press, Princeton Harre R (1979) Social-being. Blackwell, Oxford Hayes PA (2008) Addressing cultural complexities in practices. American Psychological Association, Washington, DC Jackson JS, Brown T, Williams D et al (1996) Racism and the physical and mental health of African Americans. Ethn Dis 6:7–20 Kerner Report (1969) National advisory commission on civil disorders report. NJ: Priceton University Press reprinted 2016 Kramer BM (1973) Racism and mental health as a field of thought and action. In: Willie CN, Kramer BM, Brown BS (eds) Racism and mental health. University of Pittsburgh Press, Pittsburgh, pp 3–24 Littlewood R, Lipsedge M (1988) Psychiatric illness among British Afro-Caribbean. BMJ 296:950– 951 McGoldrick M, Giordano J, Garcia-Preto N (eds) (2005) Ethnicity and family therapy. Guilford Press, New York Perera R, Owens D, Johnstone E (1991) Ethnic aspects: a comparison of three matched groups. BJPsych 159(Suppl):40–42 Pettigrew TF (1973) Racism and the mental health of white Americans: a social psychological view. In: Willie CV, Kramer BM, Brown BS (eds) Racism and mental health. University of Pittsburgh Press, Pittsburgh, pp 269–298 Phinney JS (1996) When we talk about American ethnic groups, what do we mean? Am Psychol 51:918–927 Pinderhughes CA (1973) Racism and psychotherapy. In: Willie CV, Kramer BM, Brown BS (eds) Racism and mental health. University of Pittsburgh Press, Pittsburgh Smedley A, Smedley B (2005) Race as biology is fiction: racism as a social problem is real. Am Psychol 60:16–26 Spickard PR (1992) The illogic of American racial categories. In: Root MPP (ed) Racially mixed people in America. SAGE, Newbury Park, pp 12–23 Sternberg RJ, Grigorenko EL, Kidd KK (2005) Intelligence, race and genetics. Am Psychol 50:912–927 Thomas CS, Cromer JP (1973) Racism and mental health services. In: Willie CV, Kramer BM, Brown BS (eds) Racism and mental health. University of Pittsburgh Press, Pittsburgh, pp 165– 184 Thomas A, Sillen S (1972) Racism and psychiatry. Ontario Citadel Press, Toronto WHO (1997) Lexicon of cross-cultural terms in mental health. WHO, Geneva

Part II Special Groups

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Therapeutic Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intercultural Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparison of Cultural Representations of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Person-Centered Cultural Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implementation of Cultural Competence in the Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Medical Anthropology and Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical and Social Practices: Migration Requires Medico-psychosocial Care . . . . . . . . . . . . . . . . . Avoiding Stigma and Cultural Assignation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strengthening Doctor-Patient Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Create a Multilingual and Multidisciplinary Therapeutic Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Cultural Mediator Is Part of the Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Training Professionals Within the “Cultural Competence” Framework . . . . . . . . . . . . . . . . . . . . . Work with the Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assure Healthcare Access to All . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

We examine mental health among South Asians living in the UK, framed within a multilevel conceptual model of health reflecting an interplay of biological and environmental risks over the course of life. We highlight epidemiological differences in the occurrence of different psychiatric disorders, and consider the role of

R. Bennegadi (*) Minkowska Centre, The World Association of Social Psychiatry (WASP), Paris, France e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_5

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socio-cultural patterns of help-seeking behavior. Ultimately, epidemiological approaches, while vital for planning services, identifying unmet population need, and evaluating the effectiveness of services and interventions, often risk conflating and obscuring important historical, cultural, and gendered influences on mental health in this particular diaspora, and others. Keywords

Mental illness · Cultural competence · Psychiatry · Person-centered · Migrants

Introduction Global migration and the flow of migrants, refugees, and asylum-seekers, throughout the world, certainly contributed to an increase in the cultural diversity of all societies, especially in urban areas. However, inevitably this raises practical, conceptual, and ethical challenges in the delivery of mental healthcare services. The way cultural representations and explanatory models are expressed in different countries and the way they vary according to their specific public health policies need to be recognized and understood. These responses require training in a medico-psychosocial approach which will be detailed in this chapter.

There is a large body of evidence on the impact of culture on illness behavior and experience. Social and cultural processes shape the mechanisms of disease, the symptoms of distress, and the subsequent ways of coping or help-seeking (Kirmayer 2005). Castles and Miller (1998) distinguish four broad models of citizenship: (i) the imperial model (e.g., the British Empire) which brings together diverse peoples under one ruler, (ii) the folk or ethnic model (e.g., Germany) which defines citizenship in terms of common descent, language, and culture, (iii) the republican model (e.g., France) which defines the state as a political community based on a constitution and laws so that newcomers who adopt the rules and the common culture are accepted as full citizens, and (iv) the multicultural model (e.g., UK, Canada, Australia) which shares the political definition of community with the republican model but accepts the formation of ethnic communities within the nation. The health systems created on the basis of these conceptions of citizenship and unique histories of migration have influenced both the direction of cultural psychiatry and the development of mental health services in each country. In recognition of this problem, cultural psychiatry in the UK highlighted inequalities in care for immigrants and in providing services that are explicitly anti-racist (Fernando 2005). In France, the republican ideal downplays the significance of culture to assert the common values of political participation in the state. Ethnocultural identity is something individuals are free to express in their homes but is not actively supported by the state, which is conceived of as a neutral space that accommodates all citizens. Mental health services in France have been somewhat influenced by psychoanalytic tradition which, not surprisingly, tends to situate problems in the individual psyche. In fact, cultural difference also involves the personal and professional background of the clinician and the cultural assumptions of their clinical practice.

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Table 1 Source FRA (Interviews with health providers and public authorities) Country Belgium France Germany Greece Hungary Ireland Italy Poland Spain Sweden

Access and conditions YES If entitled to AMU YES If entitled to AME, if not entitled to AME access via PASS facilities NO NO But examinations possible via municipal clinics and first aid centers NO NO YES with STP code NO YES with health card NO

In an effort to explore the access to healthcare granted to irregular migrants in 10 EU Member States, the European Union Agency for Fundamental Rights published a report (2011) which identified the legal, economic and practical obstacles that hinder the migrants from accessing healthcare. Interviews were made with a range of different sources, including public authorities at the national and local level, health professionals, nongovernmental organizations (NGOs) providing healthcare, and irregular migrants themselves. This report concluded that access to mental healthcare of irregular or illegal immigrants was not met. In only four of the ten countries studied (Belgium, France, Italy, and Spain) migrants in an irregular situation do have, at least formally, access to mental healthcare services, such as medication and treatment for depression, stress, psychosis, and anxiety-related disorders (see Table 1). In all other countries, migrants in an irregular situation are only treated in emergency cases, such as if they are considered to be a threat to themselves or to others (e.g., psychosis). Health staff in Hungary pointed out that this suggests that following stabilization, there is no further treatment provided. Other groups, such as the poor and the uninsured individuals, might also be excluded from full access to healthcare in some countries. The particular conditions of migrants in an irregular situation also expose them to specific health risks. These migrants can fall victim to racist crime and violence putting their lives at risk. In addition they are also often exposed to health-impairing or life-threatening working conditions. They are more likely to work in sectors such as construction and domestic work, which have a higher incidence of workplace accidents, and are more vulnerable to exploitative working conditions and precarious housing, which in turn undermine their physical and psychological well-being. More than a million migrants and refugees crossed into Europe in 2015, sparking a crisis as countries struggled to cope with the influx and creating a division in the EU over how best to deal with resettling the refugees. The International Organization for Migration (IOM) estimates that more than 1,011,700 migrants arrived by sea in

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2015 and almost 34,900 by land. This compares with 280,000 arrivals by land and sea for the whole of 2014. The figures do not include those who got in undetected. The EU’s external border force, Frontex, monitors the different routes migrants use and numbers crossing Europe’s borders and puts the figure in 2015 at more than 1,800,000. According to the IOM, more than 3770 migrants were reported to have died trying to cross the Mediterranean in 2015. Although Germany received most of asylum applications in 2015, Hungary had the highest in proportion to its population, despite having closed its border with Croatia in an attempt to stop the flow of refugees in October 2015. Nearly 1800 refugees per 100,000 of Hungary’s local population claimed asylum in 2015. Sweden followed close behind with 1667 per 100,000. Although huge numbers have been applying for asylum, the number of people being given asylum is far lower. In 2015, EU countries offered asylum to 292,540 out of the million who applied. Moreover, applying for asylum can be a lengthy procedure, so many of those given refugee status may have applied in previous years (Eurostat 2015).

The Therapeutic Framework In an effort to improve the delivery of mental healthcare for immigrants, refugees, and members of ethnocultural minorities, McGill Division of Social and Cultural Psychiatry developed a Cultural Consultation Service (CCS) that sees cases referred from primary care settings or mental health practitioners (Kirmayer et al. 2003). Patients are referred by clinicians who believe that issues of cultural difference are complicating their care, either in terms of diagnostic assessment, treatment planning and adherence, or, most basically, the unfolding of the clinician-patient relationship itself. The aim is to provide a more comprehensive assessment to identify relevant social and cultural dimensions of the case and so to assist the referring clinician and, ultimately, the patient. The CCS assessments use interpreters and culture brokers to collect background information necessary to understand the patient’s narrative and experience in cultural context.

Intercultural Communication The ethics of clinical help rely on sharing with someone who we are and what we have. The ethics of solidarity requires one to go a step further, by also learning cultural codes and representations of the other. Solidarity, in an intercultural context, is a technique to be completed by training, to achieve humanist objectives. To strengthen the patient/therapeutic relationship, we combine the notions of intercultural communication and cultural competence training. We can summarize these phases by the following table:

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(i) Engagement: In this phase the clinician and patient both notice differences and similarities with each other and then go on to build rapport and mutual understanding (see Table 2). (ii) Therapeutic alliance is at the core of the interaction which determines what treatments or interventions are offered and accepted by the patient (see Table 3). (iii) Outcome: Therapeutic outcome is a result of how therapeutic alliance is formed and how it can be utilized to deliver help to the patients (see Table 4). Only the following conditions of the therapeutic setting allow to exercise the therapist profession with respect to ethics. 1. Intercultural communication. 2. The confrontation of cultural representations of mental health and mental illness between the individual who is seeking help and the individual who is providing it. Table 2 Therapeutic engagement Therapist Notices difference: “Oh my god, I’ve never had a patient from this culture!” Doesn’t acknowledge importance: “I don’t think that everything this patient is telling me has any importance for me to suggest a diagnosis.” Sees client as stereotype: “Oh I see now, I have been taught that this is a common behavior in people from this culture!”

Patient Notices difference: “It’s the first time I’ve been referred to a psychotherapist!” Assumes therapist won’t understand: “Does she understand that what I’m telling her about women is important for me?” Fears of being judged: “My God, I hope he’s not judging me by the culture I come from.”

Table 3 Therapeutic alliance Therapist Does not understand client: “I don’t know what therapeutic help to propose!” Fails to respond to mistrust: “How am I going to be able to convince this patient to trust me?” Sees client as unmotivated or not psychologically minded: “It’s not a real demand for help, and I’m wondering if this patient is even ready to engage in a psychotherapy.” Assumes client is resistant: “I understand that this person isn’t prepared enough, and I also think that there is tremendous resistance.”

Patient Feels misunderstood: “I hope he’s not going to propose something that instead of helping me is going to complicate my life!” Shows increased mistrust: “How can I trust someone who belongs to a society that colonized me?” Decreases self-disclosure: “Finally I don’t think that I should go any further with my help seeking demand.”

Does not develop rapport: “I came to ask for help, and I have the impression that I came to the wrong place and to the wrong person.”

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Table 4 Therapeutic outcomes Therapist Shows anxiety and frustration: “I’m aware that I’m not handling this situation correctly and it’s worrying.” Exhibits misalliance; may misdiagnose: “I’m not very happy with this first session, it’s going to be hard to diagnose this patient correctly.” Perceives faulty treatment planning: “. . .And yet I thought that he was suffering from depression. . .!” Observes failed outcomes: “I really don’t think that I made the best therapeutic choices for this patient.”

Patient Shows frustration and anxiety: “What a pity that I’m obliged to follow a treatment that I don’t believe in.” Cancels sessions: “I don’t know why I’m cancelling some sessions.” Fails to show for appointments: “I’ll show up for my appointments if and when I can.” Terminates treatment prematurely: “I’m going to stop with this therapist and find myself someone else!”

3. The necessary approach of the therapist of decentring himself or herself so as to not fall into stereotypes regarding the individual who is mentally suffering, irrespective of their cultural origin. 4. The necessary professional training of therapists who need to be qualified in the system where they work and exercise the duties of a therapist and in the ethical responsibilities of a caretaker. 5. The person who is asking for help must have the possibility to express himself or herself with full confidence in one’s own representations and in the language that appears to be the most accurate and natural to describe one’s suffering. 6. The transfer is only possible if the individual is allowed to express oneself in one’s own language or through an interpreter, to build one’s confidence; it is not easy to tackle taboos and to imagine that there is interest, empathy, or someone willing to listen. 7. The countertransference must focus on the possibility of listening; possible resonances, with a mastered empathy; and a confrontation of cultural representations, in order to reach a diagnosis and a possible therapeutic indication. 8. The conditions of access to healthcare should be affordable for migrants and refugees so that even in the absence of financial means, they can receive the same quality of support as any other person. 9. We must ensure that the therapeutic setting does not have an adverse effect by stigmatizing either the patient or the therapist. 10. It is impossible to ignore the organization of the healthcare system in order to alleviate the psychological suffering and treat psychological or psychiatric disorders of migrants and refugees. The funding of the healthcare systems needs to be recognized. As noted above, cultural mediation is one of the most representative interventions and practices in a transcultural health model and, yet, the less clearly defined professional identity in the healthcare sector. Because of nonuniform clinical practices, unequal training requirements, and often an absence of a regulatory

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professional body or committee, cultural mediators may be seen to lack legitimacy and recognition in terms of their professional identity. Although definitions of cultural mediations have evolved, in some places, cultural mediators are still perceived as “interpreters of traditions” and “representatives of the culture of origin.” On the other hand, culture brokers may well take some of these responsibilities to teach the team about the culture of people they are serving and teach the community the roles and functions of the team and its members. Cultural mediation involves more than linguistic translation. The use of mediation only for translation needs must be discouraged in a clinical context. The risk to reduce the cultural mediator intervention to a mere technicality and translation activity is high. This approach is detrimental to the quality of care, and it doesn’t consider all relational dimensions, nonverbal communication included, feeling of ashamedness, confusion, suspiciousness, trust and mistrust, etc. As most observers note, its function is to bridge between two worlds, two sets of representations. Culture is understood to be located on both ends of the communication, not simply on the immigrants’ or the ethnic minority members’ side. Also, the concept of cultural mediation must give full significance to cultural aspects in an anthropological way, giving value to cultural identity including tradition and experience. Language aspects are of primary importance including all forms of communication including body language. Identity is here a factor of significance. Dialogue between diversities is to be considered an added value if it develops new cultural relationships in a universal citizenship model. The cultural mediator, preferably a person sharing the origins and/or the migration experience of the patient, is neither only a translator nor a sort of (fictitious) “cultural expert.” With her or his active and critical presence, the cultural mediator introduces a “difference” in the setting, representing the possibility to reformulate the meaning of stories, experiences, and symptoms in a new productive form. Identity is not a fixed and stereotyped attribute of the person but a representation of oneself and the other constantly enacted and reformulated according to the situation. Cultural mediation is thus properly “productive” of a new “possible common identity,” allowing communication, mutual reformulation, and efficacy with a clear element of sharing. To acquire and strengthen the necessary skills, involved health cultural mediators should recognize and respect the code of conduct that acts as a professional regulation. As indicated earlier, cultural mediators are not mere translators. Their role is to help bridge knowledge between explanatory models. Such a skill requires an ability to move from one symbolic and semantic system to another (as underlined in the “decentring” definition) and to act as a bridge, moving across different representations of illness and healing models of the patients and their social and cultural context. The cultural mediator will be introduced to the team and to the patient in order to maximize mutual comprehension at both levels in the clinical setting. Nevertheless, it is important to bear in mind that, by no means, the contact with the user is the exclusive responsibility of the mediator, whose function is to accompany and facilitate the process. Therefore, the mediator’s presence should not be imposed.

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Acculturation is the process through which an individual’s cultural behaviors and values change when they come into direct or indirect contact with a new culture. Although some individuals accomplish acculturation smoothly, most experience psychological stress during the acculturation process. There are different levels of acculturation. Acculturation taps a variety of areas, including familiarity with mainstream new culture, endorsement of certain cultural behaviors and values, maintenance of a particular lifestyle, choices of social network, and decisions about how and where to seek help from. These are cultural variants that should be noted in a descriptive rather than a judgmental approach. It is important to recognize the diversity that exists within groups be they migrants or not. On the one hand, we should focus more on the acculturation process to obtain better psychological information and to give a wider range of answers to the patients. On the other hand, the acculturation process allows migrant patients to challenge the care provided, so they can decide for themselves what is reliable or not for their mental equilibrium. The multicultural process is much more complex than an accumulation of skills or a smart management of paradoxical attitudes. Biculturalism can lead sometimes to difficulties and misunderstandings which, in turn, could lead to interpretative thought and wrong appreciation of the intercultural dynamic in the process. It may generate communication problems not anyone can solve even with good coaching, linguistic skills, and a solid sense of humor. Biculturalism seems to be a dichotomy and a paradox; one is both cultures, and at the same time, one is neither. Some research has been done on this psycho-anthropological process, and the majority of studies demonstrates that many items are essential, for example: – The links between culture and personality – The attitudes of the host societies – The social, historical, and economical background to explain failures or success of acculturative dynamics The framework proposed by Berry (1990), on the process of acculturating immigrants and ethnic minorities, deals with two issues: – The extent of which they are motivated or allowed to retain identification with the culture of origin (the ethnic culture) – The extent of which they are motivated or allowed to identify with the mainstream, dominant culture According to Berry, the negotiation of these two central issues results in four distinct acculturation positions: – – – –

Assimilation (identification mostly with the dominant culture) Integration (high identification with both cultures) Separation (identification largely with the ethnic culture) Marginalization (low identification with both)

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Bicultural identity integration (BII) (Benet-Martinez and Haritatos 2002) is a framework for investigating individual differences in bicultural identity organization, focusing on bicultural subjective perceptions of how much their dual cultural identities intersect or overlap. BII captures the degree to which “biculturals perceive their mainstream and ethnic cultural identities as compatible and integrated vs. oppositional and difficult to integrate.” Individuals high on BII tend to see themselves as part of a “hyphenated culture” (or even part of a combined, “third,” emerging culture) and find it easy to integrate both cultures in their everyday life.

Cultural Competence The clinical medical anthropology has a very special advantage in the understanding and management of the doctor-patient relationship in intercultural situations. Instead of falling into the culturalism trap (exoticism) that is especially ineffective, cultural aspects of the representation of health and mental illness are integrated as one of the elements and not as the main theme. Moreover, when the caregiver or therapist has no control over the anthropological elements, this prevents him/her from dumping his/her own nosographic and explanatory model that does not necessarily integrate the cultural aspects. Clinical medical anthropology allows a mental health worker, regardless of theoretical orientation, to create a professional relationship, leading to diagnosis, therapeutic orientation, or psychotherapeutic work. Migrants’ mental health is largely the result of self-management in relation with the host society in each individual’s particular context. It is logical to assume that adaptive dysfunctions may arise in difficult situations, especially in terms of selforganization and interactions with the environment. This is an active mechanism, truly dynamic, depending on the logic of committed relationships; it may lead, through a process of acculturation, to results depending as much on the maturity of the defense mechanisms or the social perception of the migrant. Indeed, whether one borrows a cultural value or not, it costs psychic energy and socialization effort that directly or indirectly impacts the mental health of the migrant. Acculturation is an interaction between the individual and the environment, mobilizing his/her psychic energy at conscious and unconscious levels. It is a non-morbidity provider process which may lead to a mix between self-seeking, coping, resilience, and mental pathology. When a doctor-patient relationship is established, it aims at providing an indication resulting in either a treatment or a social orientation. It is a matter of interaction, how patients express their beliefs about the lack of health, and the presence of evil or illness, based on cultural explanatory models. Cultural items determine the benefit. The framework thus laid makes sense to consider this as a subsystem, which will determine the future therapeutic care’s decision and particularly in case of the migrant psychotherapeutic care (Moussaoui and Casas 2007). Based on clinical experience, what are the barriers that are often found?

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The challenge is to give the patient the opportunity to develop their own version of the disease or lack of health (some cultures do not consider the lack of health as corollary/or the presence of disease per se). This notion of illness, which reflects the subjective experience of pain, impotence, is the mental construction of lived abnormality; it is what the patient presents to his/her therapist. For Kleinman (1993), it includes “all changes and consequent physical and psychological reorganizations constitutive of the disease state. It is not just the patient’s sole subjectivity as non-patients increasingly share this as well. Therefore, it appears as a secular concept of the notion of the disease itself, its causes, consequences of his/her experience, and the means to address them.” In addition, the therapist will rebuild these representations of illness from the terms used by the patient, referring to their own personal explanatory and theoretical models; it is objectively attestable through the biophysical state and by the technicality of the practitioner, which aims to purify the notion of illness from all subjectivity. All professionals in the medical, psychological, and social fields share this representation of illness. This is called disease. Finally, tripod clinical medical anthropology is completed by the notion of sickness, which covers several aspects of living and social representations of the disease that we will detail further. This cultural competence is often a major asset in the complex process of the patient’s request, including possible obstacles in the proposed therapeutic care management. Directing the patient’s speech on spirits, ancestors, witchcraft, and hearing meta-communicative messages is being solely interested in the “background noise.” The therapeutic formatting and sustainability is therefore a job for two; culture does not play the role of the “third party.” One must let the cultural elements underline the speech without paralyzing it in an ethnological and stigmatizing approach and contextualize the cultural references within the framework proposed by the healthcare system, therefore emphasizing the cultural elements at hand. With this relational cover, it is not necessary to be a specialist in a particular culture, as it is not strictly necessary to remove all cultural references, in the name of the universality dogma of the psyche or, more seriously, the universality of the therapeutic practice. It is obvious that any therapeutic strategy, aiming to lock the subject solely in their cultural references, takes the risk of patient’s stigmatization and, perversely, the therapist as well. It is important to remind that there are rules on the doctor-patient interaction and relationships in a multicultural and intercultural context. For example, a migrant patient expresses his/her mental illness through cultural representations (illness). This subjective presentation belongs to him/her and is shared by a majority of his/her ethnic group. It is fundamental not to confound the migrant patient and his/her personal fate with the migrant group to which he/she belongs. Lived experiences are always to be considered with care: ethnocentric unconscious attitudes are risky for any therapist, whatever is his/her origin. The phenotype, knowledge of language, and knowledge of the culture are all conscious and unconscious information involved in the transference and countertransference relationship. A nonmigrant therapist entangled in his/her ethnocentric issues is just as ineffective as a migrant therapist entangled in the perverse effects of cultural complicity.

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The question inappropriately asked is “what therapist for the migrant?” The debate should not be on ethnicity, which would only be a way of stigmatizing “foreigners” further, but on the therapist’s cultural competence skills, which is another form of good clinical practice. Clinical medical anthropology allows us to understand better the systemic aspects that emerge in the confrontation of the migrant mental suffering with the healthcare system, presenting hence a real advance in medical ethics. With this “fertilization,” we must use continuing education and training, trivialize the use of linguistic and cultural interpreters when it is the most practical way to solve serious communication dysfunctions, and facilitate assistance to the diagnostic or therapeutic decision. This approach will add to the consistency of care. Clinical cases differ depending on the individuals at hand, pathology, and how this condition is expressed. This is not the place to list all the “specific” diseases that we believed there is a need to isolate here and there, freezing them in its cultural traps (exoticism remoteness vs good distance). The debate on the universality of psychosis or mental illness is a false one, especially as it is often an attitude of denial about the anguish of ignorance or the inability to learn from the other. The clinician can identify the psychological disorder only if the mind lets its thoughts run through. For this, it must be accepted in any background whatsoever. If the patient develops a cultural explanation which could be seen as almost delusional and that during the interview he is able to criticize or distance himself from this explanation, by demonstrating his capacity to admit other etiologies, including neurobiology and psychoanalysis, then the delusions become more easy to discuss. In psychopathology, the possibility for the patient of whatever origin to express himself confidently in good language conditions, in a location identified as a safe environment, respecting professional privacy and secrecy, is a guarantee for a good binding relationship. But what if a therapist secretly laughed at the patient’s speech that claims to be bewitched by an evil spirit or a patient who says that she contracted marriage with a spirit in a parallel universe? What if a therapist refuses to differ from his/her quick diagnosis of psychotic disorder when exposed to such strangeness that can sometimes be perceived as cultural rejection? And why not say, to better know ourselves, that racism is not confined to others and that, unfortunately, we are not immunized against stereotypes on migrants and refugees? What to do when faced with the patient’s delusions, the therapist feels personally concerned, either by the fact that it is a reference to his social group or by the skin color or in relation to alleged political positions? What to do when the proposed therapeutic solutions have more negative than positive effects? What to do when a traditional healer challenges the treatment? What should be done when a cultural practice is considered as addiction by the caregiver? How should one make a diagnosis when a Buddhist patient describes severe depression symptoms but does not consider them as such? Should we get into a “cultural trance” or should we be “possessed” by a vast anthropological knowledge? Can we know everything about all cultures worldwide? Wouldn’t it be more practical to organize ourselves around a universalist theory that would venture into “all unconscious” or all

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biological whatever the ethnicity at hand? Should we provide specializations and trainings to specific professionals that would be more culturally qualified than others? If we list all these issues, it is not to make the clinician’s work more difficult, but complexity, as Edgar Morin meant it, is important to interface with knowledge, beliefs, and assumptions. The clinical medical anthropology, as promoted by primary care physician Helman and psychiatrist Kleinman, has the advantage of leaving a much greater room for the patient’s speech. The patient can therefore assert his/her argument using his/her own representations on the one hand and on the other urge the caregivers to understand their own explanatory models. This is the approach that is operative, not just the theory. It is the first psychological and ethical step when working in the migration and mental health field. “The thickness of experience” in transcultural psychiatry does not exclude that, at any moment, it is possible to feel incompetent. The art of healing or providing support sometimes consists of appointing resourceful professionals from a specialized linguistic and cultural interpreter to a colleague/therapist from the same culture, to untangle a serious situation. Social workers have long been confronted to interculturalism in their daily practice. It is an encounter with the migrant who comes seeking help with his/her unique history and migratory path. This consultation is sometimes punctuated with obstacles where the cultural argument is often seen itself as an obstacle. The great difficulty in intercultural situations is that the implicit knowledge is not always shared. Of course, the world of the social field, like society as a whole, is not immune to different ideological representations and discourses on migrants, their cultural performances, and serious stress in case of failed acculturation process. It is easy to fall into a trap of culturalism where it freezes “the other” in its culture by focusing only on the cultural, ignoring this dynamic phenomenon that is acculturation. The other trap is denial, which reinforces cultural difference and opens the door to many ethnocentric slips, through racism and xenophobia. Clinical medical anthropology offers an open approach. Without being anthropologist of all cultures, it helps to decentralize from our own cultural references, to depart from certainties, not pathologizing what is cultural or culturalizing what is pathological. Like the transcultural clinical work, cross-cultural social intervention integrates the migratory and cultural facts to better understand and help. This is not culture instead of care or social intervention, but the opposite, and without stigmatizing the patient or user or professional. Social interventions may help overcome some crises or promote change to a state of well-being and, in that sense, may have a therapeutic effect. A precarious social situation, as lived by a number of migrant families, asylum solicitors, recognized refugees, or rejected asylum-seekers, with an arduous migration path, without legal status, without papers, without work, and often homeless, may be the cause of psychological breakdown. On the other hand, unstable mental balance can cause a deterioration of social equilibrium. Mental suffering, along with social suffering, requires multidisciplinary work, a shared practice to co-build and innovate.

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Confrontation of cultural representations may be seen in parental roles: in some traditional societies, one of the educational levers is made of corporal punishment and confronts itself to child protection laws. We must here be attentive to social suffering: living conditions, environment, family, labor, housing, legal status (the famous papers, without them, mean no job and no home without work; it is a vicious circle), and exclusion. All these elements come together in the concept of sickness. It is part of the clinical medical anthropology triptych where a patient is expressing illness and the therapist will interpret it into disease. A balance is needed between these three dynamics to provide an appropriate response to the demand of treatment. One should not neglect any of these three aspects to provide the best medical, psychological, and social response. We can conclude that this particular support, this specific knowledge associated with a precise know-how, prevents from focusing on the cultural origins and instead promotes focus on the person’s suffering. All professionals can make theirs this approach, even if they do not have control over the anthropological elements. It allows “avoiding to dump indiscriminately explanatory models that do not necessarily integrate all cultural representations.” While sometimes, in the words of Rapaille (2008), “a lot of answers are there before our eyes, but we do not know how to read them, it lacks the cracking code.” The inclusion of cultural representations is what allows us to use this framework for action, by adopting an attitude of eccentricity, which the social psychologist CohenEmerique so clearly observed (2000), but also curiosity to another (in the engaging conversation, agreeing to say “I do not know, you tell me”) and professional rigor to see these “caretakers” in their singularity, without stigmatizing or using an ethnocentric perspective, avoiding certain excesses, such as abusive placements of children. That is why it seems essential not to use this approach without adequate training in cultural competence that relies on three essential points: • Mastering intercultural communication • Acceptance of the confrontation of explanatory models • Identification of the mental health professional’s area of expertise in the healthcare system To conclude, we would like to recall some essential lines that govern our current operation: • Cultural representations of health and disease and language barriers are central to the doctor-patient relationship and remain the key challenge in the diagnostic process, therapeutic indication, and any accompanying or support strategies. • Avoiding strictly to bind patients to a culture prevents the risk of stigmatization on the one hand and on the other puts the caregivers in the risk of the “burnout” syndrome stuck with the cultural kit (that’s how it’s done in their culture) or the fantasy of saving universalism (that is how we heal the world). • Good practice in these cases would be:

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– To bypass the language barrier when necessary by using a linguistic and cultural interpretation – To consider that the explanatory model confrontation improves medical service and psychotherapeutic or social support – To focus the therapeutic project on the person and not on his/her culture and maintain an active position in the professional care’s response to the patient’s request (Kleinman 2006) Other approaches may have their place and role but are within the innovative perspective of clinical medical anthropology: • The patient has the opportunity to express his/her physical or mental suffering by using cultural metaphors that seem most explicit (illness). • The caregiver confronts these formulations to his/her own theoretical approaches, a valid diagnosis and/or prognosis (disease) without losing the necessary distance of empathy or countertransference as appropriate, thus avoiding the risk of cultural complicity (only someone of his/her own culture may understand) or supposedly universal remoteness. • In any case, we will need to give all the space needed to the social and cultural elements which also structure the lived experience (sickness) of any pathology, let alone heavy chronic diseases, debilitating or life-threatening.

Comparison of Cultural Representations of Mental Illness What could be more normal for a migrant or refugee as to have his illness unfold using the subtleties of language and basing himself or herself on cultural references drawn from their imagination, itself being the product of an educational and cultural sociological impregnation? Besides, nothing prevents an immigrant or refugee from being aware of new therapeutic approaches which, through intuition or having researched on the Internet, an individual eventually finds himself or herself referring to these potentially therapeutic strategies; what we mean by that is that it is not forbidden to refuse to be stuck in one’s culture through the eyes of another, albeit the other is a therapist. In the same way, a therapist in his theoretical and ethical approach must avoid two pitfalls that everyone describes – namely, cultural fascination or cultural rejection. It is not excluded that any therapist can understand that a process of witchcraft or divination can have their meaning in psychological defense mechanisms mobilized by a migratory path or a path of exile.

Person-Centered Cultural Psychiatry Person-centered psychiatry aims to reorient clinical practice around understanding and engagement with the patient as a person. A crucial aspect of this shift is systematic attention to the social world in which the person lives, both in terms of

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historical and biographical developments of individuals and their current living conditions. Human beings are social and cultural beings. Hence, medicine and psychiatry must take cultural and social context into account in understanding and responding to illness and promoting health and well-being. However, as our social worlds have changed with new technologies, forms of community, and global networks, it is within the nature of culture. Ultimately, we will need to discuss specific tools and strategies for assessment and treatment that are culturally informed as well as highlight some issues for healthcare policy and promote mental health, mainly through cultural epidemiology surveys (Weiss 2014). In this approach, culture is not simply a matter of discrete social factors, values, or beliefs but is composed of a matrix. As such, understanding how cultural identities play a role in a society is the subject of psychiatry centered on the person that seeks to provide equitable and efficient care. It is equally important to explore with each patient not only their cultural origins and their stories but specific aspects of their knowledge, lifestyles, and social identities or affiliations relevant to their healthcare. These hidden cultural dimensions include the dimensions of personal and collective identity, the experience of health and disease, social determinants of health, and the wider sociopolitical context of the clinical encounter and health of the population. Revealing these tacit dimensions of culture requires a systematic investigation guided by perspectives of social sciences. In this way, a culturally informed clinician can develop a more complete picture of the world as lived by the patient and the patient’s situation. The care centered on the person starts with the involvement of patients as persons in their own terms, and this includes how they understand their own identities. However, identity is not a monolithic construction. The answers that the clinician can obtain in response to questions about the identity depend on how the question is asked, as well as the perceptions of the clinician, the safety of the clinical setting, and finally how people consulting understand symptoms and illness, their current difficulties, their paths in life, and their social position. However, self-understanding has its limits. People may not be aware of most of the social, cultural, and contextual factors that shape their identity and health problems. That’s why we must admit that we are in front of a person and not a culture. In fact, the notion of person itself is a cultural construction, and there are significant variations in what is considered a central element of the person, constitutive of identity, revealing some health indicators, adaptive functioning, and social, moral, religious, spiritual, and ethical values (Kirmayer 2007). However, the forms of social life vary considerably across cultures. Research on social determinants of health has drawn attention to a range of factors related to social inequality, structural violence, and the political economy of healthcare (Allen et al. 2014).

Implementation of Cultural Competence in the Healthcare System Globalization has not eliminated cultural diversity but has given rise to new hybrid forms. The networking made possible by information technology has created new types of identity and community, new sources of resilience and recovery, and new

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illnesses. The resolution of these new forms of personality, lifestyle, and conflict requires epidemiological research and ethical clinical innovations. With globalization and increasing migration, communities everywhere are increasingly diversified, and policy makers must respond to changing demographics. One can argue that person-centered care that is culturally sensitive deals with the quality of the clinician-patient relationship, with a security of framework and clinical practices, and organization of healthcare systems and institutions (Kirmayer et al. 2014; Mezzich et al. 2010). The cultural formulation process can be facilitated by such frameworks as the Cultural Formulation Interview in DSM-5 (Lewis-Fernández et al. 2014; Mezzich et al. 2009). Significantly, the DSM-5 recognizes the Cultural Formulation Interview as part of the person-centered care regarding all patients, no matter what their origin. While the reflex of many clinicians, when confronted with a patient who is culturally or linguistically “different,” is to focus on language barriers and cultural references, person-centered transcultural psychiatry developed by Minkowska Center (Bennegadi et al. 2009) is not centered mainly on the language or any other sociological consideration but approaches each patient with a consideration of the person in all its complexity. The aim should be to ensure diversity and cultural competence in all aspects of mental healthcare but also to emphasize that mental health is as important as physical health in the policy of social development and the long-term integration. This way mental health services can facilitate adaptation and social integration of immigrants and promote cultural capital associated with diversity (Kirmayer 2011). Table 5 illustrates various strategies which can be used for the integration of cultural competence into healthcare provisions.

Clinical Medical Anthropology and Cultural Competence IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC 2007), endorsed by more than 35 organizations involved in humanitarian assistance, provides essential guidance for multi-sector responses to protect and improve people’s mental health and psychosocial well-being in the midst of an emergency. Treatment can only be provided by certified clinicians and in accordance with national regulations. Whenever possible, it is preferable to refer people with severe mental disorders to appropriate secondary services. This may include people with preexisting disorders in relapse or crisis, people with psychotic symptoms, people who are unable to function or who are at risk of harming themselves or others, and also substance users in abstinence due to the crisis. When referral is not possible and immediate treatment has to be provided, considering the prescription of medications that are likely to be available in other countries, such as those from the WHO list of essential medicines, it is important to provide a list of essential medicines at health posts in arrival and transit areas. A pharmacological prescription should not only include the brand name of the medication but also its chemical/pharmacological one, in order to make identification easier. The clinician or the prescriber must give all patients a written text about the prescription to show at border checks. It is better

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Table 5 Strategies for the integration of cultural competence into healthcare provisions (Bennegadi 2016) Strategy Bettering access to healthcare Aiming to reduce stigma

Strengths • Teaching individuals and communities how to identify mental health problems • Bettering access to mental healthcare services

Improve intercultural communication by working with linguistic and cultural interpreters or ideally cultural mediators as part of mental health (culture brokers, Kirmayer) Cultural competence of the clinician Healthcare centered on the individual and not only on a language or a culture

• Well-trained interpreters who adhere to ethical guidelines • Cultural mediators trained in the field of mental health

Cultural competence of the institution Generalization of the approach of clinical medical anthropology (Kleinman) Early university education in the training of therapists (Bennegadi) Expansions of opportunities in researching cultural epidemiology (ETIC-EMIC) (Weiss)

• Professional competence in the profession of a psychotherapist (diploma and supervision) • Training in clinical medical anthropology that allows the foundations of cultural competence • Training of all mental health professionals in cultural competence in the framework of lifelong training • Generalize the utilization of the interpreter in all healthcare facilities • Not losing sight of the organization of the healthcare facilities from the legal point of view

Weaknesses • Problems of information vectors (website, multilingual brochures), messages that take into account cultural references • The difficulties of making a real effort in the education of health • Difficulties in maintaining a relevant discourse that does not stigmatize to explore the cultural context • Difficulties in mastering clinical medical anthropology • A tendency to place culture with the patient and expertise with the clinician • It may not fully underline the questions of ethics

• Resistance to cultural changes and to practices despite the competition between facilities for the “best practices” • Difficulties in evaluation of practices to enhance empowerment

to use simple health travel cards to enable refugees and migrants to carry information with them about their medical problems and the required treatment.

Clinical and Social Practices: Migration Requires Medicopsychosocial Care Avoiding Stigma and Cultural Assignation “We can only avoid stereotypes if we are conscious of them.” Cross-cultural education can be divided into three conceptual approaches focusing on attitudes (cultural sensitivity/awareness approach), knowledge (multicultural/categorical

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approach), and skills (cross-cultural approach). Research to date demonstrates that training is effective in improving provider knowledge of cultural and behavioral aspects of healthcare and building effective communication strategies.

Strengthening Doctor-Patient Relationships Several research studies suggest that the consistency and stability of the doctorpatient relationship is an important determinant of patient satisfaction and access to care. Having a usual source of care is associated, for example, with the use of preventive care services (Agency for Healthcare Research and Quality 2001). In addition, having a consistent relationship with a primary care provider may help address minority patient mistrust of healthcare systems and providers, particularly if the relationship is with a provider who is able to bridge cultural and linguistic gaps (LaViest et al. 2000). Minority patients, however, are less likely to enjoy a consistent relationship with a provider, even when insured at the same levels as white patients (Lillie-Blanton et al. 2001). This is due in part to the types of health systems in which they are enrolled and the relative lack of providers located in minority communities. Within each cultural group, there is a tremendous amount of variability or individual differences. It is true that “they are not all alike.” Differences arise from a number of factors and should be recognized so that providers can serve clients’ individual needs.

Conclusion Create a Multilingual and Multidisciplinary Therapeutic Team Create a multilingual and multidisciplinary therapeutic team integrating their competences in a complex intervention. For mental health work, this means psychotherapists and psychiatrists, anthropologists, cultural mediators, social workers, community and clinical psychologists; for women health and family, this includes general practitioners and pediatricians, breast specialists, gynecologists, cultural mediators, psychologists, social workers, nurses, and anthropologists. The multidisciplinary and professional team is able to receive users from different nationalities or communities that have specific linguistic, religious, and cultural characteristics through using their first or preferential language and with consideration for their cultural representations of healthcare, of the body, and of suffering. It is up to the professionals to answer specific care-seeking concerns: diagnostic and therapeutic view, mediation, collaboration with other teams (particularly in the perspective of joint therapies), but also prevention through raising awareness. Favoring multidisciplinarity can also be achieved by including social services which will ensure/assist with healthcare access.

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Health Cultural Mediator Is Part of the Team The unit of cultural mediation is part of the therapeutic team and composed by professionals who preferably share language and origins of the main migrant and ethnic minority populations, providing the possibility of activating intervention “on demand” for specific needs. As a general standard, family and friends are not used to provide interpretation services. In case of specific patients’ request in this sense, the new guest will be considered an interlocutor in the therapeutic process and not a surrogate of the cultural mediator. Service providers should have written guidelines and a contract that mediators are asked to adhere to and ideally sign – covering aspects such as confidentiality, roles, responsibilities, and ethics.

Training Professionals Within the “Cultural Competence” Framework Training healthcare professionals and operators in “cultural competence” and cultural mediation in the context of healthcare is important. The training should also be extended, when possible, to community health workers.

Work with the Network The team works in a continuous relationship with the network of services available in the community and community health workers, offering interventions addressing clinical and social needs. Moreover, the team should represent a resource available to other institutions for activities of consultation on patients, supervision, or institutional advice. Cases, in which users are sent by other institutions that expressed difficulties with them (particularly social services or educative organizations), will be given particular attention in the sense that the team’s approach will include the relation between the user and the institution.

Assure Healthcare Access to All The access to the service is guaranteed for all patients independent of their administrative status: paper regularity will not represent a discriminating feature, and in no case patients’ data will be reported to the authorities for immigration. The general principles that must always be taken into account are ethical awareness, respect for people’s rights and dignity, beneficence, non-maleficence, professional responsibility, justice, competence, context-centered practice, and consciousness of the complex dimensions of difference.

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References Agency for Healthcare Research and Quality (2001) AHRQ quality indicators—guide to prevention quality indicators: hospital admission for ambulatory care sensitive conditions. Agency for healthcare research and quality, Rockville, MD. AHRQ Pub. No. 02-R0203 Allen J, Balfour R, Bell R, Marmot M (2014) Social determinants of mental health. Int Rev Psychiatry 26(4):392 Benet-Martinez V, Haritatos J (2002) Bicultural Identity Integration (BII): components and psychosocial antecedents. J Pers 73:1015–1050 Bennegadi R, Bourdin M-J, Paris C (2009) Les apports de l’anthropologie médicale clinique dans la relation soignant-soigné en situation interculturelle. La revue du soignant en santé publique, novembre-décembre 34:14–16 Berry JW (1990) Psychology of acculturation. In: Berman JJ (ed) Nebraska symposium on motivation, 1989: cross-cultural perspectives, Current theory and research in motivation, vol 37. University of Nebraska Press, Lincoln, pp 201–234 Castles S, Miller MJ (1998) The migratory process and the formation of ethnic minorities. In: The age of migration. Springer, New York, pp 19–47 Cohen-Emerique M, Camilleri C (2000) Chocs de cultures: concepts et enjeux pratiques de l’interculturel. L'Harmattan, Paris European Union Agency for Fundamental Rights (2011) Migrants in an irregular situation: access to healthcare in 10 European Union Member States. http://fra.europa.eu/en/publication/2012/ migrants-irregular-situation-access-healthcare-10-european-union-member-states. Accessed 18 Nov 2016 Eurostat (2015) “The number of asylum applicants in the EU jumped to more than 625 000 in 2014”. http://ec.europa.eu/eurostat/web/products-press-releases/-/3-20032015-BP. Accessed 8 Nov 2016 Fernando S (2005) Multicultural mental health services: projects for minority ethnic communities in England. Transcult Psychiatry 42(3):420–436 Inter-Agency Standing Committee (IASC) (2007) IASC guidelines on mental health and psychosocial. Support in emergency settings. World Health Organization. http://www.who.int/mental_health/ emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf. Accessed 20 Nov 2016 Kirmayer LJ (2005) Culture, context and experience in psychiatric diagnosis. Psychopathology 38(4):192–196 Kirmayer LJ, Groleau D, Guzder J, Blake C, Jarvis E (2003) Cultural consultation: a model of mental health service for multicultural societies. Can J Psychiatr 48(2):145–153 Kleinman A (1993) In: Gaw AC (eds) Culture, ethnicity and mental illness. American Psychiatric Press, Washington, DC Kleinman A (2006) What really matters: living a moral life amidst uncertainty and danger. Oxford University Press, New York La Viest TA, Nickerson K, Bowie J (2000) Attitudes about racism, medical mistrust, and satisfaction with care among african american and white cardiac patients. Med Care Res Rev 57 (1):146–162 Lewis-Fernández R, Aggarwal NK, Baarnhielm S, Rohlof H, Kirmayer LJ, Weiss MG et al (2014) Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry 77(2):130–154 Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M (2001) Race, ethnicity and the health care system: public perceptions and experiences. Med Care Res Rev 57(1):218–236 Mezzich JE, Caracci G, Fabrega H, Kirmayer LJ (2009) Cultural formulation guidelines. Transcult Psychiatry 46(3):383–405. https://doi.org/10.1177/1363461509342942 Mezzich JE, Salloum IM, Cloninger CR, Salvador-Carulla L, Kirmayer LJ, Banzato CE, Wallcraft J, Botbol M (2010). Person-centred integrative diagnosis: conceptual bases and structural model. Can J Psychiatr 55:701–708

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Mitchell G, Weiss (2001) Cultural epidemiology: an introduction and overview. Anthropol & Med 8:1:5–29. https://doi.org/10.1080/13648470120070980 Moussaoui D, Casas M (2007) Salud mental en el paciente Maghrebi. Barcelona, Editorial Glosa Rapaille C (2008) Culture Codes : Comment déchiffrer les rites de la vie quotidienne à travers le monde. JC Lattès, Paris Tseng WS, Streltzer J (eds) (2004) Cultural competence in clinical psychiatry. American Psychiatric Publishing Inc, Washington, DC

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Mental Health Among Latin American Migrants in the USA Renato D. Alarcón

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immigration Phenomena and Latino Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Why, How, and Where of Latino Immigration to the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age, Education, Work-Related and Financial Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hispanic Acculturation and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Findings in Latino Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiological and Clinical Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Treatment Systems for Latino Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Service Availability and Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accessibility and Utilization of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practical Aspects of Clinical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outcomes and Satisfaction Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The Hispanic or Latino population is currently the largest minority in the USA. Thirty-three of the total of 54 million Hispanics in the country are not US-born and have arrived as immigrants from countries of the large territory that includes Central and South America and the Caribbean Islands, besides Spain. This chapter reviews the sociodemographic realities of Latino migrants to the USA,

R. D. Alarcón (*) Mayo Clinic College of Medicine, Rochester, MN, USA Universidad Peruana Cayetano Heredia, Lima, Peru e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_7

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specific circumstances of the actual migration process, and its impact on the mental health of migrants and their families. The acculturation experience and its stressful nature are examined as one relevant source of a variety of clinical conditions. Prevalence and incidence figures of depressive, anxious, substance use, psychotic, and other disorders are analyzed, and the characteristics, resources, adherence, response, and outcomes of services provided to Latino migrants are also described. The growing relevance and role that the Hispanic community plays in the daily life of the USA, positive and negative factors in their adaptation to the host country, and research needs from clinical and social sciences’ perspectives are presented. Keywords

Latino/Hispanic migrants · Cultural psychiatry · Acculturation · Mental health services

Introduction One of the most complex realities in today’s world, migration, both within the confines of a country or a region or that of an international or intercontinental nature, provides a truly human ingredient to the globalization process and, nourished by the massive, yet impersonal advances of technology, often defies also the most careful approaches by governments, world agencies, social contracts, political systems, and financial planners (Kraidy 2005; Carballo 2006). It can be said, without exaggeration, that migration has drastically changed the face of world’s society, particularly in the last two or three decades (Fisher and Cooper 1990). In the USA, considered the country with the most diverse population, immigration’s effects on its sociodemographic status have been a pervasive yet changing feature. From the beginning of its modern history about five centuries ago, the composition of the US population has frequently changed due to different waves of immigrants from practically every region of the globe. Although the notion of “melting pot” conveys an idealized process of integration and wishful thinking regarding homogenization (Jacoby 2004), social scientists, political leaders, and even the public seem to accept more today the concept of “pluralism” to justify and explain the persistence of original habits, beliefs, collective practices, and language, in spite of the demands and expectations of the newcomer-host society transactions (Connolly 2005). This chapter will describe aspects of the immigration process as experienced by Latino (or Hispanic) men and women from all age groups, born and originally living in 20 countries south of Rio Grande and 4 Caribbean islands which have predominantly Spanish-speaking populations. Epidemiological and clinical facts about the mental health implications of such experience and the variety of interactions regarding the treatment and overall management of Latino immigrants as patients in the US health system will also be explored.

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Immigration Phenomena and Latino Populations The question on Hispanic origin was first introduced in the 1970 US Census documents (Davies 2009), reifying the Latino or Hispanic condition as an ethnic/ cultural group, not a race. Throughout the last 15 or 20 years, Latinos have consistently constituted just over half of the foreign-born living in the USA (Acosta and De La Cruz 2011; Grieco et al. 2012; Passell and Cohn 2014). In 1980, 14.8 million Hispanics made up only 6.5% of the US population, while, according to recent data, in 2014 there were 55.3 million, comprising 17.3% of the total population; this is the largest minority in the country in the twenty-first century and the second largest total behind Mexico’s 121 million (would be the third, if Portuguese-speaking Brazil is included). Moreover, projections for 2050 (104 million) and 2060 (128 million) only confirm a consistent growth pattern (US Census Bureau 2015). It is important to point out that the Latino demographic picture in the USA includes mainly Mexicans as the largest subgroup (over half of the total, 33 million people in 2013), Cuban/Caribbeans, Puerto Ricans, Central Americans (largest subgroup from El Salvador), and South Americans (largest subgroup from Colombia). During the first decade of this century, the Puerto Rican group grew by 36%, from 3.4 to 4.6 million, and Cubans by 44%, from 1.2 to 1.8 million. Hispanics of other origins increased by 22%, from 10.0 to 12.3 million, whereas South American Hispanics doubled up from 1.4 to 2.8 million, reaching 5% of the total Hispanic population. Of note, the Spaniard subpopulation showed the largest percent increase, from 100,000 in 2000 to 635,000 in 2010 (Stepler and Brown 2016). The realities of exclusively Mexican immigrants to the USA have been the subject of many studies. Durand et al. (2001) delineate “four key historical junctures” in this process: (a) the “classic era” of open immigration before restrictive policies were established in the 1920s; (b) the Bracero era (1942–1964), prompted by World War II needs, led the US government to sponsor a large temporary worker program; (c) the era of undocumented migration, between the end of the Bracero Program and the passage of the Immigration Reform and Control Act (IRCA) in 1986; and (d) the post-IRCA era (extended to the present time), a period in which attempts to suppress or slow down undocumented migration have led to fierce political debates throughout the country. It is also a fact that, in a relatively short number of years, Mexican immigration has changed and expanded in terms of geographic origin and destinations, economic rearrangements, and levels of sociocultural engagement. Since the change in political landscape in 2016 Presidential elections, President Trump’s views and rhetoric have added another dimension. Colby and Ortman (2014) describe the “baby-boom cohort” in the USA up to 2012 and comment on projections made toward 2060. The largest percentage increase in the baby boom population (148%) occurred between 1946 and 1947. Growth continued through 1964 and remained stable for the next two decades (about 0.5% each year) mostly driven by international migration. After a slight increase in the early 1990s, growth declined by 1999, and the prediction is that such trend will

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continue: it was 0.6% between 2011 and 2012, projected to fall to 2.7% between 2030 and 2031, and go further down between 2059 and 2060, to 21.9%. A point to be made, however, is that the elderly Latino population was one of the fastest growing segments among the “baby-boomers”; currently, they comprise 11% of the total Latino population, projected to increase to 12.4% in 2060.

The Why, How, and Where of Latino Immigration to the USA People migrate due to a variety of reasons (“why”) and do so (“how”) in different ways to, finally, settle down (“where”) in different zones of the host country. Among Latinos, the why of migrations to the USA entails economic, political, and social factors, natural disasters, family, and professional reasons (Alarcón et al. 2016). Poverty, from different origins, is a powerful determinant, particularly among many undocumented Mexican and Central American immigrants (Durand et al. 2001) in addition to Caribbeans such as Dominicans and those born in Barbados, Grenada, Haiti, Trinidad and Tobago, and St. Lucia (Livingston et al. 2007). Another important social factor may be gender or sexual orientation-related violence (i.e., homophobia) (Alcalde 2014). Political factors encompass exile or persecution, violence, or ideological conflicts and, over the last several decades, have determined migration from countries like Cuba, Nicaragua, Guatemala, El Salvador, Chile, Colombia, Bolivia, or Ecuador. Quite frequent in Latin America, earthquakes, ocean storms and floods (tsunami), volcanic eruptions, and other natural disasters trigger decisions to migrate. Family-related factors involve young adult immigrants who, once more or less “established” in the USA, call, urge, and pay their parents’ or other relatives’ way to join them (Durning 1991; Beiser and Hyman 1997). Finally, professionals in a variety of fields migrate in search of more attractive work opportunities; actually 17.5% of the 10.5 million college-educated immigrants in the USA are Latinos (Zong and Batalova 2016). Practically speaking, there are only two ways (“hows”) through which Latino immigration to the USA may occur: legal and illegal. The latter is, of course, source of political and bureaucratic debates, and its ultimate fate remains uncertain in the present political climate. From 2009 to 2012, the population of unauthorized immigrants grew in 7 states and fell in 14, the latter mostly due to a decline in Mexican immigrant numbers (Passell and Cohn 2014). In 2012 there were 11.2 million “illegals” (3.5% of the total US population), one million less than the peak year of 2007, before the last recession (Baker and Rytina 2013). 8.1 millions of them were working or looking for work and made up 5.1% of the country’s labor force. Where do Latino immigrants settle down once in the USA? Historically and mostly due to their geographic proximity to the Mexican border, California, Arizona, New Mexico, and Texas have been the most frequent receivers of both Mexican and Central American immigrants. However, as Durand et al. (2000, 2001) point out, factors such as economic growth and subsequent needs in other areas of the USA, and changes of the country’s policies, have altered this pattern. For instance, Illinois, a non-border state, is now an important destination. During the first two decades

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of the twentieth century, the development of railroads in the USA, connecting agricultural and mining areas as well as industrial cities in regions other than the West, and their integration with Mexican rail systems facilitated labor supply. In the “classical era” of immigration, Colorado and Kansas became salient destinations; later on, the so-called Bracero Accords made possible the annual importation of Mexican farmworkers and, in the 1960s, the turning of Mexican immigration to industrialized, non-gateway states such as Michigan and New York. Nevertheless, the emergence of states like Florida, Idaho, Nevada, New Jersey, and Utah as recipients of Hispanic immigrants was already evident by the late 1950s. During the “undocumented era,” Illinois was the only exception to a downward course of immigrant numbers. As a result of IRCA’s general amnesty and a special legalization program, local labor markets were flooded, and newly legalized immigrants had more freedom to move. An early 1990s economic crisis in Mexico resulted in a rapid shift away from California and toward those “nontraditional destinations.” Soon thereafter, states such as Georgia and North Carolina in the Southeast, Minnesota in the mid-West, and Oregon in the West were added. By 1990, California housed 57% of all Mexican immigrants, followed by Texas with 23% and Illinois between 8% and 10%. But in 2010, California had only 25.8% of Latin American and Caribbean immigrants, followed by Texas (14.2%), Florida (13%), New York (10.2%), and New Jersey and Illinois (4% each). When combined, the first four states accounted for 63% (or 13.4 million) of the total Latin Americanborn immigrants (Acosta and De La Cruz 2011). Interestingly, percent-wise, New Mexico has the highest rate of Hispanic population in the country (47%). The post-IRCA period saw also more single men and women moving from agricultural/rural to urban employment. In addition to California metropolitan areas, their counterparts in New York City, Houston, Phoenix, Dallas, Las Vegas, and Minneapolis settled in an increased diversity of immigrant subpopulations. In 2010, more than half of foreign-born populations in 19 states came from Latin America, staying mostly in the West and Southwest. Only in nine states did Latin American immigrants constitute less than 25%, e.g., 10% in Maine and North Dakota and 8% in Hawaii.

Age, Education, Work-Related and Financial Issues The median age of Latin American migrants is 34.7 years, the lowest, among Mexicans (33.4 years), and the highest, among Cubans (46.5 years). Among all Latino immigrants, Mexicans have the lowest rate of high school completion (40%), the second smallest percentage of naturalizations (32%), but the most likely to be married (58%) and have the largest family size (4.4 persons) (Acosta and De La Cruz 2011; Kochhar 2008). With regard to language, 32% of Caribbeanborn were more likely to speak only English at home versus 15% from South America, 7% from other Central American countries, and 3% from Mexico. Work and occupational status among Latino immigrants exhibit an equally heterogeneous scope. Even though between 2009 and 2013, Latinos accounted for

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43.4% of total jobs growth, and the group’s purchasing power is on the rise, still the majority of Mexican migrants are mostly involved in agriculture and manufacturing jobs, Puerto Ricans work more in industrial factories (leather and textile), and Central and South Americans have taken white-collar and administrative jobs (Fullerton 1991; US Bureau of Labor Statistics 2013). Cubans (particularly in Florida) seem to have followed the most successful path since the arrival of the first exiles in the 1960s (Cattan 1993). Latino women are less likely than non-Hispanics to be part of the workforce. Income levels reflect the same situation: Mexican householders had the lowest median annual household income in 2014 (US $ 39,200) versus US $ 49,741 among householders born in South America, compared to US $ 85, 369 earned annually by North American households. 29.1% of the Latino population in the USA does not have health insurance coverage. The annual growth rate of noninsurance (7.6%) has always been the heaviest among Mexican immigrants; for all Latino immigrants, it was 7.6% in 1977, up to 19.7% in 1992, whereas Cubans experienced only a 1.1% increase. By 2010, 71% of Caribbean immigrants were covered versus 51% of the rest of Latino immigrants with some form of health insurance; yet in all Hispanic subgroups, the likelihood of a private insurance coverage was lower than in non-Hispanics (Berk et al. 1996).

Hispanic Acculturation and Mental Health Acculturation, the process of contact, mutual interactions, and resulting new products between two and more different cultural patterns, is a social phenomenon classically connected with migrations. There is no uniform or conflict-free acculturation – its outcome may be the result of many, even unknown, variables (Sam and Berry 2006). Acculturation research has mainly explored: 1. The role of positive and negative factors from the two or more cultures involved in different phases of the process 2. The reasons, motivation, group composition, and methods of immigration 3. The characteristics of the society of origin 4. The constant need for measurements and comparisons (Cabassa 2003) Acculturative stress among Latino immigrants to the USA is lower for those who migrated voluntarily than for those who had to leave their country of origin as refugees (Lueck and Wilson 2011; Torres and Wallace 2013). Most acculturated individuals succeed, although to varying degrees. This includes, supposedly, English proficiency, even though findings among Latino immigrants are somewhat paradoxical: the risk of mental disorders in this group was significantly higher among those with high English language proficiency (Ding and Hargraves 2009). Bacallao and Smokowski (2007) conducted a study on Mexican family system changes after immigration. Using in-depth semi-structured interviews with parents and adolescent children of ten undocumented families recruited from Latino

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communities in North Carolina, these authors explored reasons for the relocation (“the context of getting ahead”) and the changes that came along with economic opportunities in the USA. In turn, “the costs of getting ahead” (separations, shifting family roles, loss of contact with those left behind, etc.) required the following “coping with the costs of getting ahead” phase which had the “Americanization” of the migrants’ children as a new and strong challenge. In all these processes, cultural characteristics (i.e., familismo, machismo, hembrismo, or marianismo, among Mexican families) may reach overwhelming, intergenerational, and conflict-perpetuating dimensions (Carteret 2011; Carreira and Beeman 2014). Studies about the relationship between acculturation and physical health in general and between acculturation and social habits (i.e., cigarette smoking and alcohol consumption) document stress-related situations in the form of aggravation of a variety of medical conditions (chronic pain, asthma, diabetes, immune system diseases, etc.) and increasing need to utilize the health-care system. Middle-aged and elderly Latino women have been systematically neglected from studies examining the association between level of acculturation, physical exercise, obesity, and sleeping patterns. Cantero et al. (1999) interviewed 604 Latinas over the age of 45, from 17 publicly subsidized housing projects in Los Angeles. The final sample included 573 probands, 19% of whom rated their health as excellent or good, 47% as fair, and 34% as poor. Acculturation was measured by language and length of residence in the USA. Women in the high acculturation group were more likely to be current smokers and heavier drinkers than their less acculturated counterparts, but an interesting trend was that Latino women aged 75 and older reported healthier practices than the younger ones, a feature not affected by acculturation. From the psychopathological perspective, acculturative stress may reflect psychosocial features working against neurobiological vulnerabilities (Caplan 2007; McGuley et al. 2010). It can be etio-pathogenically connected with diagnoses such as suicidal behavior, post-traumatic stress disorder, alcohol, and drug abuse. Among Latino immigrants, the onset can be non-specific, but within weeks or a few months, anxious, depressive, cognitive, and somatic symptoms may emerge, leading to the so-called role entrapment, lowering of labor performance, and, in cases, ineffective relationship with health professionals, all these leading to a pattern of chronicity (Torres and Wallace 2013).

Clinical Findings in Latino Immigrants An important conceptual precision in the study of clinical entities among Latino immigrants in the USA is the so-called Hispanic paradox, basically defined as the evidence of better physical and mental health in the newcomers (particularly women) as a group, when compared with both their compatriots staying in the original country (in many studies, Mexico) and US-born individuals (Markides and Coreil 1986; Gil and Vasquez 1996). With acculturative stress as a point of departure (Caplan 2007; Comas-Díaz 2011), immigration as a risk factor for psychopathology among Hispanics becomes a rather persuasive possibility. Yet,

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epidemiological research has yielded contradictory results. Historically, studies on Scandinavian immigrants to the US Midwest conducted in the 1940s and 1950s (Odegaard 1945) showed a higher prevalence of clinical problems when compared with American populations. On the contrary, Mexican immigrants in California were found to be healthier than their American counterparts and even than their Americanborn descendants, second-generation Mexican Americans (Arias et al. 2001; Vega et al. 2004; Alegría et al. 2007a), the birth of the Hispanic paradox. The intense debates that followed and occur even more so now reflect the complexity of factors at play on a theme that, due to the growth of the Hispanic population and of the so-called minorities in the USA, has become prominent in the country’s public health/mental health field.

Epidemiological and Clinical Studies Risk factors for a variety of mental disorders among Latino migrants include female gender, younger age, widow, divorced or separated civil status, and low educational level (Jurado et al. 2017). Interestingly, length of stay in the host country does not show a consistent association with psychiatric morbidity even when controlling with age (Alegría et al. 2007a). Psychological characteristics generating a similar risk are low self-esteem (Lee et al. 2013), pessimism, poor self-control, and resulting distress. Closely connected with this is the level of social or family support, a valuable factor in a reduced probability of emotional symptoms (Ornelas and Perreira 2011). Finally, perceived discrimination, measured by different vectors, is directly related to an increased prevalence of mental disorders among Latino migrants (Gee et al. 2006; Ornelas and Perreira 2011; Lee et al. 2013). Lifetime prevalence of mental disorders and mental health (MH) risk factors in migrant farmworkers from Mexico and Guatemala, both Indian (Zapotec, Mixtec and Mayas) and non-Indian, laboring in California, is the subject of Alderete et al.’s (2000) study, part of the Mexican American Prevalence and Services Survey (MAPSS) in Fresno County. A modified version of CIDI, the instrument jointly developed by the World Health Organization and the former US Alcohol, Drug Abuse and MH Administration, and a 7-item acculturation measure adapted from the Cuellar et al. (1995) scale were used. The main finding among the indigenous subsample was a lower lifetime rate of any psychiatric disorder for women (16.3%) than for men (27.6%). Rates of alcohol dependence (9.9%) were nine and, of drug dependence, five times higher among men than among women. Men and women had similar rates of mood and anxiety disorders, agoraphobia being the most prevalent disorder among women and alcohol dependence among men. Similar levels were found among non-Indians: 6.2% prevalence of simple phobia in women and alcohol dependence in men. Younger (26–39 years) and more educated subjects had a higher risk of alcohol abuse or dependence, whereas respondents who were primarily residents of Mexico showed less than half of it. Overall, the lifetime prevalence of mental disorders among Fresno County immigrants was similar to that of recent immigrants and to rates found in Mexico

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City (20–23%) and less than half the rate of US-born Mexican Americans (48.7%) or the US Hispanic population (51.4%). The Los Angeles (LA) site, one of five in the Epidemiologic Catchment Area (ECA) project, (Robins et al. 1984; Burnam et al. 1987; Karno et al. 1987), studied 1243 Mexican Americans and 1309 non-Hispanic whites in the first large-scale, community-based data of lifetime prevalence for DSM-III disorders. Drug abuse/ dependence was prominently present among young non-Hispanic white men and women, uncommon among Mexican American women of any age, and men or women over 40 years of age of either ethnic group, and only moderately prevalent among young Mexican American men. On the other hand, alcohol abuse/dependence showed exceptionally high prevalence among both Mexican American and non-Hispanic whites of any age, while Mexican American women were less afflicted by those conditions. There was also a substantially greater prevalence of antisocial personality disorder among younger compared with older Mexican American men. Table 1 attempts to summarize average lifetime prevalence figures of different psychiatric disorders in different regions of the world using, to calculate them, data from a variety of sources (Murray and Lopez 1996; Grant et al. 2004; Stuart et al. 2005; Saavedra-Castillo et al. 2013) and following Kessler and Üstün’s (2008) nomenclature style (Goldner et al. 2002; Cohen 2000; Cohen and Marmo 2013, Gureje et al. 2008, 2010; Suarez-Richards 2006). These are, admittedly, somewhat arbitrary estimates, mostly due to several factors: the studies did not cover all the countries of each continent, and the methodologies applied and types of samples included may have varied significantly from study to study. The general purpose is to establish panoramic referents vis-à-vis the prevalence of the main mental disorders among Latino immigrants to the USA. Even though the prevalence of “any psychiatric disorder” among Latino migrants is the second lowest from the six groups included in the table, the figures for specific conditions show some differences: highest for “any mood” and “any psychotic disorder,” second highest (after the Table 1 Comparative lifetime prevalence estimates between continents and the Latino contingent of migrants to the USA (percentages)

Europe Asia/W. Pacific Africa Latin America USA Latino Immgrant

Any anxiety disorder 13.9 12.1

Any mood disorder 14.1 10.5

Any psychotic disorder 3.5 9.6

Any subst. use disorder 7.2 7.4

Any impulse control disorder 4.7 14.0

Any psychiatric disorder 28.2 23.5

11.1 19.8

6.5 11.9

3.0 2.3

8.5 8.7

0.3 7.6

21.2 27.6

31.0 28.0

21.4 32.8

11.6 13.6

14.6 10.5

25.0 8.0

47.4 21.5

Sources: Kessler and Üstün 2008; Carballo 2006; World Health Organization 2000, 2001; Kessler et al. 2007

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USA) for “any anxiety” and “any substance use disorder,” and third highest for “any impulse control disorder.” The main lesson from this assessment is that immigration to the USA takes a more or less significant clinical toll from its Latino component. Younger Latino immigrants (18–25 years old) show a strong association with a first depressive episode, but the risk declined as they became older (Breslau et al. 2007, 2011). In a variety of studies, ethnic status and acculturation were found to be less influential than SES, gender, or occupational status on depression scores among Latino immigrants. Females were found, in general, to report more symptoms than males: Hispanic women, therefore, reflected the same robust gender gap in depression found in general community studies (Kessler et al. 2005; Compton et al. 2006; Aguilar-Gaxiola and Gullotta 2008). However, other factors important for female Latino immigrants include the perceived protective role of being married and the cultivation of cultural and religious beliefs, the opposite being distance-imposed risks such as the impossibility to visit the place of origin (Gil and Vásquez 1996; Aranda et al. 2001). Suicidal risk also increases with years lived in the USA (Oquendo et al. 2004). Puerto Rican immigrants show significantly higher rates of anxiety disorders than any other Latino subgroup (Canabal and Quiles 1995; Alegría et al. 2006). Explanations about these findings cover areas of reduced income and perceived social inequities, in spite of their American citizenship and related better English fluency. Political conflicts and social violence in countries like Colombia, Guatemala, El Salvador, Cuba, Venezuela, and Nicaragua and pressures of economic nature in Mexico or Brazil are strong causal factors of anxiety disorders, in general, and post-traumatic stress disorder, in particular, even though there is agreement in that the latter’s incidence is lower than expected (Kessler et al. 1995). Studies on substance and alcohol use disorders show, in spite of some inconsistencies, that nativity could still be considered either a protective or a risk factor among different Hispanic groups: Puerto Ricans and Cuban Americans had lower rates than US-born non-Latino Whites, but Mexican immigrants and Mexican Americans reach levels similar to the US general population in this rubric (Vega et al. 1998). The general assumption about the presence of psychotic disorders (mainly schizophrenia, bipolar, and brain injury-related psychoses) in Latino immigrant groups is that the numbers are generally similar to the world population. That is the reason why, special care must be taken in evaluating these symptoms or syndromes among Hispanics, as culturally related or “putative” psychotic symptoms may be part of their belief system repertoire or accompanying manifestations of other emotional and mental disorders (Vega et al. 2006).

Mental Health Treatment Systems for Latino Immigrants A key aspect in this area, even though beyond the scope of this review, is the consideration of neurobiological (i.e., genetic) characteristics of the Latino subpopulation vis-à-vis those of other minorities (African-Americans, Asians, or Native

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Americans) and of Caucasians. Perhaps the most significant implications in this regard are the pharmacogenomically determined physiological, pathophysiological, biochemical, and neural circuit-based responses to psychotropic agents. From this perspective, doses, speed of clinical response, secondary effects, and even prognostic estimations are unique to Hispanic patients (Mrazek 2010; Schwab et al. 2010; Silva 2013) as they are to other ethnic population groups. The “four A’s” (availability, accessibility, affordability, and accountability – some would add a fifth: acceptability) (Backman et al. 2008) in the provision of health services have a particular relevance in the case of Latino immigrants, considering the variety of sociodemographic and cultural factors at play. There are specific patterns that Latino individuals and families follow as they seek and face care for emotional and mental conditions in the USA.

Service Availability and Disparities A recent analysis of the national distribution of Medicaid outpatient MH treatment facilities revealed that these settings were less likely to be found in communities with large proportions of Latinos (Cummings et al. 2013). In addition, Alegría et al. (2007b) identified significant differences in demographic characteristics, geographic location, zone of residence, insurance status, and income as variables that link SES with environmental context and result in a significant gap in the provision of specialty care for minorities. Wells et al. (2001) examined differences by ethnic status in unmet needs for alcoholism, drug abuse, and MH treatment. Compared to whites, African-Americans were more likely to have no access to these services, while Hispanics were more likely to have less than needed or delayed care. Barrio et al. (2003) examined case management services to a sample of 4,249 European American, Latino, and AfricanAmerican patients with a diagnosis of schizophrenia or schizoaffective disorder seen in public MH facilities of San Diego County, California. Twenty-six percent of the sample received services, and one third of them were European Americans (the minority in the population at large) versus only 19% and 17%, of Latinos and African-Americans, respectively. In Fortuna et al. (2008) study, Cubans and other Latinos reported higher PV exposure and Mexicans and Puerto Ricans, lower. Cubans were older as a group, had higher educational level, and were more likely to report chronic illnesses than Mexicans, Puerto Ricans, or other Latinos but had a decreased likelihood of 12-month service use when compared to Puerto Ricans. In general, higher education (i.e., having at least a college degree) reduces the likelihood that PV-exposed individuals make use of any MH services.

Accessibility and Utilization of Services The above findings have an obvious sequel of poor accessibility (to services already scarce) and low utilization of MH facilities and professionals by Hispanics,

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particularly immigrants. Fewer years in the USA, stronger Latino ethnic identity, and Spanish language/Latino social preferences are associated with this finding (Keyes et al. 2012). Latinos who had experienced a psychiatric disorder in the past 12 months used less services than non-Latino Whites. No differences in service use were found between Latino ethnic subgroups and factors such as nativity, language, or immigration characteristics. However, foreign-born, Spanish-speaking, and recently arrived Latino immigrants search for MH services and use prevention agencies less than non-Latino Whites (Arias et al. 2001; Alegría et al. 2007c). Mexican Americans have the lowest rates of service utilization for MH problems among the Latino subgroups. A stratified field survey conducted in Central California (Peifer et al. 2000) found that 69% of the exclusively Mexican sample did not use any health services; many of those who sought treatment for their symptoms turned first to medical and informal providers. In a similar study in Los Angeles (Hough et al. 1987), Mexican Americans were half as likely as non-Hispanic Whites to have a MH visit. Folsom et al. (2007) concluded that for Latinos, Spanish as a preferred language may be more important than ethnicity per se in MH service use. This feature is complemented by Garcia et al.’s (2011) finding that immigrant Latinos, particularly those living in rural areas, have limited knowledge and information regarding MH resources, a fact that added to culturally based beliefs and helpseeking patterns limits their access to care. In contrast, Puerto Ricans have the highest rates of service utilization, even though subgroup differences disappear after controlling for symptom severity and nativity. US-born Mexican Americans from Fresno County, CA, as well as non-Latino Whites exhibit a higher rate of service utilization compared to those nonUS-born or primarily Spanish-speaking Latinos (Keyes 2012; Alegría et al. 2007b). Rates of detection and service utilization for problems like anxiety and depression are low in this subgroup and even lower for alcohol and drug use disorders. Lower MH service utilization among Latinos is due to a heterogeneous, even paradoxical list of factors: lower income, higher level of satisfaction, possession of private insurance, female gender, higher educational attainment, unemployment, and comorbidity. As could be expected, uninsured Latinos with psychiatric disorders are significantly less likely to use MH services than those with public or private insurance coverage (Alegría et al. 2010). A hopeful sign, nevertheless, rates of service use appear to have increased substantially during the first decade of this century (Peifer et al. 2000; Folsom et al. 2007).

Practical Aspects of Clinical Management In contrast with their reduced use of specialized MH services, foreign-born Latinos and primarily Spanish speakers seek and attend general medical services for their MH problems, at the same rate as US-born and primarily English speakers (Alegría et al. 2007b, c). Furthermore, Latinos with higher family support (familismo) used less MH specialized services and tended more to utilize informal or religious services for mental health-related concerns (Villatoro et al. 2014).

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Treatment adherence is a relevant factor of the findings about MH treatment inequalities in Hispanic groups. Rates of adherence to psychotropic medications (particularly antipsychotics and antidepressants) are lower for Latinos (77%) than for Caucasians (90%) (Opolka et al. 2003; Díaz et al. 2005; Lanouette et al. 2009; Dixon et al. 2011). Older age seems to be a significant predictor of higher adherence among monolingual Hispanics, while depressive symptoms were associated with lower adherence. Fortunately, examples of promising adherence-enhancing approaches are emerging, both in relation to medication and behavioral treatments. Motivational pharmacotherapy, for instance, seems to improve the retention rate of Latino adults in antidepressant treatment (Balán et al. 2013; Interian et al. 2013). As mentioned above, prevalence estimates for mood, anxiety, and substance abuse/dependence disorders are greater among individuals with putative psychotic symptoms compared with those without them. Receiving treatment was associated with reporting any putative psychotic symptom among both men and women, but three symptoms were statistically associated with higher treatment seeking: auditory hallucinations among immigrant women (15%) and persecutory delusions (47%) or delusions of control (53%) among US-born males. Caution is essential, however, to avoid one of the two mistakes: stereotyping the presence of putative symptoms as “psychosis” or missing cases belonging to any psychotic spectrum disorder (Olfson et al. 2002; Minsky et al. 2003; Vega et al. 2006). In terms of behavioral treatments, in a school-based random clinical trial, higher rates of treatment adherence were identified among depressed adolescents (about 70% Latinos) treated with interpersonal psychotherapy (IPT), compared to those receiving treatment as usual (Mufson et al. 2004). In addition, multifamily group therapy (MFG) improved medication adherence among Spanish-speaking Mexican Americans with schizophrenia (Kopelowicz et al. 2012). However, an educational strategy focused on teaching patients to make decisions in collaboration with providers (DECIDE) did not have an impact on treatment adherence, retention, or engagement, even though it improved the study primary outcomes, patient activation, and self-management (Alegría et al. 2014).

Outcomes and Satisfaction Levels A small number of studies, some with methodological limitations, seem to show an overall positive trend for Latinos, comparable to those found in nonminority populations (Miranda et al. 2003; Huey and Polo 2008). For instance, the level of satisfaction moves up particularly when the therapist is perceived as culturally competent and responsive, a phenomenon called “cultural sensitivity effect” (Atkinson et al. 1992). Specific strategies, such as a quality improvement intervention, may be particularly advantageous for Latino patients diagnosed with depressive and anxiety disorders (Antoniades et al. 2014; Schraufnagel et al. 2006). No differences regarding patient satisfaction have been observed among Latino service users according to nativity, language, age at migration, generational status, or insurance status. Nevertheless, Mexicans and other immigrants who have resided in

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the USA for 5 years or less reported lower levels of satisfaction, compared to other Latino subgroups and to those who had resided in the USA for more than 20 years. On the other hand, those arrived at 35 or more years of age showed higher levels of satisfaction than those arrived at 17 years or younger (Kopelowicz et al. 2012). Thus, both maturity and acculturation seem to play an important role regarding satisfaction with counseling style, counselor understanding, and trustworthiness (Pomales and Williams 1989). In general, however, Latino/Spanish patients are significantly more dissatisfied with the provider’s communication than Latino/ English and white respondents (Morales et al. 1999). The process and outcomes of specific treatments, particularly psychotherapy, have been found to be closely related to real and perceived levels of acculturation in both, patients and therapists. Among 74 patients in outpatient treatment, Acosta (1980) found that the reasons given by Mexican Americans for premature termination of therapy were non-beneficial results, environmental constraints, and selfperceived improvement; negative attitude toward the therapist was only their fourth reason but the first for African-American patients. The therapist’s race (predominantly white), SES, and theoretical orientation (psychodynamic) may have played a significant role, but the fact that Mexican Americans showed the least negative attitude toward the therapist may be linked to Hispanics traditionally professing higher levels of respect for authority figures (Acosta and Sheehan 1976). Not surprisingly, subjects with a strong commitment to the Mexican American culture expressed greatest preference for an ethnically similar counselor and the least willingness to self-disclose, both clear expressions of cultural attitudes (Sánchez and Atkinson 1983). In this connection, Flaskerud’s (1986) list of predictors of dropout status (language match, ethnic/racial match, and agency location in the ethnic/racial community) reinforces the benefits of culture-compatible factors in the success or failure of a variety of therapeutic interventions, including pharmacotherapy, education, psychotherapy, and previous treatments.

Discussion The circumstances leading to immigration vary depending on the country, subregion, or continent of origin and its social, labor, political, and economic conditions. The Latino or Hispanic waves are the largest and most powerful component of the immigration phenomenon in the USA. The numbers show consistent growth, in spite of bureaucratic, political, and plainly discriminatory maneuvers by different sectors of the American government and society. On the other hand, that the acculturation process often varies from group to group or subregion to subregion lends support to the observation that Hispanic immigrants are not a monolithic community that differences exist at such a level that, paradoxically, this population sometimes parallels the heterogeneity of American society and the contradictions of the shrinking Caucasian majority. The notion of diversity can be applied not only to the whole of the USA but also to the different layers (ethnic origin, gender, age, education, income, and employment) detected among the Hispanic subgroups. This

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heterogeneous picture evidently has many implications for policy-making, clinical care, and public health actions. The mixed nature of the Latino immigrant groups is, however, attenuated by a generally common, simple but powerful objective: to reach a better “quality of life.” Yet, this sentence should not be taken as the answer to “why” they migrated, an aspect of the process that is much more complicated and multifaceted. The sociodemographic, economic, and occupational characteristics of these immigrants present now an impressive variety of settlements and geographic locations throughout the country, a growing exhibit of aspirations and achievements. At the same time, their general and mental health and specific clinical occurrences show a spectrum of possibilities and facts that this chapter has attempted to synthesize. Mental health impairment may be the result of a variety of stressful agents. Latino immigrants still confront occupational disadvantages. Hispanics have been less likely than non-Hispanics to hold managerial and professional jobs; younger age distribution and lower average educational level are the two main factors behind this disparity. As a result, Hispanic men and women have traditionally been overrepresented in the lower-paying occupations (operators, factory jobs, construction, and other blue-collar positions) (Fullerton 1991; Cattan 1993; US Bureau of Labor Statistics 2013). Furthermore, every immigrant’s experience in the host society entails a variety of individual and group-based exchanges at social, psychological, and specifically cultural levels, exchanges that, in most cases, lead to normal or acceptable adaptation if not total assimilation (Parra-Cardona et al. 2006). The links so established between interacting cultural contexts, individual behavioral development, and family- or group-based relational mechanisms have many long-term consequences. Acculturation is the paramount phenomenon in this process (Berry 1989, 1997). Its defining factors (Krieger 1994; Beiser and Hyman 1997) include socioeconomic status, generational position, education, English language fluency, strength of religious factors, and overall receptivity from the host society. The most typical example of this is the Puerto Rican immigrant subgroup: while sharing many characteristics with other Latino immigrants, they are American citizens and differ in life conditions and experiences before and after migration to the USA. They migrate seeking primarily employment, social, and professional mobility, have located primarily in Northeastern states, and have been described occasionally as feeling “different” from other Latino immigrants, doubtlessly a reflection of the dynamics of their immigration history and cultural processing (Alegría et al. 2010; Keyes et al. 2012; Keyes 2013). The group’s overall perception regarding the receptivity of American society is not free of negative ingredients (discrimination or failed expectations) and has been called the “frustrated status hypothesis” (Canabal and Quiles 1995; Cabassa et al. 2006; Fortuna et al. 2008). The resulting acculturative stress can be a predictive factor of a variety of clinical conditions, a prodromic stage of a different entity, a symptomatic component of a recognized diagnosis, or a diagnostic category per se. Mood, anxiety, psychotic, substance abuse, and other clinical disorders in different age and gender groups are the result of these circumstances; their incidence and prevalence figures reflect

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a significant, heterogeneous impact. Moreover, clinical manifestations related to adjustment problems in a new culture constitute the code V62.4 (Z60.3) in DSM-5, under the name of Acculturation Difficulty, listed as “a condition that may be the focus of clinical attention” (American Psychiatric Association 2013). Neurobiological and sociocultural factors play powerful roles in this process, and further research is needed using better defined models of stress and coping for Hispanics and including treatment issues and preventive measures against the negative factors of the immigration experience. The provision of mental health services to Latino immigrants (and even to the total US Hispanic population) reflects many of the features discussed above. The use of services by Hispanics is more closely related to female gender, English language proficiency, and lower levels of perceived discrimination. It is not only the variety of clinical diagnoses (reflecting, in cases, high prevalence and severity levels), the insufficient volume of services, or limited availability of clinical settings and human resources but fundamentally the human receptivity, the quality of the provider-patient relationship, the inspiration (or lack) of trust and hope, and the integrity of shared objectives are what constitute important and urgent aspects of this reality. Even though Latino immigrants may show a slightly better general picture, when compared to other ethnic minorities, particularly African-Americans, there is still a lot to do in order to improve the management processes and their outcomes. Among Latino immigrants, Mexicans and US-born Mexican American are unlikely to use MH services, even when they have recently experienced a disorder; however, they may prefer to consult general practitioners, raising a variety of questions about the need and orientation of these services. Clearly, most if not all the above factors must be part of any future research agenda in this field. Longitudinal studies; determination of the impact of length of stay in the host country; the who, the why, and the how of Latino migration; the evolving lives of the newcomers and their descendants; and the size, quality, and outcomes of MH service systems should all be better documented and studied. In this context, the clinical evaluation of Latino immigrants in the USA offers the unique opportunity of using the newly developed Cultural Formulation Interview (CFI) included in Section III of the DSM-5 (American Psychiatric Association 2013) to assess the patient’s cultural identity, help-seeking patterns, explanatory models, and causal attributions to better outline comprehensive, culturally strong management procedures (Keyes 2013; Lewis- Fernandez and Aggarwal 2013).

Conclusions The Hispanic/Latino immigrant population is a significant presence in the current pluralistic demographic reality of the USA. As the largest minority group in the USA, its contribution to several aspects of American contemporary life is significant even though not uniformly recognized. It shows a variety of features that can play both positive and negative roles in the social, health, and health-care scenarios. In addition to the impact of the acculturative process, the availability, accessibility,

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and acceptability of MH services to Latino immigrants generate both a variety of clinical diagnoses and sets of management expectations and outcomes. The clinical assessment would undoubtedly benefit from a cultural input, particularly rich and vigorous in this migrant subpopulation. All these factors must be taken into account in any judgment on the role and fate of Hispanic immigrants in the USA, be that in areas of social integration, public health, or illness-related behaviors. Research in all these areas is mandatory, their cultural component being critically important from both the social and the health sciences perspectives.

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The Mental Health of South Asians in the UK Vishal Bhavsar, Antonio Ventriglio, and Dinesh Bhugra

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Background of South Asians in the UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe Mental Disorders: Schizophrenia, Bipolar Affective Disorder . . . . . . . . . . . . . . . . . . . . . . . . . Common Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personality Disorders and Deliberate Self-Harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Use of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The original version of this chapter was revised. The chapter was inadvertently published with an incorrect spelling of the author’s name as Antonio V. Ventriglio whereas it should be Antonio Ventriglio. The correction to this chapter is available at https://doi.org/10.1007/978-981-10-23668_45 V. Bhavsar (*) Department of Psychosis Studies, King’s College London, London, UK Section of Women’s Mental Health. Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK e-mail: [email protected] A. Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy e-mail: [email protected] D. Bhugra Centre for Affective Disorders, IoPPN, Kings College, London, UK e-mail: [email protected]; [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021, corrected publication 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_9

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Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Abstract

We examine mental health among South Asians living in the UK, framed within a multilevel conceptual model of health reflecting an interplay of biological and environmental risks over the course of life. We highlight epidemiological differences in the occurrence of different psychiatric disorders, and consider the role of socio-cultural patterns of help-seeking behavior. Ultimately, epidemiological approaches, while vital for planning services, identifying unmet population need, and evaluating the effectiveness of services and interventions, often risk conflating and obscuring important historical, cultural, and gendered influences on mental health in this particular diaspora, and others. Keywords

UK · Mental health · South Asians · British Asians · Health service use · Epidemiology · Cultural psychiatry

Introduction In this chapter, we consider mental health among South Asians living in the UK. Ordinarily, a person’s mental health is reflected in interpersonal interactions shaped by individual and contextual factors taking place throughout the life course (Marmot and Wilkinson 2005). Contextual factors include neighborhood context, family structure, wider social networks but also collectively held sets of beliefs, practices and values, and “cultural identity,” which tends to vary more between groups than between individuals within a group (Bhugra and Bhui 2011). Although cultural identity is exceedingly difficult to measure (Corin and Bibeau 2006), ethnic group categories provide a useful proxy for the comparison of cultural factors between groups (Smith et al. 2000). This chapter attempts to provide an overview of the mental health of South Asians in the UK. Our approach takes the following steps. After definitions of the relevant terms, we present further background information related to the history of the South Asian migrant diaspora in the UK and to the concept of mental health in South Asian cultures themselves and mental health as it is experienced by South Asian immigrants to the UK and their descendants. Our approach is organized by broad diagnostic grouping. These diagnostic categories are clearly problematic for any number of reasons (Alarcón et al. 2009); however they present a useful starting point for considering the interplay of cultural identity and mental health status and for identifying where such considerations could be clinically useful. We review empirical evidence on the occurrence, persistence, and response to treatment of these disorders within an evidence-based medicine framework.

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Background There are challenges in understanding current evidence on the mental health of South Asians. There is no clear definition of South Asian ethnicity, or definitions of and measurement of disorders, and the role of unmeasured or difficult to measure social/cultural factors is unclear. At the time of writing, South Asian immigrants to the UK and their descendants are often socioculturally distinct and form an economically important group in UK life. Understanding of this group is important for mental health in general in a number of ways: 1. As a relatively large ethnic group in the UK, the occurrence of mental health problems/disorders in that group is of corresponding interest. 2. In particular, relatively high/low rates of occurrence/recovery from these disorders could be of interest for health professionals, in the identification of risk/ protective factors and of factors influencing help-seeking and recovery from particular health problems in other ethnic and migrant groups. 3. South Asians in the UK are among the most highly educated and economically powerful minority ethnic groups in the UK and form a relatively large part of UK healthcare delivery, in the form of the UK National Health Service (NHS). For example, doctors of Indian origin make up around 20% of UK medical staff. In psychiatry, this percentage is closer to 30%. Understanding how people of South Asian heritage engage with and employ ideas of mental health (and its causation) is therefore crucial for a coherent understanding of mental health in the UK from a cultural perspective. 4. Studying mental illness in diasporic groups could be useful in understanding how mental illness is interpreted in different groups and how patients can be served better.

Definitions In keeping with scholarship in the field of South Asian studies, South Asia in this chapter is defined as the geographic area encompassing the countries of Afghanistan, India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and Maldives. Thus, South Asians in the UK are defined as migrants from those countries to the UK and their descendants. There are a number of aspects of this definition that are relevant to an understanding of mental health in this group. For reasons of brevity, we highlight only three here. Firstly, it is quite clear from anecdotal evidence that the term South Asian is a politically correct, geographically located term for brown-skinned people living in the UK, as opposed to people classifying themselves as Black or White. It is unclear from published evidence how commonly people of these heritages ascribe this particular term to themselves, whether or not they use mental health services. There is anecdotal evidence that migrants from the subcontinent do not see

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themselves as Black, raising problems for the broad Black and minority Ethnic (BME) category. However, mental health services in the UK use this term, and therefore it is relevant to understanding their health and use of health services. Moreover, the geographic scope of South Asia encompasses an area contiguous with historic British colonies in that area, a relationship not immediately evident from the term “South Asian.” Finally, the term implies homogeneity across constituent ethnic identities that may or may not exist – for some disorders/risk factors/ domains, the conflation of Maldivian with Afghan may be appropriate, in others it may not – for example, British Punjabis may hail from the same geographic area, retain the same language and diet, but differ considerably based on whether they live in India or Pakistan. Tamil families living in India and in Sri Lanka may share diet and rituals but may have considerable other, equally important, differences. Understanding and investigating this heterogeneity is of paramount importance in developing effective and tailored interventions. Having said all of that, problematizing a definition is not the same as offering better alternatives. We leave this issue by pointing out that definitional issues (of what it is to be South Asian) may be particularly important in situations where one’s ethnic identity is itself at issue, as may be the case in some mental disorders or clinical scenarios. In this chapter, we retain this definition of South Asian ethnicity, in order to aid comparison with previous work. However, the mental health of the less prevalent South Asian backgrounds, and the distinctiveness of their experience in relation to mental health and the use of services, is an important issue for later examination. Similarly, it is clear that comparing individuals from one particular geographical region with another on the basis of skin color is fraught with difficulties, but we follow convention by continuing to use these well-worn terms. In keeping with this, when using the term second-generation migrants, we follow convention, despite this group being descendants of migrants, rather than migrant themselves.

Historical Background of South Asians in the UK The UK’s status as a multicultural society is historically consequent on migrations from its Empire. However, the South Asian migrants of the eighteenth and nineteenth centuries were students and wealthy people who frequently returned to their countries of birth (Visram 2015). The ructions of the Second World War resulted in active encouragement of migration from colonies, especially of young males, with the aim of rebuilding Britain’s war-ravaged infrastructure. The 1960s saw active encouragement of British-ruled parts of Asia and the Caribbean. Further Asian migration to the UK followed Idi Amin’s expulsions of Asians from Uganda (Patel 1972); migrants from other African countries followed. Despite this underlying trajectory of changing migration patterns in response to grand historical processes, today the constitution of the South Asian population of the UK is dynamic and probably more so than other ethnic groups in the UK. As a result, factors influencing migration, the reasons why people are in the country, are under continual change.

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Mental health is a widely understood and employed concept, however disputed the definition. Possibly it is sufficient here to acknowledge competing models of mental health, illness, and care exist in the countries that make up South Asia and that the various confrontations of these models with UK mental healthcare has seen relatively little systematic research work. For the purposes of the chapter, we will take definitions of mental health and illness espoused by the DSM-V and ICD-10 as read. A final point is necessary to underline the dangers of considering the terms “South Asian” and “mental health” as unchanging entities. This is that the relationship between changing social attitudes toward migration and migrants and mental healthcare, since at least the beginning of the South Asian diaspora, has seen relatively little investigation. This is important for academic reasons (for building a coherent picture of the history of mental health practice in the UK) but also for influencing how ethnic minorities are looked after by mental health services in the UK at present, in order to ethically provide mental healthcare for people who might have lived through periods of time when perhaps providers were not as enlightened by ideas of ethnic equality as they are today. Empirical evidence on mental health, whether collected as part of the provision of routine healthcare, large surveys of consenting research participants, or small qualitative studies of service users, depends on the quality and completeness of information not only on ethnicity itself but also the social and economic conditions of people. Given that ethnicity information was only collected in the census from 1991, (Sillitoe and White 1992) 30 years after the approximate start of commonwealth migrations, underlines the way in which data has lagged behind real demographic and cultural shifts in the lives of people living in the UK.

Conceptual Model We have presented South Asian ethnicity as a historically and politically loaded cultural category, but one with resonance and relevance to today’s mental health practice. We have asserted and accepted the WHO’s definition of mental health even though there remain problems with this definition in the twenty-first century and broadly structure our approach along the lines set out in the WHO ICD-10 document. The relationship between South Asia ethnicity and mental disorder as defined by the ICD-10 may be conceptualized in the following ways: 1. Do South Asians in the UK have a greater risk of developing mental health problems, or incompletely recovering from them, compared to non-South Asians? 2. Are these effects causal, i.e., are there inherent aspects related to South Asian ethnic group status that cause worse mental health? 3. Or, is this effect related to enrichment in the South Asian immigrant population of particular risk/protective factors for mental health problems?

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4. Finally, is there evidence that South Asian ethnic identity modifies the effectiveness of risk/protective factors or treatments for any/all mental health problems? Although we consider that it is possible for an ethnic group identity to be a causal factor in the production of health outcomes (e.g., mediated through the experience of discrimination), there is dispute about this, and although we accept that the debate is a largely academic one, the focus on asymmetries in health outcomes along the lines of presupposed ethnic categories, enshrined in the census, is clearly problematic (Krieger 2012).

Method We consider our methods in addressing the above questions to be housed within the framework of evidence-based medicine and to adopt a broadly epidemiologic approach. For each disorder identified below, we report best estimates of occurrence and recovery in South Asians from the literature. Relatedly, we examine levels of access to treatment and rates of recovery in this group for each disorder. Then, in an attempt to explain these estimates, we examine evidence for the reasons for differences in the distribution of mental disorders between South Asians and non-South Asians in the UK, focusing in particular on social, economic, and cultural factors. In most circumstances comparisons are made with the White majority group, the emphasis remains on identifying factors which contribute to the occurrence/persistence of mental health problems in South Asians, as well as to the relative frequency/ infrequency of these problems compared to the White reference group. Although a disorder-specific approach is preferred during the bulk of this chapter, physical and emotional access to mental healthcare remain a challenge, and this care is an entity in itself and is dealt with as a single category at the end, separately from the different disorders and their treatment. Throughout these discussions of empirical evidence, we will return to potential biases introduced into this evidence arising from small samples, unmeasured explanatory factors (such as socioeconomic position and social support), and error due to inaccurate measurement tools (e.g., for depression in minority ethnic groups) and nonrepresentative samples (e.g., through the systematic under-numeration of elder women, single unemployed males, or groups with particular national origins).

Severe Mental Disorders: Schizophrenia, Bipolar Affective Disorder Schizophrenia has an incidence in the UK of between 15 and 35 cases per 100,000 people per year. It displays asymmetries of occurrence by all major sociodemographic characteristics, with positive associations with younger age, male gender, lower socioeconomic position, and minority ethnic group status. Although the occurrence of schizophrenia and psychotic disorders may be lower in South

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Asians compared to the UK White majority, South Asian people diagnosed with the illness may also have a lower prevalence of socioeconomic disadvantage compared to White sufferers. In keeping with evidence that socioeconomic status shapes both the incidence and natural history of schizophrenia, South Asians with schizophrenia also experience better outcomes at 1 year. In contrast to this, a study of first episode psychosis in East London Coid et al. reported that incidence rate ratios for psychosis were higher in all migrant groups including Asians, compared to the White reference group. However, adjustments were not made for socioeconomic status, and the background rate of psychosis was high, at 36.8 cases per 100,000 person years of observation, suggesting this population could be an outlier in terms of risk attributable to Asian ethnic status. This in turn is in contrast to the earlier study based on West London data of Bhugra et al. (1997) which found lower standardized rates of psychotic illness compared to Blacks and Whites. While there appears to be a consensus regarding the better outcomes of psychosis in poor/less developed/LAMICs, data on the outcome of treated psychosis in among South Asians in the UK is less prevalent. In general, compared to the White majority, fewer South Asians are diagnosed with psychosis, treated for psychosis, and remain under psychiatric care after an episode of treatment.

Common Mental Disorders Consonant with Cochrane’s early research (Cochrane 1977) suggesting lower frequency of admissions for anxiety and depressive disorders, a later study by Nazroo (1997) reported lower prevalence of anxiety symptoms in South Asian subjects compared to White participants in a household survey. In this study, occurrence of symptoms in Bangladeshi subjects were notably low compared to both Indian-origin and Pakistani-origin respondents, indicating the possibility of considerable heterogeneity in underlying rates of anxiety, and/or considerable under-numeration of this relatively small and overlooked segment of the South Asian population in the UK. Gender asymmetry in the prevalence of anxiety in favor of females was less pronounced in Nazroo’s South Asian sample. This could be because of higher levels of social support in South Asian males compared to their White counterparts or to relatively lower reporting of socially stigmatizing symptoms among White men compared to South Asian men. This pattern was preserved on reviewing weekly, as opposed to point prevalence, data on anxiety symptoms in the general population. Depressive disorders were also less prevalent among South Asians in the Nazroo study, with Bangladeshi origin subjects again being the least likely to report depressive neurosis to investigators. Similar observations have been made with respect to drug treatment for common mental disorders. In one study, 8.7% of White respondents were currently treated with an antidepressant, compared to 4.6% of Pakistani/Bangladeshi respondents, with Indians reporting a 6.4% prevalence of antidepressant usage.

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The experience of depression in South Asian people may be different. Fenton and Sadiq (1996) found that depression was expressed as weakness, listlessness, tearfulness, sleeplessness, and loss of self-confidence and life meaning, rather than in terms of low mood or depression. In a study based on a focus group study of eight South Asian women aged between 40 and 69, 15–30 years since migration, Bhugra and colleagues identified various atypical features of depression in subjects, including, an internal feeling of heat, fainting, weight on the heart/mind, and pressure in the brain. As well as a defining symptom of depressive illness, ideas of wanting to complete suicide are an indicator of poor mental health in and of themselves. Not only may suicidal ideation be more common among South Asian women compared to White females, but marital status, protective in White respondents of both genders, may display a less pronounced protective effect in South Asians. This might be because the sociocultural context of marriage may be different between South Asian and White individuals. Married South Asian women may suffer consequences of economic, social, and political exclusion in ways that White married women do not. In a small study of suicide attempters in Ealing area in West London, South Asians were more likely to be owner occupiers and less likely to have used alcohol at the time of their attempt. Moreover, regret for the attempt and wish to die were both more common in South Asians compared to Whites. Heterogeneity in risk for depression and anxiety has been found between people of Indian and Pakistani origin. In a follow-up study based in Bradford, the frequency of depression in Pakistani women was much higher than Whites and the rates among Indian women lower (Hitch 1981).

Personality Disorders and Deliberate Self-Harm Systematic elevation in the occurrence of suicides in migrants has been recognized since the early 1980s (Marmot et al. 1984). In an early study of deliberate self-harm in South Asians, Burke examined case records of people presenting to emergency service with self-harm and investigated the attribution of the self-harm made by the treating clinicians. South Asians were underrepresented according to population figures at the time, and 58% of case records cited interpersonal problems as the reason for the presentation. Burke made note that among young presenters, South Asians had very low levels of drug use and were frequently single presenters, rather than repeated presenters, implying different relationship between DHS and both personality issues and drug use disorders in South Asians compared to White individuals. There is reasonably strong evidence to indicate that South Asian women are at much higher risk of both attempted and completed suicide compared to White females. Raleigh’s 1990 study found high levels of suicide despite a relatively highly socioeconomically advantaged sample. The investigators also found higher frequency of completed suicide in young married Asian women compared to unmarried women, in contrast to observed frequencies in White subjects (Soni Raleigh and

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Balarajan 1992). Qualitative research based on this population identified postmigration isolation, familial strife, and financial problems related to marriage as major drivers of suicidal thinking. Another qualitative study based on South Asian women recruited from religious centers attributed suicidal thinking prominently to intimate partner violence, a feeling of being trapped by one’s marital family (particularly in younger respondents), and to mental health problems. Since early work in the 1990s, evidence for systematic differences in the occurrence of self-harm in South Asians has crystallised (Al-Sharifi et al. 2015). Although further discussion is limited by space, it is clear that DSH in South Asian women is qualitatively different to DSH in other groups and represents the outcome of complex interplay between conventional individual-level epidemiological risk factors in women (class, marital status) and culturally shaped characteristics of the person’s social networks, values, family relationships, and identity. Although early studies suggested that self-harm presentations in South Asian women may have a more psycho-cultural attribution compared to self-harm in Whites, these hypothesis and explanations have seen limited empirical examination since. For example, a model linking culturally patterned systems of acceptable behavior, family conflict, and acculturative stress is an attractive explanation for increased levels of selfharming behavior in South Asian women; however there has been little empirical examination of this in relation to self-harm in real-life clinical settings or assessment of relevant interventions.

Use of Services Goldberg and others have pointed out that the development of mental health symptoms does not always correspond to the development of diagnosable disorder or to the use of mental health service for that disorder. Most prominently, this has been presented in the form of a widely referenced five-filter model for mental disorder involving “care filters” at multiple levels. Passage through each filter is influenced by individual and contextual factors that shape health through proximal mediators influencing behavior, lifestyle, stress processing, and access to resources. In this regard, ethnic identity can therefore be regarded to be a potential influencer not only on which symptoms evolved but also whether care is sought for them. Based on data from the National Adult Psychiatric Morbidity Surveys, Cooper et al. found that Asian people were less likely to have contacted a GP in the previous year, after account for symptoms severity. A study from Scotland Bansal et al. reported lower risks of treated psychiatric disorder in Indian women and Pakistani men, although Pakistani men had a trend toward a higher risk of mood disorders. There was a twofold excess in the risk of psychotic disorder in Pakistani women. A study by Gillam and others (1989) suggested that while South Asians had the highest probability of consulting a GP, they had the lowest probability of consulting the GP for mental health reasons. There was some evidence for systematic differences in types for treatment received, with White subjects more likely to leave the surgery with a prescription, a sick certificate, or follow-up appointment. Ultimately,

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more frequent consultations with GPs by South Asians may mainly be due to socioeconomic disadvantage and other confounders, rather than due to differences in help-seeking behavior per se. Having seen primary care services in West London, onward referral pathways appeared similar between White and South Asian patients in the studies of Bhugra et al. (1999) and Burnett et al. (1999) (reviewed in Bhui et al. 2003). However, in Birmingham, South Asians were significantly more likely than White people to consult primary care with mental health problems and were also least likely to be referred to specialist care. South Asian patients were less likely to be admitted to inpatient care than Black patients in a systematic review (Bhui et al. 2003), including care in secure facilities. Studies suggested shorter admissions (Gupta 1991), and fewer readmissions (Birchwood et al. 1992) in South Asians compared to White people.

Dementia Research into the mental health of South Asians has been influenced by broader sociodemographic shifts in the UK. For example, the increase in UK life expectancy since the 1970s has resulted in over 65 s outnumbering under 15 s for the first time (Spijker and MacInnes 2013). Life expectancy estimates based on 2001 census data suggest that while the life expectancy of Indians and Sri Lankans have kept up with that of White people, life expectancy in Bangladeshi men is consistently lower by about 1.5 years (Rees et al. 2011). In this context, there is limited research into the presumably increasing frequency of dementia and cognitive disorders in South Asians living in the UK (Patel 1998) – a systematic review (Daker-White et al. 2002) identified only two reports of dementia prevalence in UK minority ethnic groups: a community survey in Bradford estimated the prevalence of cognitive impairment (using the Geriatric Mental State Schedule) at 7%, (Bhatnagar and Frank 1997) while a survey of English speakers of different ethnic groups in Liverpool evaluated people of Chinese and Black African origin, but not South Asians. Qualitative research studies are also small in number. Bowes and Wilkinson (2003) interviewed 11 health professionals working with South Asians with dementia about their experiences of working with South Asian subjects and identified high demand for services, limited knowledge about dementia in South Asian communities, and negative views about residential care. Lawrence et al. (2008) undertook qualitative interviews with carers of people with dementia of White British, Black British, and South Asian origin living in the UK. They identified two distinct typologies of “caregiving ideology,” one reflecting traditional caregiving attitudes – caregiving as expected, natural, virtuous, rewarding, and part of natural reciprocity – and nontraditional caregiving attitudes, where caregiving gave rise to conflicts with expectations and roles, lack of rewards, and stagnation in one’s life. Although they did not find substantial differences in caregiver ideology by ethnic group, this emphasizes the importance of richer understanding of the experience of service users and their families/carers, irrespective of ethnicity, if ethnic differences

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are to be placed in their proper context. Although the model of South Asian people as family-orientated and willing caregivers, relatively rejecting of residential care, seems to have some support, (Bowes and Wilkinson 2003; Lawrence et al. 2008; Mukadam et al. 2011) there is little research on how these values might be undergoing transition in light of the changing composition of South Asian communities in the UK and an increasingly mobile and “globalized” young population (Bhavsar and Bhugra 2008). Moreover, qualitative understandings of cognitive function in minority ethnic groups appear to lag behind research into the experiences of physical and emotional problems and seem to warrant closer research attention.

Future Research Although many studies have now been published examining differing frequencies of mental disorders in South Asian compared to the UK White majority, whether more studies are necessary on this are unclear, estimates tend to vary by the nature of the sample, the type of analytic approach, and the types of outcome. In contrast, research addressing how migrant groups use mental health services is less frequent. An assessment of the prospects for future research on the mental health of South Asian immigrants in the UK necessarily involves speculation on the future of their role in British life. Although the story of higher rates of self-harm in South Asian women is now relatively widely known among mental health professionals, disparities in more specific domains of mental health practice, such as specialist services, remain in need of inveistigation (de la Cruz et al. 2015). There are a number of distinctive characteristics of research and clinical work in populations of South Asian descent. Racism, a crucial driver of morbidity and mortality in other BME subgroups, may need detailed exploration of an issue in this group. The concept of ethnic density concords with the idea that ethnicity is something which is experienced not only by individuals of that identity but others around them. This concept is challenging to measure or to operationalize in formal empirical designs. One approach to framing the interaction between individuals in the causal pathway to mental health problems involves the use of computer simulations to generate models of how individuals interact in different circumstances. Such methods have seen little attention in the content of ethnicity and mental health in the UK. An overriding observation in this review of mental health in people of South Asian ethnicity in the UK is the great heterogeneity in the production of evidenceincluding diagnostic categories, outcomes, and populations (including definitions of what a South Asian is). Moreover, attempts to consolidate this empirical work formally, for example, using meta-analysis/systematic review designs, are far outweighed by the sheer weight of relatively poorly designed/implemented studies. Clinical assessment in the psychiatric clinic is often modeled as involving the passive implementation of taxonomies of mental disorders. However, it should be pointed out that these classificatory systems themselves are under cultural influence. Although there is little evidence that ethnicity status systematically affect the

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allocation of individuals to particular diagnoses, it may be that cultural processes affect the definitions of the disorders themselves. Therefore, future research stands a greater chance of influencing clinical practice if it adopts more locally meaningful definitions of ethnic/cultural group and focuses on consolidating previous research on South Asians, rather than developing new empirical work on a potentially misleading census-derived category.

Conclusion South Asians have lower rates of psychosis than other minority ethnic groups in the UK, higher frequency of deliberate self-harm and access mental health services in similar numbers to the White majority. The conclusions of a chapter written 20 years ago would have concluded much the same. Little evidence exists that levels of selfharm among South Asian women have reduced over time. Evidence for geographic heterogeneity in the association between South Asian ethnicity and probability of self-harm has increased (e.g., contrasts in the experience of Bangladeshi and Pakistani women in terms of affective disorders and possibly higher, not lower, rates of psychosis among South Asians in East London); however, explanations remain limited. Standard epidemiological approaches are limited in teasing out nuanced aspects of culture, identity, and belonging. This is because definitions of the characteristics are not agreed, and therefore measurements vary in accuracy and interpretation. Analytic methods generally evaluate the association between variables but assume constant associations between variables and outcomes over time, an assumption which is unlikely to hold in many cases. A further important issue regarding the interpretation of evidence is the role of socioeconomic confounding. Ultimately the ability to truly identify causal effects of the effect of ethnic identity would require the ability to alter someone’s status, which is impossible. More innovative approaches are needed to investigate the impact of ethnicity on mental health.

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Bhugra D, Leff J, Mallett R, Der G, Corridan B, Rudge S (1997) Incidence and outcome of schizophrenia in whites, African-Caribbeans and Asians in London. Psychol Med 27:791–798 Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G (2003) Ethnic variations in pathways to and use of specialist mental health services in the UK. Syst Rev 182:105–116 Birchwood M, Cochrane R, Macmillan F, Copestake S, Kucharska J, Carriss M (1992) The influence of ethnicity and family structure on relapse in first-episode schizophrenia. A comparison of Asian, Afro-Caribbean, and white patients. Br J Psychiatry 161:783–790 Bowes A, Wilkinson H (2003) ‘We didn’t know it would get that bad’: South Asian experiences of dementia and the service response. Health Soc Care Community 11:387–396 Burnett R, Mallett R, Bhugra D, Hutchinson G, Der G, Leff J (1999) The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multiethnic population. Psychological medicine 29(2):475–483 Cochrane R (1977) Mental illness in immigrants to England and Wales: an analysis of mental hospital admissions, 1971. Soc Psychiatry 12:25–35 Corin E, Bibeau G (2006) Speaking about culture in multiple voices. Transcult Psychiatry 43:106–125 Daker-White G, Beattie A, Gilliard J, Means R (2002) Minority ethnic groups in dementia care: a review of service needs, service provision and models of good practice. Aging Ment Health 6:101–108 de la Cruz LF, Llorens M, Jassi A et al (2015) Ethnic inequalities in the use of secondary and tertiary mental health services among patients with obsessive–compulsive disorder. Br J Psychiatry 207:530–535 Fenton S, Sadiq A (1996) Asian women speak out. In Mental Health Matters: A Reader (pp. 252–259). Macmillan Education UK Gillam SJ, Jarman B, White P, Law R (1989) Ethnic differences in consultation rates in urban general practice. Bmj 299(6705):953–957 Gupta S (1991) Psychosis in migrants from the Indian subcontinent and English-born controls. A preliminary study on the use of psychiatric services. Br J Psychiatry 159:222–225 Hitch P (1981) Immigration and mental health: local research and social explanations. J Ethn Migr Stud 9:256–262 Krieger N (2012) Who and what is a “population”? Historical debates, current controversies, and implications for understanding “population health” and rectifying health inequities. Milbank Q 90:634–681 Lawrence V, Murray J, Samsi K, Banerjee S (2008) Attitudes and support needs of Black Caribbean, south Asian and White British carers of people with dementia in the UK. Br J Psychiatry 193:240–246 Marmot M, Wilkinson R (2005) Social determinants of health. Oxford University Press, Oxford Marmot MG, Adelstein AM, Bulusu L (1984) Immigrant mortality in England and Wales 1970–78. OPCS studies of medical and population subjects No 47, vol 27. HMSO, London, pp 229–32 Mukadam N, Cooper C, Livingston G (2011) A systematic review of ethnicity and pathways to care in dementia. Int J Geriatr Psychiatry 26:12–20 Nazroo JY (1997) The health of Britain’s ethnic minorities: findings from a national survey. PSI Patel HH (1972) General Amin and the Indian exodus from Uganda. Issue J Opin 2:12–22 Patel N (1998) Dementia and minority ethnic older people: managing care in the UK, Denmark and France. Russell House Pub Limited, Lyme Regis Rees P, Wohland P, Norman P, Boden P (2011) A local analysis of ethnic group population trends and projections for the UK. J Popul Res 28:149–183 Sillitoe K, White PH (1992) Ethnic group and the British census: the search for a question. J R Stat Soc Ser A Stat Soc 155:141–163 Smith GD, Chaturvedi N, Harding S, Nazroo J, Williams R (2000) Ethnic inequalities in health: a review of UK epidemiological evidence. Critical Public Health 10:375–408 Soni Raleigh V, Balarajan R (1992) Suicide and self-burning among Indians and West Indians in England and Wales. Br J Psychiatry 161:365–368 Spijker J, MacInnes J (2013) Population ageing: the timebomb that isn’t. BMJ 347:f6598 Visram R (2015) Ayahs, lascars and princes: the story of Indians in Britain 1700–1947. Routledge, Abington

Mental Health in Multicultural Australia

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Diversity in Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Reform in Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health of Immigrant and Refugee Communities in Australia . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Determinants of Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concepts of Mental Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Service Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health of Caregivers from Immigrant and Refugee Background . . . . . . . . . . . . . . . . . . Investigator-Initiated and Strategic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immigrant and Refugee Mental Health Data Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gaps in Immigrant and Refugee Data Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Representation of Immigrant and Refugee Participants in Australian Mental Health Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Cultural and linguistic diversity is a core feature of the Australian population and a valued element of national identity. The proportion of the population that will be overseas-born is projected to be 32% by 2050. While a very active process of mental health system reform has been occurring for more than two decades – at national state and territory levels – the challenges presented by cultural and linguistic diversity have not been effectively met. A review of Australian research H. Minas (*) Global and Cultural Mental Health Unit, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_10

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on mental health of immigrant and refugee communities and their patterns of mental health service use reveals many gaps. Although lower rates of utilization of specialist public mental health services by immigrants and refugees are repeatedly reported, the lack of adequate population data prohibits conclusions about whether the observed patterns constitute underutilization. There are virtually no data on quality of service outcomes. A review of studies published in four key Australian journals reveals considerable neglect of cultural and linguistic diversity in Australia’s mental health research. The purpose of this chapter, which is an abbreviated and updated version of Minas et al. (Int J Mental Health Syst 7(1):23, 2013), is to examine what is known about the mental health of immigrant and refugee communities in Australia, whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population, and whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia. A set of strategic actions is suggested to improve knowledge about, and policy and service responses to, mental health problems in immigrant and refugee communities. Keywords

Australia · Multicultural society · Mental health

Introduction Cultural and linguistic diversity is a core feature of the Australian population (Australian Bureau of Statistics 2012) and a valued element of national identity. If net overseas migration continues at the current rate, the overseas-born component of the Australian population will increase from the current proportion of more than 25% to around 32% in 2050 (Cully and Pejoski 2012). The existing cultural and linguistic diversity of the population and the arrival of immigrants and refugees from a very wide range of source countries (Australian Bureau of Statistics 2012) will continue to present challenges for all forms of service delivery, including mental health services, into the foreseeable future. The process of mental health system reform has been occurring in all States and Territories since the 1950s. The development of a National Mental Health Strategy in 1992 (Whiteford et al. 2002), endorsed by the Commonwealth and all State and Territory governments, has given considerable impetus to the reform process. There have been a major shift from hospital- to community-based service delivery (Australian Bureau of Statistics 2008), substantial increases in the mental health workforce, improved access to mental health services in primary care, improved mental health literacy in the general population (Jorm et al. 2006), substantial increases in participation in decision-making by people with mental illness and their families and support persons (Department of Health and Ageing 2010), and a continuing move from a focus on medical treatment to recovery-oriented mental

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health (Commonwealth of Australia 2010; Mental Health 2011) and psychosocial support services. Key components of the national reform process have been a clear statement of rights and responsibilities (Australian Health Ministers 1991), the development of national standards for service delivery (Commonwealth of Australia 2010), a commitment to evidence-informed policy development, service delivery and reporting of progress against policy intent (Department of Health and Ageing 2010), and a focus on service outcomes (Burgess et al. 2012). In almost all relevant Commonwealth, State, and Territory mental health policy documents, immigrant and refugee populations have been identified as warranting particular attention in order to ensure equity (Minas et al. 2007a). However, it is not clear whether immigrant and refugee communities – particularly those who do not speak English, the most recently arrived and refugees, who are among the most vulnerable – have benefited fully from this process of major mental health system reform. The collection and analysis of mental health data are central to moving toward equity in mental health. Without data on the population distribution of mental health and mental illness, the patterns of service use by different sections of the population, and the quality of outcomes of health service contact, unjust inequalities remain invisible. Mental health and mental health service inequities need to be made visible to enable evidence-informed policy development, mental health service design and delivery, and clinical and recovery practice. Comprehensive and reliable data are essential to evaluate the degree to which policies and programs enhance equity, provide direction for research into root causes, and guide new strategies for promoting health (Hung et al. 2000). The purpose of this chapter, which is a revised, updated, and abbreviated version of a recently published paper (Minas et al. 2013), is to examine: • What is known about the mental health of immigrant and refugee communities in Australia • Whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population • Whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia

Cultural Diversity in Australia The cultural and linguistic diversity of the Australian population has been shaped by Australia’s unique history. At the end of the World War II, the population was approximately seven million, of whom 10% were overseas-born (Department of Immigration and Citizenship 2011). Since the end of the Second World War, the proportion of overseas-born has steadily increased (Cully and Pejoski 2012). The first postwar wave of migration consisted predominantly of new arrivals from Europe (Department of Immigration and Citizenship 2011). In each of the

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subsequent decades, an additional one million immigrants arrived (Department of Immigration and Citizenship 2011). By June 2011, the population was 22.3 million of whom 26% were born overseas and an additional 20% had at least one overseasborn parent (Australian Bureau of Statistics 2012). Over the past 10 years, the overseas-born population has increased by 23.1% (Australian Bureau of Statistics 2012). In 2011 persons born in the United Kingdom continued to be the largest countryof-birth group (5.3% of the total population), followed by people born in New Zealand (2.5%), China (1.8%), India (1.5%), Vietnam (0.9%), and Italy (0.9%) (Australian Bureau of Statistics 2012). Migration source countries have continued to change, with a reduction in migration from the United Kingdom and significant increases in migration from New Zealand, China, and India. The most rapid population growth between 2001 and 2011 was for persons born in Nepal (with an average annual increase of 27%), Sudan (17.6%), India (12.7%), Bangladesh (11.9%), and Pakistan (10.2%) (Australian Bureau of Statistics 2012). Recent immigrants are younger than the general population (Australian Bureau of Statistics 2012), while longer-standing immigrants are older than the general Australian population (Australian Bureau of Statistics 2012). The relative youth of recent arrivals is important for mental health. Adolescence and young adulthood are the peak periods of onset of most mental disorders. This is also a period for many immigrants when they are dealing with the many stresses associated with migration and settlement. For longer-settled immigrants, the key issue is the mental disorder of old age. Disorders associated with cognitive impairment are substantial challenges for families and for the mental health system, particularly when they include deterioration in the person’s capacity to communicate in English. The majority of recent immigrants (67%) and almost half (49%) of the longerstanding immigrants speak a language other than English at home (Australian Bureau of Statistics 2012). For longer-settled immigrants, Mandarin (4.3%), Cantonese (4.2%), Italian (3.7%), and Vietnamese (3.2%) were the most common languages spoken at home other than English, while for recent immigrants, Mandarin (10.8 %), Punjabi (3.7%), Hindi (3.3%), and Arabic (3.0%) were the languages other than English most frequently spoken at home (Australian Bureau of Statistics 2012). Approximately half (51%) of the longer-settled immigrants reported that they could speak English very well, while only 2.6% reported that they could not speak English at all. Among recent arrivals (past 10 years), 43% reported that they speak English very well, while 3.1% reported not speaking English at all (Australian Bureau of Statistics 2012). There is, as expected, wide variation in level of English fluency among country-of-birth groups. While cultural and linguistic diversity represents a significant challenge, the development of mental health services that are responsive, accessible, culturally appropriate, and effective in meeting the needs of people with mental illness and their families and support persons, is not a distraction from the “core business” of mental health services. Working through the process of reforming services so that

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they are capable of meeting the needs of a culturally diverse society will have the direct benefit of making those services more flexible and responsive to the needs of all members of the Australian community.

Mental Health Reform in Australia An analysis of Commonwealth, State, and Territory mental health policies, and of specific transcultural mental health policies developed in New South Wales, Queensland, Victoria, and Western Australia, revealed that statements concerning the need to incorporate considerations of cultural and linguistic diversity in research and practice are common (Minas et al. 2007a). Commonwealth, State, and Territory mental health policies were examined for their relevance to mental health system responses to depression in immigrant and refugee communities. Specialized State “transcultural mental health” policies provided comprehensive policy coverage of issues relevant to mental health and immigrant and refugee communities. Key topics were identified from these transcultural mental health policies and used to analyze each of the general Commonwealth, State, and Territory mental health policies. There was a highly variable degree of attention to issues relevant to immigrant and refugee communities. Commonwealth policies contained a relatively comprehensive coverage of issues. Areas that were unrepresented or underrepresented included providing information which supports access, interpreters/language services, coordination of care, support for ethnic community workers, data collection, and service utilization. More recent policies tended to include a clearer focus on immigrant and refugee communities and highlighted the need for improvement in the evidence base for all forms of mental health activity in relation to immigrant and refugee communities. Policies developed have tended to repeat the same aspirations concerning immigrant and refugee communities, as illustrated by the quote above from the 4th National Mental Health Plan (Department of Health and Ageing 2009). While such statements of policy intent are a welcome acknowledgement of the need to focus on cultural and linguistic diversity, two key questions remain. To what extent are such statements of policy intent included in policy implementation plans or used to establish funded programs? Do Commonwealth, State, and Territory governments and mental health service agencies report progress against such statements of policy intent? A survey seeking information on whether services were addressing depression in immigrant and refugee communities was sent to 1,480 organizations in capital cities and major regional towns across Australia (Minas et al. 2007a). The organizations surveyed included mental and general health service providers, divisions of general practice, public health units, local governments, Migrant Resource Centres, transcultural mental health services, refugee services, and ethnic community organizations. Relevant programs were analyzed in relation to reported strategies and activities, barriers, supports, perceived role in relation to depression in immigrant communities, partnerships, and program involvement of immigrant communities, people with mental illness, and their families and support persons. From the 1,480

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organizations to which questionnaires were sent, 422 organizations (28%) responded to the survey. A total of 46 programs were identified that specifically addressed mental health in immigrant and refugee communities, and further 8 programs reported that they were mainstream mental health programs that had made some adaptation to be more responsive to the needs of immigrant and refugee communities. “Direct clinical services, such as counseling, psychotherapy, psychiatric case management, psychological rehabilitation, day activity programs, self-help, and mutual support groups for those with mental disorders, were all reported by mainstream mental health organisations. These were regarded as available to the whole of the community with no particular adaptations of programs to accommodate the varied needs of ethnic minority communities” (Minas et al. 2007a). The continuing process of mental health system reform in Australia, particularly over the past two decades, has resulted in major changes in the ways in which professionals and communities think about mental health and illness, in the ways in which mental health services are designed and delivered and in the level of priority accorded to mental health by Commonwealth, State, and Territory governments. The general population is more knowledgeable about mental health and illness (Jorm et al. 2006) and more likely to seek mental health treatment and care(Australian Bureau of Statistics 2008), services are much more community-focused, the importance of primary care in service delivery has been recognized and supported, participation of people with mental illness and their families and support persons in decision-making has been considerably strengthened, and there has been a strong and deliberate move to recovery-oriented service delivery. While these achievements have led to Australia being regarded as a world leader in mental health system reform, it is recognized that there is still much to be done (Department of Health and Ageing 2009). It is clear that policy-makers are aware of the relevance of cultural and linguistic diversity and of the need to take such diversity into account when framing mental health policy and when designing mental health services. However, there is very little implementation of those components of mental health policies that relate to the particular needs of immigrant and refugee communities. Failure to implement policy intentions in the area of multicultural mental health is all but invisible because reports of progress in implementation of Commonwealth, State, and Territory mental health policies generally say nothing about immigrant and refugee communities. A recent and important example is the National Mental Health Report 2010 (Department of Health and Ageing 2010). The report “summarizes the progress of mental health reform undertaken over the 15 years of the National Mental Health Strategy and provides a view of trends and performance at the national and State and Territory levels over the period spanning the First, Second, and Third Mental Health Plans from 1993 to 2008.” This Summary of 15 Years of Reform in Australia’s Mental Health Services Under the National Mental Health Strategy 1993–2008, like the ten National Mental Health Reports that preceded it, has nothing to say about immigrant and refugee communities. As a result of such neglect and exclusion from implementation and reporting processes, there may well be persistent disparities in availability of and access to

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mental health services, quality of care, and mental health outcomes for people from immigrant and refugee backgrounds (Minas et al. 1996; Stuart et al. 1998; Klimidis et al. 1999; Stolk et al. 2008). The lack of comprehensive and reliable data on mental health of immigrant and refugee communities means that disparities and inequities that do exist are all but invisible.

Mental Health of Immigrant and Refugee Communities in Australia What is known about mental health of immigrant and refugee communities in Australia and what are the major gaps in our knowledge? To answer this question, a search of publications reporting mental health research carried out in Australia between 1963 and August 2012 was carried out to identify studies that included immigrant or refugee communities and that focused on immigrant and refugee mental health issues. The search yielded 214 original research articles reporting findings on mental health issues from samples of participants from immigrant and refugee background. The findings below are from this review.

Prevalence of Mental Disorders Knowledge of prevalence of mental disorders is essential for several reasons (also see ▶ Chap. 15, “Mental Health in Refugees and Asylum Seekers” by SchoulerOcak and Kastrup in this volume). Without reliable estimates of prevalence of different types of mental disorders in immigrant and refugee communities, it is impossible to say anything about the scale of mental health problems in different populations. It is difficult to evaluate whether attempts to improve population mental health are effective and a good investment. It is also difficult to determine whether differences in rates of service utilization by those subgroups are due to differences in prevalence or due to other factors, such as obstacles to service access. Reliable prevalence estimates are important to inform mental health policy and service design and delivery. The National Survey of Mental Health and Wellbeing conducted by the Australian Bureau of Statistics (Australian Bureau of Statistics 2008) provides the best available estimate of the prevalence of mental disorders across Australia. Information from the survey is very important in formulating government mental health policies and decisions about mental health services. This 2007 National Survey of Mental Health and Wellbeing collected information from 8,841 Australians aged 16–85 years. The survey provides information on the prevalence of selected mental disorders (anxiety, affective, and substance use disorders), sex and age distributions, comorbidity, and the extent of impairment of core activities and health service utilization. Demographic characteristics relevant to people from immigrant and refugee backgrounds included country of birth, year of arrival, country of birth of mother or father, and proficiency in spoken English. The

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classification of countries used is the Standard Australian Classification of Countries (SACC). While the Australian Bureau of Statistics provides an overview of the findings from the survey (Australian Bureau of Statistics 2008), most of the detailed analyses that are available have been carried out by researchers with access to the survey dataset (Klimidis et al. 1999; Miletic et al. 2006; Stolk et al. 2008; Burgess et al. 2009; Johnston et al. 2009; Teesson et al. 2009; Wells 2009; Whiteford and Groves 2009; Garrett et al. 2010; Lawrence et al. 2010; Nielssen and Large 2010; Olesen et al. 2010; Pirkis et al. 2010; Reavley et al. 2010; Teesson et al. 2010; Butterworth et al. 2011; McEvoy et al. 2011; Reavley et al. 2011; Australian Bureau of Statistics 2012; Burgess et al. 2012). None of these studies has analyzed findings relevant to immigrant and refugee participants in the survey. (There was one study examining access to mental healthcare by people from non-English-speaking background using data from the first, 1997, National Survey of Mental Health and Wellbeing (Pirkis et al. 2001).) The results relevant to immigrant and refugee participants reported from the 2007 national survey are prevalence rates by country of birth (Australia or Overseas) and year of arrival of immigrants. Respondents born outside Australia were found to have lower prevalence of anxiety, affective, substance use disorder, and of any 12-month mental disorder (Australian Bureau of Statistics 2008). Those most recently arrived (in the decade prior to the survey) have the lowest rates of disorder. The ABS reports that only 2.2% of the potential sample could not participate in the 2007 Survey of Mental Health and Wellbeing due to language difficulties, which includes people with language barriers such as deafness or disability. Given the level of English fluency that would be required to respond to the survey, this is difficult to reconcile with the 2011 Census of Population and Housing (Australian Bureau of Statistics 2012) figures that only 51% of longer-settled immigrants and 43% of recent arrivals reported that they could speak English “very well,” while 2.6% and 3.1% reported that they could not speak English at all. Although there have been varied findings on whether the prevalence of common mental disorders in immigrant and refugee populations is the same or lower or higher than in the Australian-born population (Klimidis et al. 1994; Stuart et al. 1998; Minas et al. 2008; Garrett et al. 2010; Olesen et al. 2010; McEvoy et al. 2011; Reavley et al. 2011), the weight of evidence from studies in other countries and Australian studies suggests that prevalence of mental illness in immigrant communities is similar to that in host populations and that prevalence across particular country-of-birth groups is highly variable. The results of prevalence studies vary widely according to the disorder being studied, particular ethnic or country-of-birth groups, and the location of the study. It is possible to find reports of higher (Minas et al. 2008) and lower (Steel et al. 2005; Silove et al. 2007a; Steel et al. 2009; McEvoy et al. 2011) prevalence of various disorders in various groups and numerous studies where no difference has been found between immigrant groups and host populations (Kemp et al. 1987; Krupinski and Burrows 1987; Eisenbruch 1988; Mutchler and Burr 1991; King et al. 1994; Klimidis et al. 1994; Cheung 1995; Cheung and Spears 1995; Dassori et al. 1995;

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Trauer 1995; Mui 1996; McDonald and Steel 1997; Nesdale et al. 1997; Stuart et al. 1998). For young immigrants, evidence showed that fewer mental health problems were reported by immigrant adolescents compared to nonimmigrant adolescents (Davies and McKelvey 1998); nevertheless, children of immigrants were found to be similar with children of Australian-born in terms of their mental health problems (McGarth et al. 2001; McKelvey et al. 2002; Alati et al. 2003). The rates of depression, anxiety, and post-traumatic stress disorder were between three and four times higher among Tamil asylum seekers in Australia than the rates of these problems among immigrants (Silove and Steel 1998; Silove et al. 1998), and Ziaian and colleagues found that young refugees had increased risk of depressive symptoms (Ziaian et al. 2012).Substantial proportions of Burmese refugees in Australia experienced mental health problems including depression, anxiety, and post-traumatic stress disorder (PTSD) (Schweitzer et al. 2011), while Vietnamese refugees had lower prevalence of mental disorders than the Australian-born sample. Similar prevalence of PTSD was found in these two groups. PTSD was diagnosed in 50% of Vietnamese refugees and 19% of Australians with any mental disorders (Silove et al. 2007a). Additionally, refugees and asylum seekers are particularly vulnerable to self-harm and suicidal behaviors. In Australia the prevalence of selfharm among detained asylum seekers was reported to be higher than in the general population and among prisoners (Dudley 2003). Consistent with studies from other countries, Australian studies have shown that immigrant suicide rates tend to reflect the rates of their country of birth, an association that is particularly evident in males (Ide et al. 2012). In general, suicide rates are higher among immigrants born in countries that have higher suicide rates such as Western, Northern, and Eastern European countries, while rates are lower in immigrant groups from countries with lower suicide rates including those in Southern Europe, the Middle East, and Southeast Asia (Kliewer 1991; Taylor et al. 1998; Morrell et al. 1999).

Determinants of Mental Health Problems A key goal of mental health research is to understand the determinants of mental health and illness – both risk and protective factors – and to develop effective health promotion, illness prevention and early intervention, and effective treatment and psychosocial support service programs (Cohen and Minas 2010). A number of factors have been identified as potentially important risk or protective factors for mental illness among immigrant groups in Australia. The extent to which these factors are important across all immigrant groups is not known because findings are based on a very small number of studies with only very few immigrant groups. Several factors have been found to be associated with increased risk of mental disorder among immigrants. They include limited English proficiency (Alizadeh-Khoei et al. 2011), separated cultural identity (Sawrikar and Hunt 2005), loss of close family ties (Thompson et al. 2002), lack of opportunity to make effective use of occupational skills (Reid 2012), trauma exposure prior to

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migration, and the many stresses associated with migration and adjustment to a new country (Krupinski 1984). Protective factors include religious belief and observance, younger age at migration, better English proficiency, a higher sense of personal control, stronger social support, and higher self-efficacy (Leung 2002; Connor 2012). A survey of 1,139 immigrant and refugee people in two rural and two metropolitan areas in Victoria focused on their experiences of racism and its association with psychological distress (VicHealth 2007). Approximately two-thirds of participants had experienced racism in the previous 12 months and reported that this had adversely affected their mental health. The extent of experiences of racism was positively correlated with level of psychological distress. Risk of suicidal behavior among immigrants is influenced by factors including living circumstances in the host country (Kliewer 1991; Morrell et al. 1999), experiences in the country of origin (Kliewer 1991), and low socioeconomic status (Taylor et al. 1998). Strong family ties, religious adherence, and maintenance of traditional values may lead to lower suicide rates in immigrants (Burvill et al. 1983). While the mental health of refugees and asylum seekers is clearly negatively affected by pre-migration trauma (Steel et al. 2002; Steel et al. 2006), in Australia policy concerning asylum seekers that has been elaborated by successive governments over more than 20 years is one of the major factors producing severe risk of mental disorder among asylum seekers (Dudley 2003). Among the elements of asylum seeker policy that are most toxic to mental health are long-term detention (Steel et al. 2004; Steel et al. 2006; Silove et al. 2007b; Coffey et al. 2010), temporary protection (Mansouri and Cauchi 2006; Momartin et al. 2006; Steel et al. 2006), restriction of access to services (Nickerson et al. 2011), human rights violations (Momartin et al. 2003; Nickerson et al. 2011), exposure to threats of different kinds (Momartin et al. 2003), and fear for family remaining in the country of origin (Nickerson et al. 2010). The impact is likely to be greatest and most long lasting in children (Newman and Steel 2008). A sense of belonging to family and community and perceived social support are positively associated with better mental health among refugees (Schweitzer et al. 2006; Correa-Velez et al. 2010). Exposure to violence and threats to their parents is important risk factor for child refugees, whereas stable settlement and social support have a positive effect on psychological functioning (Mares et al. 2002; Fazel et al. 2012). Pre-migration trauma and longer periods of detention (Steel et al. 2006; Robjant et al. 2009; Green and Eagar 2010) are associated with increased risk of suicidal behaviors among refugees. The experience of detention increased the likelihood of mental health problems such as anxiety, depression, and PTSD, as well as self-harm behaviors and suicidal ideation (Robjant et al. 2009). Although there are more studies of refugees and asylum seekers than of most other immigrant subgroups in Australia, samples are generally very small, and not all studies use rigorous methods. This is particularly true for studies of people who are

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in or have been in immigration detention. Conclusions drawn from such studies need to be treated with caution.

Concepts of Mental Health and Illness A number of studies have explored explanatory models of mental health and illness in individual immigrant and refugee groups in Australia (Cheng 1985; Kiropoulos et al. 2004; Hsiao et al. 2006a, b; Klimidis et al. 2007; Minas et al. 2007b; di Ciano et al. 2010; Kiropoulos and Bauer 2011; Lenzi et al. 2012). The objectives and design of these studies have been variable. Although the findings of these studies are of considerable theoretical value, there has been no systematic attempt to explore the practical significance of the findings – to inform clinical practice, community engagement, and use of health services, mental health service design, or mental health policy. A comprehensive program of research that examines the relationship between explanatory models of mental health and illness, conceptions of appropriate mental health service response, and service design and delivery issues is needed to inform the development of culturally appropriate and effective mental health services.

Mental Health Service Utilization In an analysis of the 1997 National Survey of Mental Health and Wellbeing (Pirkis et al. 2001), people from English-speaking and non-English-speaking backgrounds (NESB) were equally likely to experience anxiety disorders and affective disorders, but the latter were less likely to experience substance use disorders and any mental disorder. People from non-English-speaking and English-speaking backgrounds were equally likely to use services for mental health problems, and there was no difference between birthplace groups in terms of their likelihood of reporting that their needs were fully met (perceived need for care). Country of birth data for immigrants were aggregated to the level of born in an English-speaking country and born in a non-English-speaking country so that no conclusions could be drawn about specific country-of-birth groups. In studies of particular country-of-birth groups, the likelihood of receiving treatment for mental disorder is influenced by immigrants’ country of birth (Burvill et al. 1982; Stuart et al. 1998). For example, migrants from Greece diagnosed with mental disorder were more likely to receive treatment than Australians; however, the opposite was found in immigrants from the United Kingdom or Ireland or Southeast Asia (Stuart et al. 1998). Nevertheless, in general, immigrants are underrepresented in the populations who utilize mental health service in Australia (Hassett and George 2002; Boufous et al. 2005; Wagner et al. 2006). The key barriers identified are stigma and shame attached with mental illnesses (Wynaden et al. 2005; Youssef and Deane 2006; Drummond et al. 2011). Other hindrances include limited access to

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mental healthcare, the quality of care received, limited knowledge of services, communication difficulties, confidentiality concerns, lack of trust in service providers, service constraints, and discrimination (Youssef and Deane 2006; Blignault et al. 2008). Refugees and asylum seekers in Australia have low hospital admission rates for treatment of mental disorder and low access to mental healthcare services (CorreaVelez et al. 2007; Ziaian et al. 2012). This was due to the presence of a range of impediments including Medicare ineligibility, unaffordable healthcare costs, and the impacts of social, financial, and psychological difficulties (Correa-Velez et al. 2008; Spike et al. 2011). Shame or fear of being judged by others and treatment provider and fear of hospitalization have been reported as barriers to access to healthcare services among refugees (Drummond et al. 2011). These barriers were found to be greater in refugees from higher education background and longer residency in Australia (Drummond et al. 2011). Young refugees have been reported to be more likely to seek helps from friends than from professional sources (de Anstiss and Ziaian 2010). The reasons for not turning to professional help included low concern about mental health, poor knowledge of mental health and service, distrust of services, stigma associated with mental health problems, and other social and cultural factors (de Anstiss and Ziaian 2010). In Victoria, relative to the Australian-born, immigrant and refugee communities have consistently been found to have lower rates of access to public community and inpatient mental health services (Klimidis et al. 1999), a higher proportion of involuntary admissions, and higher proportions who are diagnosed with a psychosis (Klimidis et al. 1999; Stolk et al. 2008). Similar findings have been reported from New South Wales (McDonald and Steel 1997), Queensland, and Western Australia (Bruxner et al. 1997). The low rates of access by immigrant and refugee communities may be due to lower prevalence of mental illness in immigrant and refugee communities than in the Australian-born population. This is not consistent, however, with research showing that overall community prevalence of mental illness in immigrant samples is similar to that of Australian-born samples (Stuart et al. 1998; Minas et al. 2008), or that levels of mental illness may be higher in refugee communities (Porter and Haslam 2005) than in host communities. A pattern of underutilization of mental health services by particular groups may point to systematic inadequacies in service systems and raise important questions concerning the need for service reform, community attitudes toward beliefs about mental illness and psychiatric treatment, barriers to service access, difficulties in diagnosis, and racism.

Mental Health Outcomes Australia’s National Mental Health Strategy has emphasized the quality, effectiveness, and efficiency of services and has promoted the collection of outcome data as a means of monitoring these. All public sector mental health services across Australia now routinely report outcomes. Since late 2003, the Australian Mental Health

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Outcomes and Classification Network has received, processed, analyzed, and reported on outcome data at a national level and played a training and service development role (Burgess et al. 2012). Australian governments have invested a great deal of money and effort in developing a national approach to evaluating mental health service outcomes. Despite this massive effort, nothing can be said about outcomes for immigrant and refugee clients of mental health services since immigrant and refugee variables are not part of the national outcomes data collection process.

Mental Health of Caregivers from Immigrant and Refugee Background Among immigrant and refugee communities, families are generally required to take the primary role of care giving for a relative with mental illness (Endrawes et al. 2007). However, despite the demanding nature of the caregiving role for immigrant and refugee caregivers, there is scarce evidence on the mental well-being of these caregivers in Australia. A study examined the health and social experiences of Greek families with caregiving responsibilities for their co-resident family member who had physical and/or mental disorder in Melbourne (Morse and Messimeri-Kianidis 2001). The majority of caregivers reported their psychological well-being as being worse than that of other people and also worse than their physical health. This was attributed to the burden of caregiving, which overwhelmed their ability to cope. They also reported persistent worries about their current caring role and the prospect and resources for continuing care in the future. Furthermore, caregivers of mentally ill family members revealed that they had limited knowledge about the disorders of care recipients and the type of assistance they should provide. Such lack of knowledge resulted in substantial stress and anxiety. Another study (Endrawes et al. 2007) explored caregiving experiences for a relative with mental illness among Egyptian families living in Australia. It showed that the caregiving experience in the Egyptian families was influenced by their own cultural and religious traditions. The families had a high sense of obligation and duty to provide care although they felt powerless, isolated, stigmatized, and embarrassed and with limited support. They also had poor understanding of mental illness and had limited access to necessary information due to the language barrier. There was increased experience of depression, anxiety, and suicidal thoughts in these families. There are very few studies of the effect of caring for people with mental illness on families from immigrant and refugee background. This is a largely neglected area of research in Australia, despite the importance of understanding the perspective, beliefs, and practices of immigrant and refugee carers.

Investigator-Initiated and Strategic Research The research reported above is almost entirely investigator-initiated research. This is research that is conceived, designed, and carried out on the initiative of individual

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investigators who have an interest in a particular research question, design a study that will answer the question, and secure the necessary financial and other supports required to carry out the research. Such research is extremely important in all fields and is the source of innovation and scientific progress. It should continue to be encouraged and supported. However, it is clear from the above brief review that the body of research produced in this way is fragmented, partial, and somewhat disconnected from the concerns of policy-makers and practitioners. Investigator-initiated multicultural mental health research needs to be supplemented with strategic research that will answer questions that are important to policy-makers, service designers and evaluators, and practitioners. There is a clear need for strategic multicultural mental health research that is organized on the basis of policy and practice priorities and informed by an agreed research agenda. Research agendas have been developed for refugee youth (Minas in press, #156) and for immigrant and refugee adults (Minas in press, #157) and a research agenda focusing on suicide (Colucci et al. in press, #158). Among the questions that may be of high priority in such an agenda are the following: • What is the prevalence of mental disorders (and of specific disorders) in different immigrant and refugee populations? • What are the patterns of mental health service use in different segments of the mental health system (e.g., hospitals, community mental health, primary care, forensic, child, and adolescent mental health services)? • Do specific immigrant and refugee populations under-use available mental health services? • What are the determinants of patterns of mental health service use? • Which immigrant and refugee subgroups are particularly at risk of developing mental disorders and likely to require particular attention from mental health promotion, illness prevention, and mental health service programs? • Which are the most important social determinants of mental health and illness in immigrant and refugee populations and which of these are amenable to social policy interventions? • What are the clinical and social outcomes of contact with mental health services in meeting the needs of people with mental illness and their families and support persons, in particular for people from non-English-speaking backgrounds?

Immigrant and Refugee Mental Health Data Collections The implementation guidelines for Standard 4 (Diversity Responsiveness) of the National Standards for Mental Health Services 2010 (Commonwealth of Australia 2010) include the following: “The MHS whenever possible utilises available and reliable data on identified diverse groups to document and regularly review the needs of its community and communicates this information to staff.” This section will examine whether national data collections support this aspect of Standard 4.

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In 1999 the Australian Bureau of Statistics published the Standards for Statistics on Cultural and Language Diversity to identify, define, and classify particular attributes that relate to cultural and linguistic background (Australian Bureau of Statistics 1999). The standards were intended as a replacement for the designation “non-English-speaking background” (NESB), which was previously used as a broad descriptive rubric for immigrants and refugees coming from non-English-speaking countries. The full set of recommended immigrant and refugee variables is: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Indigenous status Country of birth Country of birth of father Country of birth of mother Ancestry Religious affiliation Year of arrival in Australia Proficiency in spoken English First language spoken Main language spoken at home Main language other than English spoken at home Languages spoken at home

The ABS-recommended minimum dataset includes four variables to capture cultural and linguistic diversity: 1. 2. 3. 4.

Country of birth Main language other than English spoken at home Proficiency in spoken English Indigenous status

The standards observe that “to use a single standard variable, such as country of birth, or a nonstandard composite concept, such as NESB, is inadequate.” We identified government and nongovernment agencies that collect mental health data at national or State and Territory levels and surveys that collect data relevant for mental health of immigrant and refugee populations to examine which immigrant and refugee variables are included in the data collections to capture cultural and linguistic diversity in Australia.

Gaps in Immigrant and Refugee Data Collections Current data collections by Commonwealth, State, and Territory agencies and other relevant national agencies do not include most of the variables that are recommended by the Australian Bureau of Statistics Standards. This results in multiple data deficiencies.

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Most Australian surveys and other relevant data collections, and reports based on these data collections, only make reference to “country of birth.” Further, country of birth is very frequently aggregated into “region of birth.” If language data is collected and reported, it is generally only reported as “English” or “non-English” (Australian Bureau of Statistics 2009). In the health sector data collections, the standards are poorly implemented. A review of national surveys (Blignault and Haghshenas 2005) found that: • Seven surveys used ABS standards and classifications. Only one included all the minimum dataset variables for immigrants and refugees. • Of 17 national datasets reviewed, 12 included country of birth and 3 also included language but none included all three variables. Clearly, the standards have not been implemented as intended, and “country of birth” is most commonly used in isolation, without the even other minimum dataset variables. The use of “country of birth” as a classification of immigrant and refugee populations is problematic as it is only one of several factors that may influence culture, language, and ethnicity (Ministry of Health 2004; Bhopal 2007). This is a major problem in regard to child and youth services where the identified client, i.e., the child, has “Australia” recorded as country of birth, while her/his overseas-born parents may not speak English and the child may grow up in a family (immediate and extended) and community dominated by the culture of origin of the parents. In child and youth services, the family is often as involved in the receipt of services as the identified client; however the relevant cultural and language data is not captured and therefore not considered. Most surveys, such as the Australian Health Survey, aggregate overseas-born people into broader categories, for example, by region of birth and by whether they speak “English” or “languages other than English.” Region of birth (e.g., Africa, or East Asia) will usually include a very disparate collection of ethnicities, cultures, languages, and socioeconomic circumstances that have in common only geographic proximity. There are many problems with this approach. Aggregating people into categories averages out differences and hides differences and the most vulnerable populations (Kagawa-Singer et al. 2010). For example, one British study that explored this tendency to aggregate found that the self-reported smoking prevalence for both South Asians and Europeans was 33% (Bhopal 2009). It appeared that there was no difference between the two groups. However, when the “South Asian” category was disaggregated, it was found that the rate among Indians was 14%, among Pakistanis it was 32%, and among Bangladeshi males, the rate was 57%. This illustrates how the practice of aggregating population groups can give a “misleading average” (Bhui 2009) and obscure differences of considerable importance. The data may appear accurate but masks an important inequality (Bhopal 2009). A necessary targeted response is made impossible. Aggregation can also mask differences between immigrant and refugee men and women. For example, in New South Wales, the smoking prevalence among

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Vietnamese-born people is 16.3%. When this figure is disaggregated, it is 30% for men and 2.2% for women (Centre for Epidemiology and Evidence 2009). In Victoria, the gender impact assessment process recommends that to understand the impact of diabetes, gender sensitive or disaggregated data and reporting is required (Women’s Health Victoria 2010). Aggregation into regions is not a useful tool for policy-makers or practitioners as it does not identify which populations are at increased health risk. For example, if people born in North Africa and the Middle East are hospitalized more for a certain condition, a more in-depth mixed methods analysis is needed to identify the specific community to develop appropriate intervention strategies. Clearly, the aggregation of data in the ways in which this is routinely done in relation to immigrant and refugee populations severely limits the usefulness of the data collection and reporting. It may obscure important inequities and fail to identify important needs. One of the key reasons for aggregating country-of-birth groups into regional groups is the usually small sample sizes of the individual country-of-birth groups that constitute the overall sample. The relatively small immigrant and refugee sample size, even in larger surveys, limits the degree to which data can be disaggregated by subgroup. It is difficult, if not impossible, in general surveys to achieve an adequate sample size for individual country-of-birth groups if this is not addressed as part of the study design. A strategy that has frequently been recommended (Pirkis et al. 2001) to address this problem is to select immigrant and refugee subgroups that are of particular practical or theoretical interest in relation to the study and to over-sample from those groups in order to ensure that there are adequate numbers to enable meaningful, disaggregated data analysis. A review of Australian national datasets and surveys found that all, except for the national Census, have limited immigrant and refugee sample sizes and that people with limited English proficiency are frequently explicitly excluded (Blignault and Haghshenas 2005). The additional cost associated with translation and the employment of bilingual interviewers and the frequent unavailability of translated and validated instruments are often given as reasons for excluding people with limited English proficiency. This exclusion is a particular concern given the association between lack of English proficiency and socioeconomic disadvantage (Blignault and Haghshenas 2005). The frequent exclusion of a particular population group limits the generalizability of study findings. Data on regional country-of-birth groupings reported in national surveys are based on responses from participants who are proficient in English and who may therefore not be representative of the immigrant and refugee population of which they are part. It is difficult to find an acknowledgement in Australian research reports that there may be legitimate questions about the quality of data derived from immigrant and refugee participants. Quality issues are only highlighted in the few studies that have been conducted specifically on the issue of immigrant and refugee data coverage and quality (Blignault and Haghshenas 2005; National Health and Medical Research Council 2006; Wadiwel and Cooper 2010).

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In Australia’s Health 2010 report, the description of the health of Aboriginal and Torres Strait Islander peoples includes an acknowledgement that a number of data quality issues remain unaddressed. These are described as “logistical, analytical, and conceptual challenges” (Australian Institute of Health and Welfare 2010). All of these issues apply equally to immigrant and refugee participants in health studies. The Australia’s health 2010 report does not comment on this issue in the “overseasborn” section of the report.

Representation of Immigrant and Refugee Participants in Australian Mental Health Research A comprehensive examination of research on depression in immigrant and refugee communities was carried out in 2002 (Minas et al. 2007a). The search for relevant research was systematic and extensive. It included a systematic search for relevant Australian studies published between 1990 and 2002, a search for higher degree theses deposited in 30 Australian University libraries, and a survey of 277 relevant university departments and research organizations to identify research under way. The search for publications yielded only 30 relevant publications, 10 focusing on refugees and asylum seekers, 6 focusing on depression in the postpartum period, 6 studies of suicide rates in different immigrant and refugee communities, and 8 on various mental health problems in various immigrant and refugee communities. Of the 228 higher degree theses that dealt with depression, only five (2.2%) addressed issues relevant to immigrant and refugee communities. Of the 277 university departments and research institutions surveyed, 91 (33%) responded. Only nine relevant projects were identified. The study concludes that “the body of research published and the work currently conducted is very limited in scale and scope. Little is known about the prevalence of depression, risk factors and protective factors, cultural concepts of depression and attitudes to depression, pathways to care, and uptake and effectiveness of existing interventions in relation to immigrant and refugee communities. For depression in immigrant and refugee communities there is effectively no evidence base to support mental health policy development and service design, and there is virtually no evidence concerning effectiveness of services currently provided or regarding particular treatment approaches and models of service.”(Minas et al. 2007a) In 2010 a systematic literature review (Garrett et al. 2010) of the representation and coverage of non-English-speaking immigrants and multicultural issues in The Medical Journal of Australia, The Australian Health Review, and The Australian and New Zealand Journal of Public Health found that of more than 4,000 publications over a 12-year period, only 90 (2.2%) were articles primarily focused on multicultural health issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention. The authors concluded that “the quantum and range of multicultural health research and evidence required for equity in policy, services, interventions, and implementation are limited and uneven. Most of the original multicultural health research articles

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focused on newly arrived refugees, asylum seekers, Vietnamese, or Southeast Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies have implications for evidence-based health and human services policy.” These studies (Minas et al. 2007a; Garrett et al. 2010) indicate that research that is relevant to immigrant and refugee communities constitutes an extremely small component of Australian mental health and general health research. In order to examine the issue of representation of immigrant and refugee communities in Australian mental health research, we conducted a systematic review of Australian studies published between 1992 (the commencement of the National Mental Health Strategy) and 2012 in four key Australian journals, the Australian and New Zealand Journal of Psychiatry, Australasian Psychiatry, Australian Psychologist, and the Medical Journal of Australia. The purpose of the review was to explore the extent of representation of immigrant and refugee communities in Australian mental health research and to specifically explore the frequency with which people who are not proficient in English are excluded from Australian mental health research studies. The optimization strategy developed by Wilczynski, Haynes, and Hedges (Wilczynski et al. 2006) was used to locate mental health research published in the selected journals in searches of the following databases: Medline (Ovid), PsycINFO (Proquest), and CINAHL (EBSCO). Studies that focused on mental health and were carried out in Australia were classified into six categories: 1. Non-English speakers excluded: when the exclusion criteria clearly excluded potential subjects who were not proficient in English from the sample 2. General mention: when the immigrant or refugee populations are mentioned descriptively but were not part of the design or analysis 3. Cross-national study: when the study made comparisons between samples from more than one country 4. Part of the study: when studies specifically examined immigrant or refugee samples or issues as part of the design and analysis of the study 5. No mention immigrant or refugee communities: when immigrant or refugee populations were not mentioned in the study 6. Indigenous: when the studies examined issues in Aboriginal/ Torres Strait Islander people Of the initial 5,545 papers identified in the search, 920 duplicates were excluded; further 3,324 were excluded because the paper was not a report of original research, was not mental health relevant, or was not an Australia-based study. A total of 1,301 papers remained and were analyzed. Of these 111 papers (8.5%) explicitly mentioned immigrants or refugees as part of the samples. The great majority (77.2%) of papers made no mention of cultural and linguistic diversity of the populations that were being sampled and studied. In 2.2% of studies,

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there was some general mention, but no specific analysis, of immigrant and refugee issues or populations. In 8.5% of studies, there was specific consideration of immigrant and refugee issues or inclusion of immigrant and refugee samples. In 8.8% of studies, potential participants with insufficient proficiency in English were specifically excluded from participation in the study.

Discussion There are many positive statements of policy intent in relation to immigrant and refugee communities in national mental health policies and strategies – in the Statement of Rights and Responsibilities, in the National Mental Health Standards, in multiple State and Territory policies and mental health plans, and recently in the COAG Roadmap for National Mental Health Reform. However, there is virtually no reporting by Commonwealth or State and Territory governments concerning implementation of policy intent in relation to immigrant and refugee communities or evaluation of implementation. It is not possible to determine whether there has been any improvement in immigrant and refugee community mental health, access to mental health services, or outcomes of contact with mental health services. Investigator-initiated research on mental health of immigrant and refugee communities has yielded important insights into the mental health of particular immigrant and refugee communities, determinants of mental health and illness, and patterns of use of mental health services. However this research is limited and does not provide a coherent account of the mental health of Australia’s immigrant and refugee population. Nor does it answer critically important policy- and practicerelevant questions. An issue of particular importance in relation to immigrant and refugee communities is the lack of systematic investigation and understanding of the perspectives and beliefs of families and carers concerning mental health and illness and mental health services and the experience of members of immigrant and refugee communities who come into contact with mental health services. The most striking observation is the wide variation in findings across different immigrant and refugee communities. This variation represents a valuable and unrealized opportunity to systematically study population risk and protective factors for mental health and illness, and suicide, that would be of theoretical and practical importance for the whole Australian population. The majority of Australian mental health research does not adequately include immigrant and refugee samples. The number of studies that have specifically included adequate representative samples of immigrant and refugee populations or that have explicitly investigated multicultural mental health issues is very small. What we increasingly know about the mental health of the Australian-born population we do not know about immigrant and refugee communities. The available evidence suggests that in Australia adult immigrants appear to have lower prevalence of mental illness than do the Australian-born. There is generally no difference reported in prevalence of mental disorders between immigrant and

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Australian-born children. It is not clear whether there is in fact a lower prevalence of mental disorders in immigrant and refugee communities or whether this conclusion is an artifact of the research methods used. Conclusions about the average prevalence of mental illness in overseas-born Australians may well be accurate, but the available data allows no conclusions to be drawn about prevalence in even the largest immigrant communities. The exclusion of immigrant and refugee participants, particularly non-English-speaking persons, from national surveys and from individual epidemiological research projects does not allow any confident statement about prevalence of mental disorders in specific immigrant and refugee communities. Factors contributing to increased risk of mental health problems in immigrant and refugee populations include low proficiency in English, separate cultural identity, loss of close family bond, stresses of migration and adjustment to the new country, limited knowledge of the health system, trauma exposure before migration, and limited opportunity to appropriately use occupational skills. Factors that appear to be protective of mental health include religion, strong social support, and better English proficiency. Studies that provide information about determinants have not been systematically examined to draw reliable conclusions concerning risk and protective factors for mental health and illness or about patterns of mental health service use. Suicide rates in immigrant and refugee populations generally reflect the rates in the country of birth. Suicidal behaviors in immigrants are associated with the problematic living experiences in the host country and in the country of origin. Strong family bonds, religion, and traditional values were associated with lower suicide risk. The wide variations in suicide rates across immigrant and refugee communities represent a valuable and unrealized opportunity to systematically study population risk and protective factors that may find wide application in the development of more effective suicide prevention strategies for the Australian population. Refugees and asylum seekers are at greater risk of developing mental health problems and suicidal behaviors than is the general Australian population. Prolonged detention has been found to be associated with poorer mental health in refugees and asylum seekers, particularly among children. Other factors influencing mental health of refugees and asylum seekers include experience of human rights violations, exposure to violence and threats, ongoing temporary protection visas, and experience of pre-migration trauma. Generally, immigrants, refugees, and asylum seekers have lower rates of mental health service utilization than the Australian-born. The key barriers to access to mental health services in immigrants and refugees include greater stigma attached to mental illness and limited knowledge of mental health and services relative to Australian-born. There is a general and persistent pattern of low rates of use by immigrant and refugee communities of specialist mental health services. Anecdotal evidence suggests that this is also the case in psychiatric disability and disability support services provided by mental health NGOs. In the absence of reliable prevalence data for immigrant and refugee populations, this observation is uninterpretable. It is not known whether the low utilization rates are due to lower prevalence of mental disorders or whether system- or community-level barriers to

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mental health service access can explain them. This makes it impossible to determine whether the repeatedly stated policy intent of national, State, and Territory mental health policies and plans concerning access to services and equity of service provision has been achieved. The Council of Australian Governments (COAG) has acknowledged the general weakness of evidence for mental health system reform (Council of Australian Governments 2012). “There is a need to continue research and data development to improve our collective knowledge and understanding of mental health and wellbeing, the many factors contributing to it, their interaction, and effective ways to improve and maintain mental health for people across the population. For example, current Australian mental health and broader health data collections are inadequate in their description of the mental health and social and emotional well-being of Aboriginal and Torres Strait Islander people.” Despite the identification throughout the Roadmap of the need for specific strategies to respond to the needs of people from culturally and linguistically backgrounds, there is no similar acknowledgment of the deficiencies in data concerning immigrant and refugee populations (Council of Australian Governments 2012). Under the section title Monitoring the Journey, the Roadmap states that “Where data is available, (emphasis added) they will consider outcomes and progress for different parts of the community, particularly Aboriginal and Torres Strait Islander people, as well as by factors such as age group, gender, language and cultural background, socioeconomic status, and location (e.g., urban or remote areas).” The key finding of this chapter is that in relation to immigrant and refugee communities, the necessary data are not available. A number of interrelated strategic actions will need to be taken to improve research, policies, and practice in relation to mental health of immigrant and refugee communities and to reduce systematic and structural inequities. It is essential that the substantial and increasing cultural and linguistic diversity of the Australian population becomes a core consideration in all mental health policy-making and funding for policy implementation and mental health service design, delivery, and evaluation. Policy statements concerning the need to take into account the diversity of the population, which are plentiful, must be translated into explicit implementation objectives. Funds must be identified and allocated to enable implementation, and progress on implementation must be evaluated and reported. In the research area, national surveys and other studies of mental health must include representative samples of at least some immigrant or refugee populations to improve population relevance of findings. High priority should be accorded to research on the determinants of mental health and illness, explanatory models of mental illness, beliefs and knowledge about and attitudes concerning health services, and help-seeking among immigrant and refugee communities. Such studies must include sufficient demographic and related variables to enable disaggregation of samples for analysis and reporting. It is particularly important to include a comprehensive list of CALD variables in all outcome data collections and to include reporting of outcomes for immigrant and refugee clients of mental health services as part of national reporting of service outcomes.

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Routine reports of mental health agencies and state and national mental health systems must report on the patterns of use of services by immigrant and refugee communities, and their experience of contact with mental health services, as part of the national mental health policy reporting framework. It will be necessary to engage major research funding organizations to develop consensus about the minimum demographic variables that must be included in clinical and population mental health research studies and to develop strategies that will improve the level of inclusion of immigrant and refugee participants in Australian clinical and population mental health research. The research agendas that have been developed can serve as the basis for development of strategic research that will answer important policy and practice questions.

Conclusions Cultural and linguistic pluralism confronts societies with a series of important challenges. These challenges include issues of distribution of resources, the legitimate role of government, and the purposes, structure, and operations of social institutions, including health services. The concept of equity in health is based on an ethical notion of fairness. Inequities in health arise when disparities in health status between two groups are considered avoidable, unacceptable, and unfair. Individuals should be able to attain their full health potential regardless of age, gender, race, or socioeconomic circumstances. Social justice and fundamental human rights lie at the heart of health equity. Inequities in health deserve our attention for both ethical and pragmatic reasons (Evans and Norris 2000). If it is the case that cultural minority groups are subject to systematic disadvantage as a result of social arrangements, including the conduct of mental health research and the organization and delivery of mental health services, then a just society will change the social arrangements that result in such disadvantage. The collection and analysis of health status data are central to moving toward equity in health. The disturbing absence of population-based mental health data concerning immigrant and refugee communities is in itself a great inequity in health. The dearth of mental health information about large segments of the population renders their health status and the possible deficiencies in performance of the mental health system invisible. Such problems must be brought to light to enable the development of strategies to reduce inequities in mental health status and in provision of effective mental health services. Currently, in Australia, there exist major deficiencies in data and information on mental health status, mental health determinants, mental health service provision, and quality of service outcomes in immigrant and refugee communities. As a result, it is difficult to set equity-oriented objectives and targets and to monitor and evaluate policy and service initiatives or to estimate the personal, social, and economic costs of doing nothing to rectify this situation or of interventions that will achieve policy objectives.

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Rectifying these deficiencies, and developing mental health systems that serve all Australians equitably, is essential for improved population mental health. Commonwealth and State/Territory governments, mental health agencies and mental health professionals, consumers and carers and their organizations, and researchers will need to act collaboratively to develop a culture of inclusion and to ensure that Australian mental health research and mental health services reflect the great cultural and linguistic diversity of the Australia population.

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The Acculturation Experiences of First-Wave Kosovan Women Migrants Living in the United Kingdom

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An Interpretative Phenomenological Analysis Yllka Krasniqi Morina and Rachel Tribe

Contents Migration, Acculturation, and Psychological Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions of Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptualizing Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Theoretical Approaches Towards Acculturation Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Coping in Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kosova, Kosovan Migration, and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kosovan Acculturation Experiences and Rationale for Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rationale for a Qualitative Approach Using IPA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Participants, Data Collection, and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Decisions Influencing Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subordinate Theme 1. 1 Dissatisfaction with a Restricted Kosova . . . . . . . . . . . . . . . . . . . . . . . . Subordinate Theme 1. 2 Relating to the UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subordinate Theme 1.3 Naïve Idealization of the UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Master Theme 2- Early Phase of UK Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sub Theme 2.1 Unmet Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subordinate Theme 2.2: New Found Liberation and Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . Subordinate Theme 2.3: Ways of Coping with a New Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Master Theme 3 the Process of Acculturating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sub Theme 3.1 Valuing Openness and Individual Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sub Theme 3.2 Conflicts, Pressures, and Losses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sub Theme 3.3 Attitudes Towards the Acculturating Experience . . . . . . . . . . . . . . . . . . . . . . . . . . Master Theme 4. Implications of the Acculturation Experience to Oneself . . . . . . . . . . . . . . . . . . . Subordinate Theme 4.1 Ones Sense of Belonging and Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Y. K. Morina Department of Psychology, University of East London, London, UK R. Tribe (*) School of Psychology, University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London, London, UK © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_23

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Acculturation: A Personal Accomplishment and a Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Conclusions and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Abstract

Acculturation processes are a key part of settling down in the new country although there are huge variations in responses and the pace at which people acculturate. In this chapter we use the example of Kosovan women after migration to the UK to explore the experiences of acculturation and its perceived impact on their psychological well-being was conducted. Six participants were interviewed, and transcripts were analyzed using interpretative phenomenological analysis. Four major themes emerged: decisions influencing migration, early phase of UK life, the process of acculturating and implications of the acculturation experience for oneself. The psychological impact of acculturation and migration process was ascertained through their understanding of acculturation and their relationships with Kosovo and the UK. Acculturation was experienced as both an accomplishment and as an emotional challenge in response to conflicts and tensions related to their sense of ethnic identity and belonging. Not surprisingly these participants employed a number of strategies to cope with their migration difficulties and positioned themselves positively towards new cultures, revealing an appreciation of the UK’s multiculturalism. Theoretical implications and relevance of the findings to the field of counselling psychology are described with suggestions for further exploration. Keywords

Migrants · Kosova · United Kingdom · IPA · Acculturation · Psychological wellbeing · Mental health · Challenges · Conflicts

Migration, Acculturation, and Psychological Well-Being As a result of global sociocultural changes, increases in migration as well as intercultural transitions, acculturation has received much attention in the field of psychology. Such sociocultural changes and movement mean there are continuous encounters between many different cultures (Schwartz et al. 2006). When this occurs, individuals are considered to experience psychological and cultural changes (Schwartz et al. 2010). This has been understood in terms of the concept of acculturation (Sam and Berry 2010). Acculturation can have a significant impact for all involved. This includes the migrating individual, the people they interact with, the society they migrate to and settle in, policy makers, politicians, and mental health clinicians. Due to continuous change, there is a need to further understand individual’s acculturative experiences which often accompanies migration. Changes as a result of acculturation are said to be on-going and occur over a long period of time and thus has been discussed in reference to adaptation. In short, psychological adaption concerns the emotional well-being factors important in the acculturation process, whereas social cultural adaptation concerns the achievement of culturally fitting behavior which may be necessary to conform to a specific social

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environment (Ward and Kennedy 1994). As this transition often invites changes to original ways of living, migrants often face difficult challenges as they negotiate these changes in a new social and cultural environment (Berry 2006). Practitioners and researchers alike have emphasized the need to consider how this process impacts on several individual behaviors, including psychological difficulties (Berry 2003). The acculturation process has been associated with several difficulties during the life span; these include but are not limited to depression, anxiety, low self-esteem, increased misuse of substances, and perceived discrimination (Aroian and Norris 2002; Pernice et al. 2000; Miller and Chandler 2002; Vega and Alegria 2001; Ward et al. 2001). This is particularly relevant for the work of all mental health professionals.

Definitions of Acculturation There exist a number of definitions of acculturation; the most frequently used has its origins in the early conceptualization presented by anthropologists Redfield et al. (1936) who stated the following: Acculturation comprehends those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups (p. 149).

Modern day definitions such as that of Sam and Berry (2010) define acculturation as: “the process of cultural and psychological change that results following meeting between cultures” (pg. 472), characterizing it as both an individual and group phenomena. Sam and Berry’s (2010) conceptualization represents the most widely recognized definition. It is wide-ranging and embraces the foci of this study on the subjective experiences of acculturation. Moreover, this definition emphasizes three key elements integral in the experience of acculturation as highlighted by Sam (2006). That is, it entails intercultural contact, both groups can influence one another, and that change occurs as a result of the intercultural interaction. More significantly, it allows for individual differences in how individuals acculturate. However, this definition fails to acknowledge that in an increasingly globalized society such as the UK, there exist numerous cultures that interact with one another. Tribe and Lane (2014) in their research exploring the refugee experience highlighted the importance of accounting for the meaning-making experience that individuals undergo with respect to the cultural, sociopolitical, and familial contexts they are situated in. Thus, exploration of the ways in which individuals experience intercultural contact within such contexts, in addition to the resulting changes, is vital in order to understand the process of acculturation.

Conceptualizing Acculturation Initially acculturation was considered a linear process, referred as the “unidimensional” model. This approach suggests that over time, behaviors originating from an individual’s heritage culture become replaced by behaviors from the host culture.

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Furthermore one’s existing ethnic identity is shed through the process of acquiring a new one. Acculturation by this definition is largely an outcome rather than a process that is on-going. In contrast, the “bidimensional” model of acculturation (Berry 1997, 2006) posits a person can identify with multiple cultures in varying degrees. Furthermore this model suggests that behaviors attained from the host culture do not mean a total rejection of those of one’s heritage culture. The ‘four-fold paradigm’ model of acculturation was established by Berry (1994, 1997) which aimed to explore how both individuals and groups pursue acculturation. This model posits that how individuals acculturate is dependent on the ways in which they deal with two different aspects, that is “cultural maintenance” and “contact participation.” These two aspects are thought to meet and lead to four strategies of acculturation. In brief, these are assimilation, which posits that one adopts the host culture and rejects their own; integration, which refers to the retention of both cultures; separation, which is the retention of only the heritage culture and finally marginalization, which refers to the rejection of both cultures. There are a number of guiding factors which according to Berry (2003) influence the individual’s choice and use of strategies. These include the willingness of the dominant culture to be open to the influences of the other culture’s values; within this is the consideration of dominant culture’s ideology (Sam 2006). Berry (2005) among others has studied the factors that are involved in positive and negative psychological adjustment to a new society. He established a model in an attempt to demonstrate that in order for “integration” to occur, a mutual accommodation of both groups accepting the rights of all is required to take place, whereby all groups can live as culturally different in the same society. This involves the minority group adopting basic values of the majority group, whom likewise must accommodate the needs of all individuals living in that society. Berry noted the integration strategy had the most positive psychological and sociocultural adaptation (Berry et al. 2006). However, this model has been criticized for lacking consideration of important individual differences and contextual variances (Bhatia and Ram 2001).

Theoretical Approaches Towards Acculturation Research Much of the literature on acculturation places emphasis on the changes that occur when an individual is experiencing this process. Three key theoretical approaches towards research on acculturation process have been identified; these consider affect, behavior, and cognition (Ward et al. 2001). The affective aspect considers the emotional changes during the acculturation process and focuses on the challenges this brings. The acculturative stress model was proposed (Berry 2006; Berry et al. 1987) to explain this. The model posits that acculturative stress is likely to occur when individuals appraise the challenges of their acculturation experience as being “problematic.” This takes into consideration the complex factors that are part of the lived experience of individuals. Behavioral aspects to acculturation refers to culturally specific skills deemed essential in order to adapt to the environment. A cultural learning approach was

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proposed, viewing acculturation as a learning process (Chen and Isa 2003). This focuses on individuals’ perceptions of themselves and others during cultural contact, including how people process information about their own and other groups. The cognitive aspects of acculturation have been influenced by research on identity and social cognition. The significance of exposure to a different cultural environment with different social rules means that a migrant’s identity is likely to be affected in some way (Ward et al. 2001). Accordingly the relationship between acculturation and identity has been dominant in research exploring acculturation (Ward et al. 2001). Tajfel and Turner’s (1986) social identity theory highlights the significant impact one’s group membership has on one’s construction of identity. Various models have been put forward to address how migrants integrate their heritage and host culture identities. The “alternation” model of biculturalism for example suggests migrants can identify with two different cultures by altering their behavior in different cultural contexts depending on different cultural cues. The “blended” model of biculturalism however suggests migrants can maintain a positive heritage cultural identity while also developing a positive identity through membership in the majority culture (Phinney and Devich-Navarro 1997). Breakwell (1986) established the identity process theory (IPT) in an attempt to form an understanding of identity formation across the life-span, with a focus on the psychological and social processes involved in this process. These are considered to be important when identity is thought to be challenged such as when individuals experience a significant life transition, which questions their self-concept. Migration is one such social transition. IPT proposes that identity is a social product which is constructed through several dynamic interactions comprising memory and consciousness, biology, and social experiences. The construction of identity is thought to be organized by two different dimensions named the “content” and “value” dimensions. The “content” dimension includes phenomena which influence ones individuality, such as values and attitudes, including aspects of one’s social identity such as group membership. It is considered to be an evolving process which dynamically reacts to experiences from the social world. It is thought to shape identity by processes of assimilation-accommodation and evaluation. Assimilation and accommodation adjusts the different elements of identity into the identity structure whereas evaluation is thought to allocate value and meaning into the identity elements Both of these processes interact and influence one another in an attempt to manage the structure of identity. IPT puts forward four specific principles that guide the preferred identity structure. These are continuity, distinctiveness, self-efficacy, and self-esteem. Breakwell (2010) acknowledges the cultural specificity of these principles, although recognizes these are more fitting to Western cultures. One’s social context is also considered to play a significant role in the formation of identity and as such any change to this is thought to entail some form of adjustment within the identity structure. A threat to identity is thought to emerge when the process of assimilation-accommodation are unable to meet the guiding principles. When such threats occur, some form of action will be required. Attempts at these are referred to as coping strategies. And as such

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the study of coping has been a large focus of acculturation research which explores how migrants respond to stress.

The Role of Coping in Acculturation Berry et al. (2006) advocate that ability to cope is essential in order for individuals to deal with psychological difficulties during the acculturation process as it supports adaptation in the new cultural environment. There are large individuals differences in the ways in which migrants respond to challenges during the acculturation process; moreover, individual’s psychological responses are closely related to the coping strategies that they adopt (Bhugra 2004). Three common coping strategies have been identified; these are appraisal, problem, and emotion-focused strategies. Other coping strategies refer to avoidance and isolation and the use of substances as a means of coping which are considered to intensify difficulties. It is important to note that Breakwell (1986) in IPT refers to the use of cognitive and emotion focused strategies which acknowledge active, passive, and avoidant strategies as actions towards identity threats. In reference to Berry’s work, the acculturation strategies are considered as coping responses to the new culture. More specifically, these strategies relate to Breakwell’s conceptualization of potential actions towards identity threats such as avoidance, which relates to Berry’s separation and marginalization strategy. Moreover an individual may decide to integrate certain aspects of the social context into their identity structure, relating to the assimilation and integration strategy.

Kosova, Kosovan Migration, and Mental Health A review of the literature indicates a lack of reliable statistics on Kosovan migration and absence of research on the mental health of Kosovan migrants. Kosova is a selfdeclared independent country situated in the South East region of Europe, in the center of the Balkans. Historically, Kosova was considered as an “Autonomous Province” of the Serbian Republic within the Yugoslavian state by the former Yugoslavia. At the time, its constitutional status was determined by the then Serbian parliament. Kosovan-Albanians at the time were treated as a minority who had limited rights to their own republic state. The Serbian state posed various controls within educational, cultural, and health institutions in Kosova (Judah 2008). Years of ethnic discrimination instigated much tension between these two populations and led to conflict which broke out in 1998 (Cardozo et al. 2011). Ten years later, the state of Kosova was proclaimed independent and became the seventh sovereign state to emerge from the collapse of the former Yugoslavia. Kosova has one of the highest migration rates in Eastern Europe. It was recorded that one of every three to four households in Kosova has one member of the family who is living out of the country (World Bank Migration Report 2015). During the years 1998–1999, there was a large wave of migration following the war conflict

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(Haxhikadrija 2009). Following the end of this, Kosova experienced a rapid arrival of its displaced population (Kosova Remittance Report 2013). The available statistics from this report show the 1990s was characterized as the highest rate of migration from Kosova. There has been a decline in Kosova’s migration due to the many limitations that restrict movement out of Kosova such as the lack of visa liberalization with the European Union which is currently on-going. Kosova’s cultural background is linked to the many different empires that held power over the centuries. Kosova, although has undergone many societal changes, historically embodies many of the societal values that are considered representative of “Eastern” cultures. However, this has been increasingly changing due to the influence of “Western“values. There are many Kosovan communities evident in the UK; but particularly concentrated in London.

Kosovan Acculturation Experiences and Rationale for Study Much of the psychological acculturation literature has been dominated by quantitative methodology in a positivist paradigm (Waldram 2004); specifically, using crosssectional and correlational methods (Brown and Zagefka 2011). Such research has been statistically orientated and argued as rather incongruent with the nature of the acculturation process. The strong tendency to pathologize such a complex process may in part lay in the history of acculturation in the field of psychiatry (Berry 2005). Limited studies which have attended to finding meaning in how individuals experience acculturation and psychological well-being, have been carried out. Despite growing attention of acculturation in the psychological literature of varying migrant groups, existing research shows that study of acculturation is heavily dominated on migrant populations in America and Asia (Chun et al. 2003). However, there are large differences in how people seek to engage in the process of acculturation (Ozer 2013). The health of migrants in the UK is also of considerable policy interest and studies which are designed to develop a better understanding of these experiences are particularly necessary to enhance culture sensitive mental health practices. Limited acculturation studies on the Balkan populations exist. Despite the worldwide Kosovan diaspora relatively little is known about their acculturation and migration experiences. Research exploring the experiences of the acculturation process of Kosovan migrants cannot be located in the literature. Only one study looking at acculturation attitudes of adolescent Kosovans and Somalians living in Norway can be found (Bohn 2008). The available literature has focused on studying post-traumatic stress disorder caused by pre-migration trauma (e.g., Kashdan et al. 2009), since these individuals are more likely to present for psychological services. The Kosovan migrant population has not been represented in psychological acculturation research and requires exploration and understanding through qualitative enquiry. Conducting research exploring the experiences of underrepresented populations, such as this, is viewed as one of the primary ways in which mental health professionals participate in social justice focused actions (Vera and Speight 2003).

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Methodology Research Aim The aim of this research is to explore the acculturation experiences of female Kosovan migrants in the UK. That is their lived experiences, focusing on first wave female migrants who moved to the UK prior to the outbreak of the conflict in Kosova. This was in the early 1990s. This research aims to explore the processes of acculturation and is concerned with the perceived psychological impact of this process for this group of migrants. It also aims to shed insight into how challenges were experienced and the factors which influenced their experience of life in the UK. Greater awareness of individual’s lived experiences can enrich our understanding of this process. Acknowledgment of the psychological difficulties experienced by other migrant groups, as well as an absence of research into the understanding of Kosovan migrants’ experiences of acculturation and psychological well-being, provides a strong rationale for exploring these experiences.

Rationale for a Qualitative Approach Using IPA This research is concerned with exploring individuals’ experiences of acculturation, which entails change and adaptation, it will aim to reach this objective through getting as close as possible to the essence of the individuals’ lived experiences. This requires a methodology that is focused on exploring the experiential and an approach which recognizes the importance of social and cultural contexts in shaping such experiences. Although many qualitative approaches share this aim; IPA is seen to give this primacy (Smith et al. 2009).

Method Participants, Data Collection, and Analysis IPA encourages small sample sizes in order to achieve data that has depth rather than breadth (Smith 2008). Six female participants were recruited. Table 1. provides basic demographic information for the participant group. Data was collected via individual face to face semi-structure interviews. Interviews were carried out in accordance with University ethical guidelines and consideration was given to the ethical guidelines set out by the Code of Ethics and Conduct (British Psychological Society 2009). IPA is considered more as an approach rather than a prescriptive method of analyzing data (Smith et al. 2009). The analysis of interviews followed the procedural stages recommended by Smith and Osborn (2003) and Willig (2013). Analysis was achieved through an inductive and iterative process, whereby an interchange occurs with the data as the analysis develops, moving from the descriptive to the interpretative.

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Table 1 Participant group demographic (pseudonyms are used) Participant 1. Linda 2. Ariana 3. Blerina 4. Eliza 5. Laura 6. Suzanna

Age 42 43 45 45 43 45

Employment status Employed Voluntary work Employed Employed Employed Employed

Relationship Status Married Co-habiting Married Married Married Married

Date of arrival to UK 1992 1991 1991 1992 1992 1992

Table 2 Master Themes and Subordinate Themes Master Themes 1. Decisions influencing migration.

2. Early phase of UK life.

3. The process of acculturating.

4. Implications of the acculturation experience to oneself.

Subordinate Themes 1. Dissatisfaction with a restricted Kosova. 2. Relating to the UK. 3. Naive idealization of the UK. 1. Unmet expectations. 2. New found liberation and opportunity. 3. Ways of coping with a new reality. 1. Valuing openness and individual differences. 2. Conflicts, pressures and losses. 3. Attitudes towards the acculturating experience . 1. Ones sense of belonging and identity. 2. Acculturation: A personal accomplishment and a challenge.

Findings Analysis of the interviews led to the development of 4 master themes and 11 subordinate themes (Table 2).

Decisions Influencing Migration Many participants described their experiences of life before migration, providing a rationale behind their decisions to migrate. These appear to have had an impact on participant’s experiences of acculturating in the UK.

Subordinate Theme 1. 1 Dissatisfaction with a Restricted Kosova The theme of constraint due to political conflict and repressive regimes is inclusive of a number of different perspectives and experiences. These appear to have led to a disenchanted youth who no longer wanted to tolerate the restrictive changes to their country, specifically to their education and future life aspirations during what was a

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pivotal stage of their lives. This was seen as inhibiting of their individual growth and their cultural autonomy. Participants expressed dissatisfaction as originating from the repressive regimes in Kosova which were seen to as have damaging effects to young adulthood due to the limits this imposed upon that generation; . . .It’s just because I was so disappointed as I said you know for four years we were in secondary school we couldn’t live our young youth, age was so limited. . .we couldn’t er do as much as we wanted to do because of the situation. . .maybe I was just disappointed with the whole thing there. . . [Ariana, lines 452–457]

Participants expressed feelings of discontent with the limited opportunities experienced in Kosova which significantly influenced experiences of acculturating in the UK; I always had this in my mind, this, I wanted to go to England maybe but then the way the situation developed in the country, in a way I just thought well why not cuz what’s here for me and so erm the only option for me to, to, to erm do something for my life er then was to go to London, actually England. [Blerina, lines 52–57]

The impact of the repressive Serbian regimes in Kosova at the time has been well documented elsewhere (O’Neill 2002); however, it has not been addressed within psychological literature. The literature on motivation and psychological well-being is important when reflecting on participants’ experiences and the motivations they felt to change what they perceived as an increasingly restricted life in Kosova. Core within humanistic roots, Maslow’s (1943) theory of human motivation is significant given participants’ experiences, specifically drawing attention on the importance of an individual’s search of self-esteem. The identity process theory (Breakwell 1986) is also important in providing an understanding of participants’ motivations to migrate as a means of developing selfesteem. When taking into account participants perceptions of Kosova as limiting and an increasingly restricting place to live, thus an important factor in their migration, it is evident this threatened one’s sense of self-efficacy and esteem. Therefore, it seems identity threat stems from the old culture, rather than the new host culture.

Subordinate Theme 1. 2 Relating to the UK There was a strong sense of the participants relating to the UK by having a pre-established connection with England which was identified as both a contributing and motivating factor in their decision to migrate to the UK. These connections were the English Language, or having established networks through family or friends: I didn’t think about it, I’m moving there and because my English was ok. . . we learned in school the English language since we are well seven-eight years old. . ... I went to English

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course and my mum she’s an English teacher. . . you know English, I wasn’t really. . .scared. [Ariana, lines 74–82]

Research reveals that individuals who had previous experience of the culture and language of the new host environment adjusted more easily (Parker and McEvoy 1993). Research has shown that language ability is a significant positive factor in the psychological adjustment of new cultures (Berry 1992). These were instrumental in participants’ acculturation processes, since this provided social and financial support. Familiarity with the UK served as an important facilitator in participants’ processes of settlement. These can be understood as part of a socializing process, which has been shown to enable adjustment to the new environment (Ward et al. 2001). Research by Bhugra (2004) has specified the likely impact of communication difficulties on acculturative stress and difficulties with adjustment in the host culture. In addition, when considering IPT, deficiencies in language ability and thus problems with communication are considered to be potentially detrimental to a migrants’ self-esteem and self-efficacy. These in turn may act as potential threats toward their identity.

Subordinate Theme 1.3 Naı¨ve Idealization of the UK An idealization of the UK pre migration was strongly emphasized by participants. The role of movies appeared to be a platform where certain projections of life in the UK could be made, which seemingly offered a glimpse into the image they created of life in the UK; It was between the English movies and New York City, because every time you see movies and you see, the big building, nice, everything nice shiny, you know like you think oh my god now when I land in London I will think I’m now in, same place as New York you know like with the big buildings and everything. [Laura, lines 230–235]

In other examples, participants reflected romanticized projections formed of the UK; I choose England because of reading about Shakespeare and reading about, you know queen [R: Uhu] cuz every girls dream to see (laughs), to see a palace and all that. . . [Eliza, lines 75–78]

A sense of naivety and impulsivity was also central across participants, which can be seen to be a factor in their idealisation of the UK. All participants made reference to their age when talking about their expectations of the UK. Linda offers a description of naivety in her judgments, describing herself at the time as “young and foolish. . .” [Linda, line 627]. Many of the idealizations that participants formed can be seen to be heightened in response to the feelings of restriction with Kosova they felt and corresponded with the feelings of hopelessness and limiting of opportunities in Kosova. Research has suggested that migrants’ perceptions of the country of origin can be beneficial during their acculturation process. Tseng (2001) associated the feelings that migrants had of

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their country of origin, particularly feelings of escape with an increased likelihood of a more successful acculturation process in the new culture of the host country. Acculturation was revealed to be associated with freedom, optimism and determination for an improved life. Thus participants’ feelings of hope and motivation were understood to enhance their chances of acculturating successfully.

Master Theme 2- Early Phase of UK Life This master theme encapsulates participant’s experiences during the initial settlement period the UK, highlighting how they initially related to the UK. Their descriptions fall into both positive and negative categories of which three sub themes were identified.

Sub Theme 2.1 Unmet Expectations A strong theme to emerge was a disappointment in the reality of life in the UK. Participant’s descriptions were understood as a response to unmet expectations of life in the UK. Many did not acknowledge the potential difficulties they may encounter when they migrated to the UK, which perhaps could have served as a preventative to disappointment and conceivably enabled better preparation for possible challenges. Following on from initial feelings of elation, dealing with the reality of the life they had imagined was identified as something participants did not foresee and experienced as stressful. Participants highlighted the paradox between their actual experiences of the UK against their idealized image of the UK pre-migration; . . .that was a dream come true for me before I came to London and then it wasn’t anything like what I expected, . . . you know when somebody says how amazing one thing is and you expect something amazing and it was nothing amazing about it, . . . erm it was terrible. . . [Linda, lines 19-24]. . . .but then when I came here it was a different story (laughs). [Ariana, lines 97–98]

Such responses to an unexpected reality also brought about emotional changes for participants; whenever I tell them this they are very surprised cuz they didn’t think that we had such a good life back home. . . I remember waking up at four O’ clock . . . and just crying, because I had to sleep in my clothes because it was so cold. [Linda, lines 54–59]

This has important clinical implications for the work of mental health practitioners. It illustrates the importance of being curious about the relationship between pre- and post-migratory views and experiences in order to attain an understanding of the impact of this on the individual as well as their ability to adapt. This is considered to be an internal factor which along with personality is of significant importance in

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gaining an understanding of how individuals psychologically respond to acculturation (Bhugra and Ayonrinde 2004).

Subordinate Theme 2.2: New Found Liberation and Opportunity Following initial disappointment with the UK participants shared that there was a strong sense of freedom they felt. A dominant component of this appears to be connected with the constraining events that participants experienced pre-migration in Kosova. There was a sense of the UK being a provider of opportunity and stability without the political constraints experienced in their home towns; . . . it was a very good feeling to, to be able to walk around the streets and not see a Serb, a Serbian police with their guns and just thinking are they going to stop me now, are they going to question me now so. [Linda, lines 210–213]

Furthermore opportunity is referred to by participants when describing their appreciation of diversity in London. All participants reported valuing the UK’s cosmopolitan identity and shared the idea of London as the ‘world in one city ’. Whereas other participants highlighted their increased need for cultural awareness. The UK represented an opportunity to meet the whole world; . . . in the beginning was, it was overwhelming but I was so happy. . .because it was my dream to travel the world and I could meet the world in one place in London so I made sure I meet people from all over the world as much as I could cuz I thought I’m going to stay six months, that’s why and it’s been 23 years now. [Eliza, lines 713–719]

Subordinate Theme 2.3: Ways of Coping with a New Reality Analysis revealed participants developed several methods of coping during the early phase of settlement to the UK. These were seen to be facilitating their process of acculturation and reduced the stressful aspects of their experience. Several participants referred the use the Kosovan-Albanian community as an instrumental source of social support; . . .it was quite a tough time but er, we had people around from our community so they helped us and they show, what to do, where to go. . . [Suzana, lines 66–70]

Work and study were behavioral strategies participants voiced helped them to cope with settling into the new environment. This provided participants with confidence that they were adjusting well to the different cultural environment; I got a job everyone was doing the same things so I just adapted. . .because the majority of my friends they were working, ok I have to work too, you know so I just went with the flow. . . [Ariana, lines 137–141]

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Participants voiced cognitive strategies which included conscious and rational methods of coping in an attempt to alleviate emotional difficulties they were experiencing. Among these were self-persuasion and encouragement, focusing on priorities, normalizing, and minimizing, rationalizing, and visualization and writing. These can all be understood as promoting a psychological robustness; . . . I’m writing and I’m doing something for, for myself, it was my friend, that pen and paper they were my friend that’s how it was, because I had nobody else. . . [Laura, lines 157–160]

Master Theme 3 the Process of Acculturating This theme encapsulates participant’s experiences of attempting to adapt to life in the UK. Participants described varying experiences of which three sub themes were identified.

Sub Theme 3.1 Valuing Openness and Individual Differences All participants described valuing what they perceived as a sense of multicultural openness in the UK and the individual differences of other cultures. Participants voiced these to be important qualities in their process of acculturating in the UK as it fostered an attitude that promoted a sense of inclusiveness. The ways in which host countries respond to migrants has been extensively researched, and highlighted this to be an important factor which influences the acculturation process and psychological well-being of migrants (Berry 2003). Participants’ accounts reflected their attitude towards other cultures and the ways in which they approached integrating in the UK, revealing of their acculturation processes. Participants expressed valuing individual differences and makes direct links between being open with the ability to adapt; I just think that every, every race, every nationality every it’s just you know, there is erm, it’s individuality that counts. . .and you find things that are actually are so different that you think you know, I’ d like to adapt that to myself because it’s so helpful in life. [Blerina, lines 257–366]

Other participants described how experiences acted as a form of learning, resulting in an increased understanding and acceptance of different cultures, leading to the development enriching experiences. One participant described the concept of an “anthropologer” to illustrate her experience gained during her acculturation process; It’s better because you experience more, more things. . .your knowledge will be more wide. . . like you are any anthropologer. [Suzana, lines 327–330]

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Sub Theme 3.2 Conflicts, Pressures, and Losses Internal conflicts, pressures, and losses were voiced as important experiences which reflected participants’ descriptions of challenges faced during the acculturation process. These encompassed many dilemmas, questions and decisions they encountered, which they perceived as interfering in the process of acculturating. Descriptions of feeling torn between living in the UK and a yearning to return to Kosova were voiced. For example; . . .it’s been twenty three years I’ve been living here. . .the only thing I feel every now and again that wish to have to go and live in your country. . .being in between two countries. . .that’s the only thing. [Linda, lines 259–267]

Participants’ accounts revealed that although physically they resided in the UK, they remained emotionally and psychologically connected with Kosova; It’s just maybe actually I erm I kind of pushed myself in a way because it was so difficult living here, being here and not being here because we have to adapt otherwise er it’s just so difficult. I remember all those years. . . it was very conflicting because you live here and you think about there all the time. . . [Blerina, lines 196–202]

The above accounts reveals acculturating was a choice one had to make, requiring self-agency rather than a process which simply takes place over time. A loss of connection Kosova through the years was also voiced by participants; this appeared to be heightened during visits to Kosova. I think when at least when I go there I kind of expect erm things or people to be the way they were and probably you realise that actually yes I have changed but they have changed too so actually nothing is the same erm so I just came to realise that gradually you lose the connection. [Blerina, lines 249–252]

Participant’s accounts powerfully reveal the loss incurred during the acculturation process, with their heritage no longer ‘exists anymore’, which several continued to experience; . . .but when I go back those things don’t exist anymore so it’s just a part of me, my young hood that is in me that still is searching. [Eliza, lines 311–324]

Sub Theme 3.3 Attitudes Towards the Acculturating Experience Analysis revealed participants cognitive processes’ during their attempts at integrating in the UK, offering their evaluations of this process and the impact on their psychological well-being. Participants perceived their sense of acculturation as positive experiences, a process which required active engagement, evolving over the years;

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Erm I think it’s been good to adapt erm. . .maybe more , you adapt more as the years go by and you try and integrate. . .I don’t, I don’t remember going to a pub until. . .fifteen years coming to England [Linda, lines 675–684]

For several participants, work was an avenue which exposed one to a variety of different cultural backgrounds and acted as a platform where the acculturation process was most pertinent. Participants offered an understanding of acculturation as requiring the ability to recognize, understand, and appreciate differences and similarities between cultures. Ariana describes positively perceiving her sense of adaptation by making a comparison to other migrants who were not so successful in this process; Erm, personally I think I er I adapted very well I have friends that they went back home after six months because they couldn’t bear it, home sick. . .personally I think I adapted well I think it’s like I, I’ve er you know sometimes I feel like I’ve been here forever you know like er like I was born here. . . [Ariana, lines 359–369]

Some participants suggested acculturation involves an active attitude on the part of the individual, one that dynamically attempts to moves towards “fitting in.” Suggesting an “internal” process whereby it is crucial to consider one’s motivation towards acculturation; . . . we here were you know free and actually put into the society and you know no one can actually erm, make you fit, you have to try for yourself so yeah yes. . .because I think if you, if you decide to live here you know you have to be a bit more adaptable. [Blerina, lines 561–569]

Participants reflected that there was much resistance they observed in other Kosovans whom continue to identify themselves as “foreign.” Participants reported that their attempts at challenging this attitude led to negative judgements which viewed them as disloyal towards their ethnic roots; I know some Albanian mums you know they just don’t. . .it’s still everything foreign here and I think that must be very difficult to live somewhere and you don’t feel your home. . .. even if you try to explain you are the one. . .that you don’t care about your country anymore. . . it’s like oh you have become English as they say not British, but English. [Blerina, lines 572–586]

Participants also voiced that the homogeneity of Kosova was also seen as a factor which did not prepare one for the acculturation process. One participant described a shift from her patriotic attitude which is viewed as limiting; I’m more open-minded now. . . I used to be more conservative how to say, patriotical, conservative, but now I don’t think that way. . .I’m changing through the years. [Suzana, lines 338–442]

Such attitudes are a shared experience across many Kosovan-Albanian individuals. This is most likely owing to political threats made towards their national identity.

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This is perhaps especially so among Kosovan migrants who feel that such an attitude preserves one’s ethnic identity which is likely heightened due to the threat migration can be seen to pose towards ones sense of belonging.

Master Theme 4. Implications of the Acculturation Experience to Oneself Subordinate Theme 4.1 Ones Sense of Belonging and Identity Analysis revealed participants’ acculturation processes challenged their sense of ethnic identity and belongingness and the way they culturally positioned themselves. One participant voiced that although she developed a strong attachment with the UK, this did not put an end to her relationship with Kosova, which continues to represent an important part of her identity; I think I do feel British I don’t think I er did feel like this for erm a long time...you know, I am Albanian and from Kosova and I like to keep that but I think it’s very important . . .to feel at least a little bit part of this country. [Blerina, lines 156–166]

This relates to Berry’s (1980) acculturation model, which proposes that acquiring and taking in aspects of the host culture and retaining the heritage culture are independent dimensions within the acculturation process. For many, the UK was conceptualized as their home base and experienced as an accepting environment. In terms of Maslow’s theory of human motivation, one’s need for acceptance can be viewed as a necessary condition for the achievement of a self-actualized state (Maslow 1943), and thus particularly relevant participants in this study. Analysis revealed that national frame of the UK as inclusive was crucial fostering opportunities for belonging within the existing multicultural society. This has important clinical and governmental implications, illustrating the significance of the attitudes and policies of the larger society towards migrants. This was seen to facilitate successful acculturation. Other participants described experiences which challenged their sense of belonging in the UK, leading to feelings of exclusion and isolation which had a negative impact on her acculturation and psychological well-being; . . .you know it took me a time to understand you know it is, right a different culture erm now I got used to it but . . . I can’t fit in. [Eliza, lines 225–229]

Participants voiced their strong belonging with their Kosovan-Albanian identity, one of whom initially concealed this in fear of discrimination. The detrimental impact of discrimination on the psychological well-being of migrants has been well documented within the psychological literature (Lee 2005). Perceived discrimination was an experience which had a negative impact on participant’s acculturation processes. Discrimination signifies a clear threat towards one’s identity and

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self-esteem. In reference to IPT, moving away from such threats by concealing one’s identity, can be conceptualized as a coping strategy. Analysis also revealed participants’ need to display loyalty to their ethnic roots. This appeared to be a challenging experience owing to a lack of Kosova’s recognition. This seemingly had a negative impact on participants’ psychological wellbeing, particularly in terms of a lack of ethnic validation they felt; it’s just like nobody knew where Kosovo is. . . ok you don’t know let me tell you about it, where we are and who we are and. . . you expect like if I know about England, Italy, Germany, France, America, Africa, India, why don’t you know about my country? [Ariana, lines 165–177]

Acculturation: A Personal Accomplishment and a Challenge Analysis demonstrated that participants interpreted their acculturation processes as both an accomplishment and challenge. These were described as leading to developments in self-efficacy, learning and maturity. Challenges were expressed in terms of the emotional difficulties the acculturation process triggered for participants. These were in relation to disturbances in one’s mood, a loss of family attachments and loneliness, communication difficulties, and discrimination. Participants voiced an increased sense of independence and autonomy which they perceived as a personal accomplishment. I think I became a much more stronger person, much more confident, much more wise, I knew what I am, er what I want to do, I knew what to go, I knew how to handle things, to this day I believe that this place has made me stronger. [Laura, lines 447–458]

Whereas others used their experience of discrimination to improve her awareness of her own culture, positively impacting on her psychological well-being, providing her with cultural engagement and meaning; I had this vision that I need to prove and show. . .people where I live that I am proud to be Kosovan and we have a culture and we have traditions. . .and there are so many good things in where I come from just allow me to show you. [Eliza, lines 822–836]

Furthermore, analysis powerfully revealed the emotional challenges that their acculturation process involved, described in terms of feelings of depression and failure. You felt like nobody understands you. . .it was very, very emotional. . .you know like you feel like lost, you regret why you came, you say I’m going back, and then you think of going back you are a failure. [Laura, lines 101–117]

These revealed participants’ resilience in overcoming such challenges which were conceptualized as a personal achievement, strengthening ones identity. This seemingly provided participants with greater coping resources, maturity, self-efficacy,

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independence, and life philosophy. Such experiences are deemed important in fostering self-belief and self-determination (Owens et al. 2006). Such findings have been described as a type of “acculturative resilience” (Geeraert and Demoulin 2013), which follows initial acculturative stress, and thus particularly reflective of participants’ experience of acculturation. A study by Stopford (2008) found the experiences of migration to be characterized by an “in-betweenness,” involving multiplicity, movement, and negotiation. This was viewed as establishing a foundation for personal growth, which can lead to identity development (Papadopoulos 2002), and thus foster authenticity and lead to a renewed sense of self. This is particularly reflective of participants’ accounts, which indicated their acculturation experiences to be both a transitional and transformative learning process, resulting in increased personal development.

Conclusions and Implications These findings demonstrated the richness and complexity of the participants’ experiences. This study revealed several significant findings which are related to these migrant groups’ experiences of acculturation and psychological well-being. Analyses revealed that participants largely achieved a positive acculturation process to UK culture with a strong maintenance of their Kosovan heritage culture and identity. This supports the notion that both heritage identity and acculturation contribute to the psychological well-being of migrants. Although participants’ acculturation processes initially entailed several acculturative stressors, these were perceived as largely nonpathological. This process entailed a number of internal conflicts and dilemmas. These included tensions with one’s sense of identity and belongingness, cultural pressures of parenthood, lack of acknowledgment and validation of one’s ethnicity, loss of family ties and family closeness, and weakening cultural connection of one’s heritage culture. Furthermore, findings reveal that language ability and an established network in the host country may facilitate acculturation, acting as a type of preparatory experience. Additionally, analysis revealed that participants developed a number of coping strategies which helped them deal with acculturation challenges. This demonstrated a psychological equipment of sorts, revealing resilience and flexibility in adjustment (Ward et al. 2001). In terms of IPT (Breakwell 1986), holding such traits are considered to contribute to the maintenance of one’s self-esteem. This study illustrates the importance of exploring the pre-migratory phase and the preparatory phase in issues addressing acculturation and the psychological wellbeing of migrants, particularly in terms of the types of pre-migratory expectations individuals hold of the host culture. Of equal significance, this study showed the importance of considering the availability of a social network in the new host culture, which can be seen to facilitate the acculturation process and act as a safeguard for potential challenges experienced during this process. Furthermore, findings show that openness and individual differences are perceived characteristics

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of the UK’s multicultural society that are particularly valued and a factor that facilitated their acculturation processes. Additionally, a significant finding was the impact the social-political conflict in Kosova had on participant’s motivation to migrate and in turn influence their acculturation experiences. This appeared to be important in how participants approached acculturating to the UK, particularly in terms of valuing the opportunity and sense of freedom they felt. This was seen, by contrast to the restrictions experienced in Kosova, as enabling personal development and autonomy. Despite their desire to leave what they perceived was becoming an increasingly inhibited country, participants remain strongly attached to Kosova. Participants’ acculturation processes also entailed the development of an attachment with the UK, providing an additional sense of cultural belongingness. Such findings have important implications for clinicians, specifically in terms of being sensitively attuned to the ways in which sociopolitical forces affect migrants and shape their identities and in turn impact their acculturation experiences. Participants voiced that despite several difficulties during the process of acculturation, their acculturation experiences led to the attachment of a new home, new cultural experiences, new relationships, and sense of belonging, leading to positive personal developments. These included increased self-efficacy, cultural awareness, and openness and maturation. This has important implications for policy makers and clinicians in terms of supporting a bicultural competence which appears significant in facilitating successful acculturation.

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Canadian Immigrant Mental Health

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Kenneth Fung and Jaswant Guzder

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immigration Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Canadian Immigrant Mental Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Inequities and Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poverty, Underemployment, and Unemployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Racism and Discrimination in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Religion Tension and Moral Beliefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intersectional Marginality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Providing Care for Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Canadian Initiatives to Address Immigrant Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethno-Specific Models for Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Consultation Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical CCS Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coordination of Cultural Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Canada is a nation of immigrants, with about a fifth of the total population being foreign born. It has come a long way from exclusionary immigration policies to embracing multiculturalism, a mosaic vision of society, with the province of Quebec pursuing a model of interculturalism. Nevertheless, the examination of K. Fung (*) Department of Psychiatry, University of Toronto, Toronto, Canada e-mail: [email protected] J. Guzder Psychiatry, McGill University, Montreal, QC, Canada e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_11

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the ‘healthy immigrant effect’ suggests that for some immigrants, their physical and mental health deteriorate to non-immigrant level or in some cases worse. Some of this may be accounted for by acculturative challenges as well as the impact of social determinants of health. To enhance the mental health of immigrants, systemic changes are needed to address social inequities and oppression, reflected in the higher unemployment and underemployment rates, poverty, racism, discrimination, and the culmination of intersectional marginalization. Immigrants often underutilize mental health services until later on in the course of illness due to multiple access barriers. Further, cultural competence at both the clinical level as well as the organization level is needed to provide effective care. A number of care models in Canada have begun to address these needs, including ethnospecific services and the cultural consultation model. Keywords

Immigrants · Mental health · Healthy immigrant effect · Acculturation · Cultural competence · Ethnospecific services · Cultural consultation · Social determinants

Introduction Canada is often referred to as a land of immigrants. After the initial period of British and French settlement in Canada, there has been a history of successive waves of immigration from varying sources of country of origin. Based on latest statistics from 2011, about 6,775,800 Canadians, a fifth of the total population are foreign born, the highest proportion among G8 countries (Statistics Canada 2013). The breadth of diversity is equally impressive, including more than 200 ethnic groups. Although most immigrants were from Europe including the United Kingdom, Italy, Germany, and the Netherlands prior to the 1970s, these demographics have changed significantly over time. Between 2006 and 2011, about 56.9% came from Asia and the Middle East with the largest regional sources of immigration arriving from the Philippines (13.1%), China (10.5%), and India (10.4%). There was also an increase in immigration from Africa (12.5%) as well as the Caribbean and Central, and South America (12.3%) in recent years. About 78% of immigrants between 2006 and 2011 were visible minorities. In total, 6,264,800 Canadians or about one fifth of the Canadian population self-identifies as being a visible minority. The current inclusive Canadian reality is reflected by the increasing presence of elected parliamentarians, governor generals, professionals, and civil servants from visible minorities and immigrant or refugee origins. The majority of immigrants live in four of the ten provinces: Ontario, British Columbia, Quebec, and Alberta, with about 63.4% of immigrants located in three urban centers: Toronto, Vancouver, and Montreal. About 72% of immigrants had a mother tongue other than the official languages of English and French, with Chinese being the most common language (38.2%). About 6.5% of immigrants reported that they did not speak either of the official languages. About two thirds of Canada’s

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population is affiliated with a Christian religion, including 12.7 million Roman Catholics. About one million Canadians identify themselves as Muslim. Among recent immigrants, 47.5% were Christians and 19.5% had of no religious affiliation. Muslim, Hindu, Sikh, and Buddhist immigrants represented 2.9% of immigrants before 1971 but account for 33% of immigrants between 2001 and 2011.

Immigration Policies While early Canadian policies related to immigration were focused on protecting the public against communicable disease, including quarantine measures (Gushulak 2010), policies also evolved to explicitly restrict entry for perceived social, economic, or political negative effects. This had led to various historical policies of exclusion, including some criteria influenced by eugenics ideology (e.g., “prohibit or limit the admission of persons by reason of nationality, ethnic group, occupation, lifestyle, ‘unsuitability’ with regard to Canada’s climate and perceived inability to become readily assimilated into Canadian society”) and others based on health problems (e.g., “deformed, handicapped, or mentally ill”). Contemporary policies, including the current Immigration Act, no longer have blanket exclusion of groups of people and evaluate entry criteria by individual case assessments with a more inclusive policy on the health and well-being of newcomers. While the immigration policy protects Canada against excessive burden on the health-care and social systems, amendments to the Immigration and Refugee Protection Act in 2001 exempted the excessive demands exclusion criteria on refugees and members of immigrant families (Gushulak 2010). Canada’s policy on multiculturalism proposed in 1971 became a law in 1988 under the Canadian Multiculturalism Act (Gushulak 2010). The federal law sought to “preserve and enhance the multicultural heritage of Canada” and sought to guarantee individual rights and overcome discrimination based on race and ethnicity (Chiasson 2012). While multiculturalism favors hybridity within a mosaic vision of society, Quebec pursued a model of “interculturalism” as a paradigm which emphasizes social cohesion within a francophone society and integration to the communal values of Quebec while protecting differences and diversity (Bouchard and Taylor 2008; Chiasson 2012). Quebec has sought to balance its fundamental adherence to the primacy of the French language as a minority within Canada and its desire to preserve the unique heritage of Quebecois culture. The integration policies of Quebec include a larger provincial mandate distinct from other provinces on deciding immigration entry and an integration policy that balances assimilation into a francophone society and respect for Quebec’s unique cultural context. Bill 101, for example, limited access of immigrants and refugees to French school boards and denied access to English schooling reflecting policies of integration through an interculturalism approach. The resurgence of Quebec nationalism in the 1960s had influence the binary nature of Canada as a bicultural and bilingual state in an evolving relationship within Canada. In addition, there is the impact of the Truth and Reconciliation Commission in addressing the cultural “genocide” as an

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aftermath of residential schools. This removal of native children from their families to acculturate them in government schools across Canada has led to an official recent apology by the federal government for earlier systemic violations of human rights of those communities. These dynamics and tensions continue to evolve, generating a debate on mental health policy and patient access within a diverse Canadian reality. Since the post Holocaust era, Canada has increasingly offered a haven to refugees in times of crisis and increased its immigration of non-European origin applicants. In 1960, Canada accepted 3500 refugees including 325 with tuberculosis, and in 1979, 60,000 refugees from Vietnamese, Laos, and Cambodia were resettled in Canada. Most recently, the federal government endorsed a plan to resettle 25,000 Syrian refugees. Early Canadian history reflected policies of exclusion and racism particularly of Chinese and South Asian immigrants from the late 1800s embedded in a “white Canada” sentiment. While Canada welcomed immigrant labor, their wives and families were excluded and citizenship was not permitted to some minorities. A particular salient example of ethnic exclusion and discrimination in Canadian history was against the Asian and Chinese immigrants (Calgary Chinese Cultural Centre 2008). Many Chinese immigrants were brought in to build the railway that unified the country, with an average of four Chinese dying per mile of railway due to the dangerous conditions that they were assigned to work in. When the railway was completed in 1885, the government imposed a head tax on Chinese immigrants, raised as high as $500 in 1903 or about 2 years of wages. In 1923, the Chinese Immigration Act (Chinese Exclusion Act) further effectively excluded Chinese from immigrating to Canada. This was repealed in 1947, although discriminatory restrictions were in place until around 1967 with the introduction of a point system. In 1947, South Asians from India were granted the right to be citizens though they had been migrating from the late 1800s (Jagpal 1994). The Immigration Act, which affirmed a more inclusive policy, came into effect in 1976. The act also introduces the concept of “excessive demand” on Canadian health and social services as grounds for turning down immigration. The current point system helps to make the immigration process more transparent and equitable, favoring education, work skills, and economic benefits for Canada and for skilled immigrants. The selection process of immigration is one of the factors proposed to underlie the healthy immigrant effect.

Canadian Immigrant Mental Health and Illness Research from various countries has found that immigrants may have better physical and mental health than the general population. This has been termed the “healthy immigrant effect.” Possible explanations for this include immigration criteria that select for a healthier cohort, the attributes of people who choose to immigrate or have successfully navigated the point system of entry, as well as health examination procedures that screen out those with severe illness. In reviewing four major national health surveys drawing data from 1996 (NPHS Cycle 2) to 2005 (CCHS Cycle 3.1), the healthy immigrant effect was reflected in parameters showing consistently lower rates of depression, alcohol dependence, and self-rated mental health (Ng and

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Omariba 2010). Based on more recent data from the 2011 Canadian Community Health Survey, 6.8% of immigrants reported that they suffer from an anxiety or mood disorder diagnosed by a health professional, lower than that of the general population and showing little signs of change over the last decade based on survey data (Mental Health Commission of Canada 2015). As part of the healthy immigrant effect, there is a concern that the mental and physical health of immigrants deteriorates progressively, either to nonimmigrant Canadian level or worse. This may be due to the complex interaction of premigration factors and effects of convergence, i.e., where immigrants are exposed to similar stressors and begin to adopt similar lifestyle choices, as well as various postmigration stressors (Beiser 2005). A number of research studies support this analysis, although results vary on how long the advantage effect is sustained before there is deterioration (Vang et al. 2015). For example, Wu et al. found advantage for recent (less than 10 years) immigrants but not for established (greater than 10 years) immigrants, while Aglipay et al. found advantage for immigrants regardless of duration in terms of anxiety disorders (Aglipay et al. 2012; Wu and Schimmele 2005). There is evidence that the healthy immigration effect does not describe all groups of immigrants. In reviewing the literature, Vang et al. found that, while Canadian studies in mental health tend to confirm this for adults, it may be weak or absent in the youth or elderly (Vang et al. 2015). One potential explanation is that unlike the adult population, the selection pressure may be less applicable in these groups, such as immigrating as a family member. A recent study using the Canadian Health Survey of 2011 analyzed mood disorders by age of immigration from childhood to adulthood, showing higher rates of affective disorder for immigrants migrating in early childhood (Islam 2015). Immigrant women had worse mental health risk for perinatal depression in five out of the eight studies reviewed (Vang et al. 2015). Thus, it is important to consider the specific immigrant population, the particular context an ethnic group faces, as well as the specific mental disorders being studied in considering mental health risk of Canadian immigrants. In a retrospective cohort study based on administrative data of 4.28 million in Ontario, significantly higher rates of psychotic disorders were found among immigrants from Caribbean and Bermuda; lower rates were found among Northern and Southern Europe and East Asia (Anderson et al. 2015). Refugee status, including East African and South Asian refugees, had significantly higher rates of psychosis. Analysis of data on suicide suggests that immigrants have a lower rate of suicide than those born in Canada. This trend is especially noted for the three urban centers of Toronto, Montreal, and Vancouver which receive the most immigrants (Malenfant 2004). Urban metropolis may offer some protective effect given the higher immigrant and ethnic density which may contribute to greater community support, as well as potentially greater availability and access to employment and services and lower discrimination. A recent Canadian study found that prevalence of suicidal ideation was higher among rural minority immigrants than urban minority immigrants or white immigrants (rural or urban). A protective effect of immigrant density was observed only for rural minority immigrants; for each 10% increase in immigrant density, there was a 67% lower risk of suicidal ideation. A sense of belonging was independently

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associated with lower suicidal ideation among immigrants. More refined epidemiological studies are needed to identify the prevalence among specific diverse communities and to understand the nature of suicidal behaviors within cultural and contextual parameters. This is exemplified by a qualitative study exploring cultural factors for Korean Canadians revealing that this minority population experienced vulnerabilities for suicide, specifically related to themes of academic and work pressures, estranged family relations, and altered identifies as immigrants (Han et al. 2013).

Acculturation As immigrants settle in Canada, the process of acculturation progresses as they make psychological and cultural adaptations to their new home (Fung 2012). Some studies use language fluency or years in Canada as a proxy for acculturation, limiting accurate interpretation of these findings (Vang et al. 2015). Acculturation measures have been constructed to assess this phenomenon. A linear unidimensional model of acculturation would assume that on the one end of the spectrum would be “fully Canadian,” while the other pole would be identification with the country of origin’s heritage culture, with “bicultural” individuals being in the middle of this spectrum. A recent Iranian geriatric immigrant study found that higher acculturation was associated with increased life satisfaction, although it did not directly correlate to measures of depression (Moztarzadeh and O’Rourke 2015). In Canada, especially with the official policy of multiculturalism, acculturation is better conceived as a bidimensional or multidimensional rather than a linear construct, as outlined in Berry’s model of acculturation (Berry 2003; Ryder et al. 2000). Immigrants may identify with both their heritage and Canadian culture strongly using an acculturative strategy of integration. Alternatively, they may identify with Canadian culture while losing their identification with their heritage culture through assimilation, or they may retain strong identification with their heritage culture while not embracing aspects of Canadian culture through an adaptive strategy of separation. Others may not feel identification with either culture, resulting in a sense of marginalization. Integration may potentially result in optimal adaptation, while marginalization may result in distress. The effectiveness of the other two strategies may vary depending on the sociocultural context of the particular community including the size of the ethnic community. In an Ontario cross-sectional study with immigrant mothers of preterm infants, lower identification with Canadian culture correlated with higher depression scores, while identification with heritage culture was not significantly correlated with depression (Ballantyne et al. 2013). In a sample of Chinese Canadians presenting to primary care, higher identification with Chinese culture was associated with decreased alexithymia, while identification with Canadian culture was not associated with alexithymia (Fung 2003). These studies suggest the need to investigate differential acculturative effects on various mental health outcomes using a multidimensional approach. At the same time, it must be recognized that acculturative strategies may depend on various individual and systemic factors, including ethnic density and the receptiveness of the local community (Fung 2012).

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Children may acculturate at different rates from their immigrant parents. Often, they may function as parental children acting as the main spokesperson or bridge for the family with the mainstream society. The generation gap may be exacerbated by a cultural gap, creating tension and conflict in the family, often more evident in adolescent or young adult phases of development. Second-generation children exposed to different and potentially conflicting cultures may experience distress that evolves in a different process from first generation immigrants. Research on second-generation Canadian immigrant children have indicated complex findings with mixed outcomes (Vang et al. 2015). A national-level estimate found better mental health for first generation children compared to Canadian-born, second- or third-generation children (Beiser et al. 2002).

Social Inequities and Social Determinants of Health Poverty, Underemployment, and Unemployment Immigration is a social determinant of health as immigrants face a number of systemic factors that affect their essential needs. While poverty is a well-established social determinant of health, its effect may be particularly devastating for new immigrants who are struggling to establish themselves. Canadian immigrants on average had a 1.5–2.5 times risk higher than that of the Canadian-born population for low-income rates, with worst rates for recent immigrants (Picot and Hou 2014). This substantially accounts for the rise in overall low-income rates in Canada in the 1980s and 1990s. While there was a decline in low-income rate in 2000s, this decline was primarily driven by fall among the Canadian-born population only. There were some regional exceptions to these recent trends. For example, Toronto low-income rates did not fall for immigrant or Canadian-born populations in the 2000s, while Manitoba and Saskatchewan had decreased relative low-income rates among recent immigrants to 1.2 times that of Canadian-born population. Despite being a highly educated group, securing employment is one of the major challenges for immigrants possibly indicating systemic barriers. In 2011, about 75.6% of immigrants were employed compared to 82.9% Canadian-born, and the gap is wider for recent immigrants (Yssaad 2012). Language and Canadian work experience seemed to predict only short-term economic success, while higher education in the presence of good language skills and lower age are more powerful long-term predictors for higher immigrant earnings (Bonikowska et al. 2015; Hou and Bonikowska 2015). Not only do immigrants earn lower hourly wages than Canadian-born citizens, their quality of the employment are often inferior, including having lower union coverage or employer-sponsored pension plans and higher involuntary part-time work and temporary jobs (Gilmore 2009). About 42% of employed immigrants are underemployed in comparison to 28% of the Canadian-born population. Another potential factor contributing toward lower immigrant household income is the lower employment rate among women. While about 70% of immigrant women are employed, this is lower than the national average of about 85%, with the

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difference partly attributable to larger family size, country of origin effects, and lower wages for immigrant women (Galarneau 2016).

Racism and Discrimination in Canada Although the 1985 Canadian Human Rights Act prohibits discrimination, about one in five immigrants experience discrimination according to a national survey in 2009. About 13% of immigrants versus less than 7% of nonimmigrants experience multiple experiences of discrimination (Nangia 2013). External characteristics were most likely the basis of discrimination, including 12.6% of immigrants reporting discrimination based on their ethnicity or culture, 10.6% based on skin color, and about 7.2% based on language. Overall, visible minorities were twice as likely compared to the host culture to encounter discrimination in a number of areas. Discrimination can influence the physical and mental health of immigrants in multiple ways, including direct influences on the individual emotional well-being. Indirect impact on well-being are evident through the social determinants of health and how immigrants relate to institutions (Nestel 2012). A study of Afghan immigrant youth in Canada found that 15% reported experiencing racism and Islamophobia on a regular basis; about 15% of the sample also reported symptoms of depression and a quarter reported suicidal thoughts (Soroor and Popal 2005). A study of Korean Canadians indicated that not only did overt discrimination eroded positive mood, subtle perceived discrimination or micro-aggressions were related to depressive symptoms (Noh et al. 2007). Regarding the income inequality noted in immigrants, studies noted that the disparity persists between visible minorities and persons of European origin after controlling for educational qualification, and this finding may in part be related to racism (Hou et al. 2016). In a study of Tamil-Canadian immigrants, about 12% qualified for PTSD, but only 10% of these subjects sought treatment (Beiser et al. 2003). Among Tamil Canadians, about 10% of the sample reported experiencing racial discrimination when accessing health care. In a Montreal study, African Canadians admitted to hospital for psychosis were more likely to have been brought there by emergency services, indicating access behaviors, barriers, and systemic discrimination warrant more understanding to achieve health equity (Eric Jarvis et al. 2005).

Religion Tension and Moral Beliefs In a diverse society, religion differences may become a particular source of conflict and tension. As a group, immigrants are found to be more religious and more likely to attend religious services than people born in Canada (35% vs. 21%) (Angus Reid Institute 2015). While there have been shifts in religious beliefs due to immigration, Canada is still largely dominated by Roman Catholicism and other Christian denominations. In a 2015 national opinion poll, the general public attitudes toward Catholicism, Christianity, and Buddhism are the most positively perceived. Sikhs, Mormons, and Muslims are the most negatively perceived, with 44% expressing

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negative perception against Muslims. There are regional differences as well, with residents more likely to reject religion in British Columbia and Quebec. Concerns about religious intolerance may be especially intense in Quebec where “reasonable accommodation” sought to balance tensions between the protection of a francophone cultural identity and increasing diversity in the province (Bouchard and Taylor 2008). In 2013, the ultimately defeated proposal, Charter of Quebec Values, proposed a ban of public employees including in education, daycare, or hospital settings wearing religious symbols, raising concerns about its impact on the diverse population (Kirmayer and Guzder 2013), though this was ultimately defeated in the provincial assembly. A recent Quebec Human Rights Commissions survey found that 43% Quebecers believed that one should be suspicious of people openly expressing their religion and 49% felt uneasy around the sight of Muslim veils (Solyom 2015).

Intersectional Marginality Bias and discrimination based on skin color, religion, sexual orientation, and illness often conjointly cause severe marginalization of certain immigrant groups and subgroups. Research with the immigrant, refugee, and non-status African-Caribbean, Asian, and Latino persons living with HIV in Toronto found that they encountered stigma and discrimination-based intersecting dimensions of race, class, gender, citizenship, sexualities, body norms, and HIV status (Wong et al. 2013). Some of the encountered discrimination can originate from within their own community, related to religious beliefs and stigma concerns of the immigrant community who may resist being seen as a problem minority for the majority community (Li et al. 2016). When these patient populations proactively attempted to improve their mental health, they were often met with service provider bias or mistreatment, unavailability of appropriate services, and multiple access barriers (Chen et al. 2015). By working closely with religious leaders from these ethnic groups as well as people living with HIV through a combination of psychological intervention (using acceptance and commitment therapy) and a community-empowerment training of social justice and capacity building training, the interventions were found to shift some of these underlying stigmatizing attitudes, cultivate mutual compassion, and promote increased understanding, which mobilized the community toward positive action, integration, and change (Fung and Wong 2014).

Providing Care for Immigrants Access to Care Canadian immigrants face multiple barriers to services, reflected by many studies documenting underutilization of mental health services. A recent review of 131 articles in immigrant access to care identified three major categories characterizing these barriers (Thomson et al. 2015). Immigrants encounter barriers related to the use of health information and services, i.e., either lack of awareness about mental illness and

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available services, or cultural factors that affect their use, such as stigma or different explanatory models of illness. Secondly, there are barriers related to the settlement experience, such as poverty and experiences of discrimination. Finally, there is an inadequacy of culturally and linguistically appropriate services. In our study of 1000 immigrant and refugee women from East and Southeast Asia in Toronto, the five ethnic minority groups of women differed in their explanatory models of mental illness and distress (Fung and Wong 2007). However, for most groups, the significant factor predicting attitudes toward seeking professional help was perceived access to cultural, language, and gender-appropriate services, rather than cultural causative categories, age, education, or acculturation.

Canadian Initiatives to Address Immigrant Mental Health To improve the culturally competent care of immigrants, clinical guidelines have been developed by the Canadian Medical Association, including a set of guidelines for addressing common mental health problems of immigrants and refugees in primary care (Kirmayer et al. 2011). It recommends that the assessment of mental health problems should include consideration of premigration exposures, stresses and uncertainty during migration, and post-migration resettlement experiences that influence adaptation and health outcomes. Use of trained interpreters and culture brokers is recommended to negotiate linguistic and cultural differences that may impede communication and mutual understanding during assessment and treatment. While a review of refugee mental health is beyond the scope of the chapter, many immigrants from war-torn countries have been exposed to trauma (Rousseau et al. 2011). The guidelines caution against routine screening, based on the lack of evidence of benefits and the potential for harm as many cope well. Vigilance for symptoms of depression, anxiety, sleep problems, and somatic symptoms can help identify those who may need psychiatric interventions. Training in universities across Canada is variable for health-care professionals, though the Royal College of Physicians and Surgeons has identified cultural psychiatry as a necessary part of training for psychiatrists. Of relevance, the Canadian Psychiatric Association has developed a position paper on postgraduate training in cultural psychiatry (Kirmayer et al. 2012). It captures the requisite attitudes, knowledge, and skills for psychiatrists and mental health professionals to be able to work effectively in cross-cultural clinical situations in an integrated model aligned with the CanMEDS roles (Fung et al. 2008; Kirmayer et al. 2012): medical expert, communicator, scholar, professional, collaborator, manager, and health advocate. This framework emphasizes the importance of addressing the needs of the diverse populations at different levels, from clinical to organizational to systemic levels. Without organizational cultural competence and systemic support, clinicians will not be able to serve the needs of the diverse immigrant population. At the systems and program delivery level, the imperative to develop an approach for immigrant mental health has been noted since a senate report on mental health in 2006 (Kirby and Keon 2006). A comprehensive review further informed the Mental

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Health Commission on the needs of the immigrant population (Hansson et al. 2010). This culminated in the National Mental Health Strategy launched in 2012, in which the fourth of six identified strategic directions is to “reduce disparities in risk factors and access to mental health services, and strengthen the response to the needs of diverse communities and northerners” (Mental Health Commission of Canada 2012). Under this strategic direction, Priority 4.2 is devoted to improving mental health services and supports for immigrant, refugees, ethnocultural and racialized groups (IRER). Specifically, it recommends expanding the use of standards for cultural competency and cultural safety; increasing access to information and services; evaluating traditional knowledge, customs, and practices to address mental health problems and increase access; supporting and collaborating with IRER organizations to assess and address local needs; and developing and implementing mental health plans to address needs of IRER with their full involvement. Priority 4.4 recommends improving access to mental health information, services, treatments, and supports for minority official language communities and developing programs to identify, train, recruit, and retain mental health service providers to offer services in nonofficial languages. To build such capacity, an organizational cultural competent framework can be used for mainstream organizations to ensure that it strives to maximize accessibility and cultural competence. This includes assessing its capacity among eight domains: (a) Principles and commitment, (b) leadership, (c) human resources, (d) communication, (e) patient care, (f) family and community involvement, (g) environment and resources, and (h) data collection and evaluation (Fung et al. 2012). Specialized organizations and services can also be developed to address the specific needs of the diverse population. Over the years, many minority communities have taken such initiatives to offer advocacy or various levels of mental health-related services for immigrants and refugees. These services are more developed in urban centers such as Toronto, Montreal, or Vancouver but are also evident in other urban and semirural regions. Community services often provide the initial support for refugees or newly arrived immigrants seeking language classes, advocacy, legal advice, childcare services, or any number of instrumental supports. In addition, these may be essential first-line services for serious mental health issues including domestic violence, depression, or psychosis and may be the bridge to community clinics, hospitals, or other specialized resources. Canadian cities vary in their mental health responses to diversity as a challenge variable for access and equity, reflected in health-care disparities of cultural communities (Kirmayer et al. 2014). We will outline a few Canadian initiatives as examples of models of care.

Ethno-Specific Models for Immigrants One of the exemplar ethno-specific model serving immigrant patients is Hong Fook Mental Health Association in Toronto, a community organization funded by the government and nongovernmental sources, such as the United Way. Started in 1982, it was initially conceived as a consultation liaison model to assist patients from the

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Chinese and Vietnamese communities to overcome systemic barriers to receive adequate mental health services from the mainstream system (Lo 2005). At the time, an urgent service gap was noted in the two ethnic groups, given the large influx of refugees from Vietnam and Chinese being one of the largest immigrant groups in Toronto. Over time, Hong Fook has grown to serve six East and Southeast Asian community groups, including Chinese from Hong Kong, Taiwan, and Mainland China; Vietnamese; Korean; and Cambodian. The main model of service delivery has shifted from a liaison model to case-management services due to a persistent lack of culturally competent resources in the system. Its services have also substantively evolved and expanded, including a well-developed mental health promotion and prevention program, housing program, self-help groups, youth outreach, and family initiatives. Recent clinical developments include an Asian clinic, where ethno-specific psychiatrists help provide psychiatric consultations, and, in September 2013, a nurse-practitioner-led clinic, which provide integrated primary and mental health care, the latter also services Tamil-speaking South Asians in the region. In 2015, close to 2000 unique clients had been served by Hong Fook case managers of the 6 communities and close to 400 clients served by the Asian Clinic psychiatrists (Hong Fook Mental Health Association 2015). To do its work, Hong Fook’s resources have grown considerably over the years, from a budget of $100,000 in 1982 to a current budget of $4.7 million dollars. The successful development of Hong Fook’s various service components has been guided by its capacity to identify and respond to the service needs of the ethnic communities (Lo 2005). This includes sensitivity to changes in immigration patterns sometimes ahead of ministry’s awareness, such as the needs of newer migrant communities like the Mandarin-speaking Chinese and Koreans while respecting the readiness of the ethnic communities to engage in cultural mental health programming, such as the development of Cambodian instead of Laotian services. Pragmatically, some services and programs were developed to capitalize on unique funding opportunities from the government and other sources. Most importantly, its successful growth and outstanding reputation in the community has been guided by its unwavering commitment to underlying philosophies including social justice, community-based (“from the community, of the community, and for the community”), collaboration, education and health promotion, and consumer and family orientation. Hong Fook’s unique expertise is not only well recognized in its service to the ethnic communities including its leadership among other community agencies (such as the Chinese Interagency Network and other related community networks), it is often sought out by mainstream agencies for cultural competence training (such as its funding by the Citizenship and Immigration Canada to train settlement workers on cultural competent mental health care), by the government on immigrant mental health policy issues, and by researchers regarding collaboration on studies on the Asian community. In 2016, it will also be offered as an elective training site for psychiatry residents in community integrative care rotation in collaboration with the Asian Initiative in Mental Health Program (AIM). The Asian Initiative in Mental Health Program (AIM) is another example of an ethno-specific model in Toronto. It is a unique hospital-based community program

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serving primarily Cantonese- and Mandarin-speaking Chinese Canadians. Started in 2002, it has expanded from 1 psychiatrist/clinical director (author) and 1.5 clinician to 1 full-time and 2 part-time psychiatrists as well as 2 full-time and 5 part-time clinicians. Its core function includes provision of comprehensive biopsychosocial psychiatric assessment and treatment, including both individual and group programs. In addition to regular outpatient service, it also has an early-intervention program, the only ethno-specific one in the city. It also provides psychoeducation to patients, families, and the Chinese communities to increase awareness and decrease stigma. In 2015, it has served around 900 unique patients. AIM has a close working relationship with Hong Fook at many levels and collaborates in many community initiatives together along with other partners. The AIM clinical director is one of the Hong Fook Asian Clinic psychiatrists and provides Hong Fook staff training and programing consultation. There are three especially noteworthy collaborations, including the response to crisis, development of clinical interventions, and capacity building. At the time of the SARS crisis in 2003, the Chinese community in Toronto was particularly affected. Many in the community were anxious or traumatized by seeing their loved ones affected in Asia, and the vibrant local Chinese gathering places were suddenly deserted. Ethnic discrimination erupted, including a derogatory newspaper cartoon depicting Chinese people importing the yellow plaque of death into Canada, while Chinese school children were ostracized; the Chinese Canadian population were perceived as unwelcome foreigners. At the same time, there was concern about the lack of reliable information in Chinese, as the community was confused by conflicting advisories from China, Taiwan, and Hong Kong, all of which only worsened the public health response to implement effective quarantine precautions to curtail the spread of the virus. In an unprecedented community response, over 60 Chinese community agencies formed an ad hoc coalition, even bringing in collaboration between different political groups (e.g., from Taiwan and China). AIM and Hong Fook along with other partners were instrumental in helping to organize logistics, train volunteers, and implement a community support line, overcoming an impossibly tight timeline and coping with the daily changing health updates from the government (Dong et al. 2010). This ad hoc service fielded about 250 calls, and the experience highlighted how a crisis can easily precipitate underlying xenophobia in a multicultural society and the potential power of community mobilization to address these fears. Another gap that AIM and Hong Fook have been collaborating on addressing is the development of culturally competent psychological intervention. In a 2004 resident survey at the University of Toronto, about three-quarters of trainees endorsed preferring to focus on using psychopharmacology with minority and immigrant communities while avoiding psychotherapy with this population. This model of treatment is in clear contrast to what the community wants. In working with the Cambodian population, who had been traumatized by Khmer Rouge and limited in education, many would not have been considered “psychologically minded” nor accepted to receive therapy. We have successfully piloted two groups in the conjoint use of acceptance and commitment therapy, a mindfulness-based psychological

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intervention, with Buddhist dharma teachings provided by a psychiatrist (author) and the community Buddhist monk (Fung 2015). The congruence between ACT, Buddhism, and Eastern philosophies is noted, and ACT may be particularly effective in the Asian communities. For the Chinese Cantonese and Mandarin community, our collaboration also developed two group interventions. The Journey to Healing group is a ten-session weekly psychoeducation group, which includes two sessions led by a Chinese naturopath and a Chi-gong master, respectively. The Integrated Behavioral Group Therapy (IBGT) is developed as a 12-session group therapy with 6 sessions on cognitive behavioral therapy and 6 sessions using ACT. The project is conducted in collaboration with the Portuguese Mental Health and Addiction Services, with the groups also being offered in Portuguese. As an example of capacity building, another successful collaboration spearheaded by AIM and Hong Fook is the organization of a biennial conference on diversity and equity issues. It is a grassroots conference which is uniquely planned by community agencies and academic institutions conjointly to focus on practical issues faced by frontline mental health and other service providers. Conference themes have included ways of collaboration; approaches to working with families and communities; stigma of mental illness; and the recovery model from a cultural perspective. There are other examples of ethno-specific services in Toronto, such as the Mount Sinai Assertive Community Treatment Team, the only ethno-specific ACT Team in Canada (Chow et al. 2009). Across Boundaries is another community organization based on anti-racism framework and provides holistic care to minority populations. In a diverse community, these ethno-specific or specialized services can most optimally provide culturally competent care to immigrants and minorities. However, there are a number of common challenges (Lo 2005), limitations, and critiques. Some funders and critics are skeptical about such services, worrying that other underserved communities may demand their own services. Moreover, recruiting qualified mental health providers from small immigrant communities often proves challenging. Ethnically matched providers may or may not be culturally competent, and ethnic professionals may be reluctant to be designated as health-care provider for a community. The communities themselves may not welcome these services because of the stigma, and some patients worry about confidentiality in a close-knit community. While not a panacea, in an environmental context with a large enough minority immigrant population with the dominant system still being vastly inadequate to meet the mental health needs, the examples above demonstrate the substantial impact that small ethnospecific programs can have, not only to the benefit of ethnic communities but also helpful in increasing the overall capacity and quality of the mainstream system.

Cultural Consultation Model The cultural consultation model (CCS) was developed within a unique provincial context as a largely francophone though bilingual city of Montreal with considerable ethnic diversity (Kirmayer et al. 2003). Immigrant and refugee mental health has to be understood within Quebec’s distinct history as a “founding” francophone nation,

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Table 1 Key features of the cultural consultation approach (Kirmayer et al. 2014, p. 10) Focus on the social context of the patient’s predicament and the clinical encounter Recognize the ubiquity of culture in the lives of patients, clinicians, and institutions Explore culture as explicit knowledge, values, and practices but also as implicit, embodied, and enacted Use a systemic and self-reflexive view of mental health problems Emphasize issues of power, position, and communication Consider culture and community as resources for helping and healing Work within the system while attempting to challenge and change it through advocacy, education, and critique

urban demographics, patterns of immigration, unique politics of identity, and configurations of ethnic communities. The service currently is located in the Jewish General Hospital, a McGill University teaching hospital located opposite a specialized refugee services, Program for the Settlement and Integration of Asylum Seekers (PRAIDA), which operates within a community clinic, Centre de Santé et de Services Sociaux de la Montagne (CSSS) and integrated with the hospital and a larger institutional network. The CCS receives referrals from health practitioners or organizations in the city who request a consultation for mental health concerns which implicate cultural issues (Kirmayer et al. 2014). The key distinguishing features of this approach is listed in Table 1. The service has been responsive to a range of mental health practitioners and organizations including schools, youth protection agencies, refugee centers, shelters, and community groups dealing with cultural minorities. Referring therapists along with culture brokers and translators are included in the initial consultation, followed by a CCS team consultation with referring therapists reviewing diagnosis, cultural formulation, and intervention concerns. In more than half of the referred patients, cultural formulation within the CCS model altered the diagnosis and management of the cases (Kirmayer et al. 2003, 2014). Knowledge transfer and building skills of referring teams or mental health workers are primary goals in addition to constructing a culturally competent model of care. Child and family initiatives have now been developed within multiple community services as well as CCS with research and clinically based initiatives of Dr. Cecile Rousseau, Dr. Luci Nadeau, Dr. Toby Measham, and Dr. Jaswant Guzder.

Clinical CCS Case Example The CCS was contacted by a nurse and social worker from a specialized pediatric center after they received a call from a mother with infanticide impulses. A single consultation visit was urgently arranged for a 32-year-old Tamil-speaking married woman, Anjali, who attended the appointment with her social worker and pediatric nurse. An interpreter was arranged by the CCS services. Anjali did not want her husband to be present.

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Anjali and her family migrated from the war-torn Jaffna region to India. Her family remained in South India when her marriage was arranged with a Tamil Sri Lankan man, who had been sponsored to Canada by his relative and living in Montreal for some years. Anjali had been socially and linguistically isolated since her arrival. She was an overburdened mother with three children, including a 6-yearold and 18-month-old infant suffering a rare genetic disorder, as well as a 5-year-old with a serious learning disability and delays. Her oldest son’s critical illness from birth and years of rehabilitation care had been very traumatic for her as he had remained in hospital for his first 3 years. She later realized that this same genetic disorder had led to the death of her first-born son immediately after childbirth in India, while she was still waiting for her immigration papers. She became quite distressed that the same disorder was identified in her 18-month-old daughter and in her husband’s relatives. Anjali presented as hopeless and depressed. She had not wanted a third child and had asked that the baby not be afforded aggressive methods or resuscitated if born with the same rare genetic disorder. However, she was never given an interpreter as the hospital staff had always used her husband for interpretation. Although he reassured her that he agreed with her decision, he signed papers for the hospital staff to pursue aggressive life-saving measures. He told the hospital staff that he would stay home to care for the infant if necessary though in fact Anjali was left alone and he continued to work. Anjali’s husband’s insistence on having the third child had put her at high risk of having another sick child who “would put me back in the nightmare” of reliving her oldest son’s medical care experiences. “I would do this for a son but not a daughter,” she shared. Her husband, on the other hand, had insisted on having a daughter to “care for me as a son would not.” She revealed that she tried appealing to her mother in India to allow her to get a divorce, as her husband was also physically abusive. Her mother threatened to disown her as this was seen as bringing shame to her family. Anjali was further infuriated that her husband continued to be the only parent the pediatric staff consulted. They had noted that she had not bonded well with the infant girl without understanding her domestic situation. Although the treatment team had known her for 6 years, they had inadvertently denied her voice and agency by not having an interpreter. The CCS consultation assisted the treatment team to understand Anjali’s family context, cultural beliefs, and idioms of distress, structural gender violence, as well as formulating cultural aspects of her experiences of exile, silencing, and trauma. A diagnosis and treatment plan was made to address her severe depression and family context issues as well as underline the need for independent interpreters. Her inconsolable grief was understood not only as the aftermath for caring for their sick children but also in the context of the Sri Lankan war, domestic violence, and social isolation. The CCS consult situated Anjali’s disempowered position as a daughter of a Hindu family who had been displaced in exile. In addition, her feelings of shame, her family’s beliefs in karmic forces, and the cultural collectivist values were all elements that framed her predicament. Her suppressed feelings of helplessness and

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distress of silencing inherent to her relationship with her mother and her husband was inadvertently mirrored by the treatment team. She had not acted on her infanticidal impulses, as she shared she was afraid of being imprisoned and not being able to care for her sons. She had understood that if she removed the child’s tracheostomy tube and waited for sufficient time, her child would be beyond resuscitation. The CCS and referring team facilitated treatment of her depression, support for infant attachment and respite, and the option of placement to care for her child despite her husband’s adamant refusal of such a plan. The team privately gave her a special code to immediately remove the child by ambulance if her feelings of desperation returned. A Tamil nurse, physician, and community support were engaged to explain and initiate antidepressant treatment, provide follow-up care, and institute close home monitoring. This consultation illustrates the institutional and team consultation process that fosters changes in mental health frameworks when working in primary care and hospitals while integrating cultural formulation for intervention planning. Knowledge transfer and the cultural imagination of multiple idioms of distress is conveyed by co-construction of mental health-care parameters from these consultation processes, and for any treatment team, a seminar exchange allows all members of a referring team to benefit from the training and discussion.

Coordination of Cultural Services A number of cultural programs have been developed in Vancouver similar to those described above over the past 35 years (Ganesan 2005). To serve its large immigrant population including the Chinese and South Asian population, both formal and informal sectors of health-care system have been providing primary, secondary, and tertiary levels of health care through hospital and community-based services. The Cross-Cultural Clinic at Vancouver General Hospital has 7 part-time psychiatrists speaking 22 languages and dialects, providing culturally sensitive, responsible, and language-specific assessment and treatment (Ganesan 2005; Ganesan et al. 2011). The clinic provides services to 5000 patients annually, including diagnosis, medication recommendations, education, facilitation of community resources, and group therapy. With the regionalization of health-care services, this clinic along with other cross-cultural mental health services such as the Vancouver Association for Survivors of Torture (VAST), interpretation services, and in-patient programs is better coordinated through a centralized administrative structure, the Vancouver Coastal Health Authority.

Conclusion Immigration has been integral to the history of Canada, reflected in the culturally diverse mosaic of its citizens for generations and a federal policy of multiculturalism since the 1970s. Quebec as a francophone society has continued to refine and

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develop a unique intercultural model to preserve the host society’s culture while integrating increasing ethnic diversity after the 1960s, whereas bilingualism remains a federal orientation that has unevenly developed nationally. In this context, immigrants and their communities have been shown to be resilient, innovative, and resourceful while contributing to the economic and social development of Canadian life. Despite the positive integration of immigrants and refugees over the past decades, diversity presents specific vulnerabilities that remain a concern as well as specific challenges in the health-care system. In spite of the spirit and ideals of multiculturalism and the “reasonable accommodation” premise of Quebec’s intercultural ideals, the psychological, social, and cultural dynamics of inclusion remain, as linguistic accommodations, barriers to access, and progressive recognition of a need for cultural competence and cultural safety in mental health-care delivery for ethnic minorities and First Nations peoples continue to evolve. Research data indicate that current realities of social inequities affecting the social determinants of health erode the healthy immigrant advantage. These factors coupled with the lack of access to culturally competent services have a significant impact on health disparities. To meet these challenges, policy and training efforts continue to be undertaken by efforts at the individual, institutional, and community levels especially in major urban centers across the country. Training of health professionals, police, community workers, and caretakers has increasingly acknowledged the need to include cultural elements in addressing whole patient care. The solutions to health equity and a human rights perspective in delivery of services involve considerations of complex variables at societal, political, and health-care delivery levels, requiring further research in Canadian context. Increasing the cultural competence of mainstream organizations, supporting the development of specialized services, developing ethno-specific services for larger cultural groups including the First Nations, and providing cultural consultation services for diverse communities are initiatives that may foster systemic improvements to address the gaps in service. Canada needs to continue to refine its policies and to develop programs that improve access and delivery of mental health care through collaboration, capacity building, research initiatives, policy changes, and drawing upon the strengths of diversity.

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The French Experience Rahmeth Radjack, Sarah Le´vesque-Daniel, and Marie Rose Moro

Contents Introduction: The Psychological Vulnerability of Children of Migrants . . . . . . . . . . . . . . . . . . . . . . . The Perinatal Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Clinical History: Elavie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Beginning of Formal Education at School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extrafamilial Selective Mutism: A Paradigmatic Transcultural Pathology . . . . . . . . . . . . . . . . . The Transition to Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identity Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suicide and Transcultural Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Traumatic Confrontation to the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Creating Adapted Therapeutic Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Second Line Psychotherapeutic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Transcultural and Cosmopolitan Therapeutic Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Theoretical Framework: Ethnopsychoanalysis or Transcultural Approach . . . . . . . . . . . The Interpreter: A Major Partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Children Who Migrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

There are three periods of psychic vulnerability for a child or an adolescent coming from a migrant family: The perinatal period, the beginning of school, and the transition to adolescence. We explain how these represent periods of risk and illustrate it with short clinical vignettes. In clinical situations, taking care of R. Radjack · M. R. Moro (*) Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Paris, France INSERM CESP, Paris, France e-mail: [email protected]; [email protected] S. Lévesque-Daniel CIUSSS du Nord-de-l’Île-de-Montréal, University of Montreal, Montreal, QC, Canada Cochin Hospital, Paris, France © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_42

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these children requires using the notion of cultural “métissage” (cultural crossing), which means to build one’s identity relying on the two cultural worlds the family belongs to. This vulnerability can be overcome, but in some instances, it develops into psychopathology. Some examples in connection with the transcultural context are detailed: suicidal risk and addictions. Sometimes, a classical therapeutic approach isn’t enough in cases of blockage or cultural misunderstandings, and the clinical work can be unproductive if the clinical setting isn’t adapted. The transcultural clinical setting is a psychotherapeutic technique that allows cultural differences to be addressed. Keywords

Vulnerability · Migration · Extrafamilial mutism · Identity construction · Transcultural situations · Migrant children

Introduction: The Psychological Vulnerability of Children of Migrants In France, the field of transcultural psychiatry has been developing in our clinical practice since the 1980s. France has seen many waves of migration from different countries since the nineteenth century. Most migrants of our consultations come from West Africa, Maghreb, the Indian subcontinent, or Central Africa. The transcultural approach aims to better understand and care for migrants and their children, all those who come from elsewhere and are confronted to exile, the difficulties of living in another country, loneliness and cultural differences of language, religion, or of other sort. The concept of vulnerability was developed towards the end of the 1970s by Anthony (1978): it is a dynamic notion that affects a developing process, not the child or the adolescent himself, that is to say, the construction and organization of personality. The psychological functioning of a vulnerable child is such that a minimal internal or external change, leads to important dysfunction, intense psychological suffering and a halt or minimal development of their potential. Children of migrants constitute a group particularly at risk, specifically at the time when the early interactions are established during the first year of life, at the beginning of main school learnings at around 7–8 years of age and during adolescence. The migrant leaves an environment that has constituted a psychic and sensory envelope and has to build another one in the new country, which entails some fragility. Parents have to think of the fact that their child was born in a different cultural universe from their own, and the child has to find his place in a world constituted by two systems of reference: the one from home, the inner one, marked by the culture of origin and the outside one, being the culture of the new country, the school, the neighborhood, etc. In this way, the child can be able to take place in his filiation (family group) and his affiliation (cultural group). The mental structuration of migrants’ children is therefore built upon an insecure splitting in a context of

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instability. Hence, this mechanism of splitting should be considered as a determinant of the particular vulnerability of migrants’ children. Moro and Nathan (1989) defined the concept of the “exposed child.” It implies that the migrant child is exposed to a risk in a transcultural situation. If he can manage it, it can bring dynamism and creativity to his personality. For the “exposed child,” the price to achieve this balance is, however, a certain emotional distance from his parents. M. Mahler (1979) uses the term separation-individuation process to talk about migration, a process that leads either to a rebirth (individuation) or, on the contrary, to an illness as a failure of the process. The fragility of the child can be an expression of the family having difficulties to adapt to an environment perceived as hostile. The most exposed child is usually the first to be born in the new country. Cultural structuring has been described as a process by which the child imbibes and internalizes cultures and nuances also related to identity or psychical structuring (Nathan 1986). This separation of “I” is quite significant. The process of distancing is important for individuation and relationships with parents with respect to the cultural structuring and the distance involved in the intertwining of cultures and multiplicity. These structures are interdependent. Although the connection between the psychical and cultural dimensions is set up in childhood, it is kept alive and functional throughout life due to the homoeostasis resulting from the ongoing interaction between the individual and his/her cultural environment (Moro and Nathan 1995). Each of these structures implies the existence of the other, and they are all linked together – when one of them is difficult, the other becomes more complex, and vice-versa. Hence it is important to consider them through the approach of complementarism: psychological and cultural (Devereux 1972). Complementarism entails a necessary analysis of the interactions between each of these aspects – the complexity of children’s identity in a transcultural situation. The child from a migrant background has certain specific challenges. They will experience splitting in developing cultural structuring. This split is attributable to the two worlds which may be separate and also in conflict. The tension between the family culture which provides affect and emotionality and the outer world e.g. school, peers which provides rationality and pragmatism. These two worlds may clash but need to be traversed carefully to manage and deal with such tensions. This is also equally applicable to non-migrant children but they are less likely to experience the conflict as the institutions are also culturally influenced. Earlier studies have shown that the main object of denial is filiation that is shared by the family (Moro et al. 1989). The migrants’ child is perceived as being a stranger to his own family. At that point, all sorts of fantasies and representations drawn from myths and legends are produced in order to explain the fact of the child being a stranger/foreigner (Nathan 1987). Sometimes the child does not resemble either his/her father or mother, he/she appears to have a very good knowledge of that outside world that seems so complex to the parents. In this case, the child can be seen as the reincarnation of an ancestor, the gift of some mythical spirit, or a divinity of the Earth. In the family’s representations, such a child could have been whitened by the White Men, and thus transformed by the new society that they know so little

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of. Moro suggested the concept of the exposed child in order to represent that vulnerability (Moro et al. 1989). There is no doubt that migrant children can grow with sublimination of identity struggles. The clinicians need to support them in order to help them build connections across their two worlds which may be at a distance apart. Migrant children indeed can be stronger in some ways as they have succeeded in managing identities in more than one spheres. The cultural and psychical structuring of children from mixed backgrounds is therefore based on splitting and on conflict in a context of instability and multiplicity. These mechanisms of splitting and conflict must therefore be seen as determining the vulnerability of children from migrant backgrounds. For the migrant child, psychological consequences of migration most often reveal themselves at three points in time (Moro 1994): First period is the perinatal period when mother and child adapt to one another in the context of migration; then transition at the point when the child starts formal education at school when, for the first time, the child becomes part of the new society in an independent way and lastly at adolescence, when issues of filiation and affiliation emerge allowing the construction of an identity between the two cultures he belongs to. During each of these periods, and turning points, the child is at heightened risk of vulnerability or even psychopathology due to a difficult crossing between two worlds.

The Perinatal Period A woman in five who gives birth in France is a migrant woman (Source: https:// www.insee.fr/fr/statistiques/). Migration, especially when recent and when the couple is isolated, can lead to a feeling of brutal rupture with one’s bearings. The perinatal period in migration is one of great vulnerability. Indeed, it may lead to disruptions in cultural representations and mothering techniques. Reassurance and protection usually provided by the cultural group are most needed but frequently lacking. Moreover, most of these parents have been confronted to a traumatic event before their migration and/or they find themselves in a situation of precarity in the new country. These issues may reappear and are often reactivated in the perinatal period when it is time to welcome the baby. The concept of “Object presenting” (as defined by Winnicott) to the baby is more difficult. The mother welcomes her baby in a world that she is discovering herself. She transfers her own perception of the world, a kaleidoscope perception, sometimes pervaded with anxiety. She could have difficulties presenting the world “in small doses” and the child is constantly at risk of encountering the world in a traumatic manner. The mother can then feel destabilized in the way she imagines and sees her own child. The child can be felt as strange and even as a stranger. In situation of migration, several ontological representations of the baby and of parenthood coexist. The representations transmitted by the previous generations sometimes come into conflict with those of the new country that the parents

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themselves won’t necessarily relate to. Young mothers who come from non-Western cultures often lose their cultural points of references, without integrating nonetheless the Western way of mothering. Consequently, they feel divided between the need to promote their and their child’s adaptation to the new country, and the need to express themselves according to their own cultural system (Gabai et al. 2013). Migration also leads to a lack of support due to the absence of close family members (sisters, sisters-in-law, aunts, etc.) and traditional rituals. Yet this support is essential during pregnancy as it plays an initiatory role. Furthermore, women are confronted to medical techniques around the delivery that do not necessarily respect traditional and cultural “protections” (which are culturally-driven ways of welcoming the baby to protect him or her from potential harm or dangers). These Western medical practices are sometimes experienced as violent, indecent, and traumatic. Moreover, parents’ concerns are frequent around questions having no easy answers (at least, that is what they think): Is the baby protected in the foreign country? How is it possible to handle the rituals of birth alone, far from the family and culture? Factors of vulnerability are then at their greatest and may have an impact on the harmony of mother-baby interactions.

A Clinical History: Elavie Alfonsine, an 18 years old pregnant woman, is admitted to a Parisian maternity ward immediately after arriving at Roissy Airport. A family member put her on a plane without telling her where she was going. She is confused, in pain from the contractions and gives birth 3 h later. The maternity psychiatric team is called for evaluation. Alfonsine communicates in lingala, her mother tongue, through an interpreter. She is crying, afraid of being sent back to Congo where she thinks she will be killed. She doesn’t look at her baby girl. She tells the psychiatrist: “This baby is a stranger. If you want, you can give the baby a name, you can even give her your name; it will protect the baby.” Alfonsine explains the infant is a “war baby” and bursts into tears hiding her face. It is suggested to end the interview, but she says she wants the team to stay and carry the baby because she is tired. They accept. The baby is tonic, alert and wants to suckle. There is, then, a first visual interaction noted between mother and child. She asks the baby to be bottle-fed “as they do in France” and while the baby is away with the nurse, she proceeds to say that she often vomits and is afraid of the dark and of being touched. She recounts her traumatic story. 9 months ago, she fled the fighting in Brazzaville with her mother and brothers. She and her mother were raped on the road in front of the family by “militiamen.” Nevertheless, life had resumed. Her mother told her the most important was to be alive and together. Her mother had died, in the following months, of old age and exhaustion. When the family, later, headed back to Brazzaville the young woman was raped again. She begged her brothers to leave her there. She wanted to die, to join her mother. After telling her story, she tells the interpreter “You have a way of looking at me that is like my mother.” She says her mother “married very young, a young man that she had chosen without her father’s agreement. I was born from that.” The baby is

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brought back calm and satisfied and the interview ends. Alfonsine is suffering from a post-traumatic syndrome that is express through physical symptoms, sleep problems, death wishes, and reminiscences. It affects her sense of self and ability to invest a baby born in these circumstances. Following this meeting, long therapeutic consultations take place. Alfonsine, elaborates on her traumas giving details sometimes violent for the listeners. While some painful events will affect her future, some can be processed as long as she can find an acceptable inscription for them in her tree of life. They will then be transmissible without feelings of shame to her daughter. The narration is cathartic for Alfonsine and symptoms gradually alleviate without disappearing. She starts talking about what to do with the child: keep the living incarnation of her rape or give her up increasing her shame even further. This motivates painstaking work on the baby’s tree of life. Alfonsine remembers her mother and summons her in her dreams. One day she announces that her mother has come to see her in the night and wants her to keep the child. She chooses to start breastfeeding with a mixed feeling of transgression and guilt, noting that it is good for her daughter. She puts the baby on her back, to soothe her, asks more questions about the child’s development and feels proud of her. She decides to give the little girl the name of her mother who had been named after her own maternal grandmother. The name means “beginning.” The little girl made human by milk and her ancestors will in return make her mother human, this mother who felt sullied by rape but is consoled by the beauty of the child. Alfonsine now invests her child as a positive sign of destiny, after hesitating as to her meaning and the ties between them. In the interview that precedes her departure, Alfonsine says she feels anger when the baby cries at night, but she realizes they are cries of life. She can feel sad looking at the baby but feels like a mother even so. Alfonsine still lives in France with a cousin. Her daughter has now two first names: the first is “Lingala,” and the second was chosen by the women living around the child. The name they gave her associates the notions of life and vitality (élan, vie): “Elavie.”

The Beginning of Formal Education at School When starting kindergarten, the child is at risk of experiencing splitting between the outside world (school, institutions and language of the new country and culture, the world of rationality and pragmatism) and the “inside world,” a conception of reality transmitted by the parents at home, within the family and through maternal language where the cultural codes are freely expressed. Children with good self-esteem will be able to integrate this multiplicity of experiences while those with a more fragile sense of self-worth can encounter a blockage that can manifest as extrafamilial selective mutism. The child speaks in his familial environment and becomes quiet when leaving it. The child has the potential to speak both languages and has no constitutional language delay, but only feels safe expressing himself at home. Parents of selectively mute children often have endured trauma before, during, and after the migration process. Painful events, often repressed, are reactivated during migration.

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Furthermore, they experience within themselves two cultural universes that can be perceived as irreconcilable and radically opposed. There is then a considerable risk for defensive psychological processes of the splitting type to emerge in the mind of the migrants and those can be transmitted to their children or agitate them (Di et al. 2009; Dimeo et al. 2015).

Extrafamilial Selective Mutism: A Paradigmatic Transcultural Pathology We receive, for a transcultural consultation, a family of Sri Lankan origin. The reason for referral is anxious inhibition from the eldest of the family: Jananan, a 12 years old boy. Jananan has a 10 years old brother named Sri and a little sister, Anita, aged 8. Jananan is a young happy boy at home. He speaks Tamil perfectly with his parents there and communicates in French with his siblings. On the other hand, since starting kindergarten, Jananan almost doesn’t speak at school and keeps to himself. The beginning of collège (secondary school) at 11 years old is difficult for Jananan. He is isolated and is being harassed. He is no longer in the same school as his little brother (in France, elementary and high school classes take place in different facilities). His academic performance is normal. In front of the apparent homeostasis of the family in consultation, it is understood that separation from his family is causing Jananan to feel insecure and unconsciously reactivates separations the family have gone through before (including separations in the context of migration). Jananan and Sri are designated as “twins” by the family. They are close, dress the same way and compensate for each other: Jananan is described as a boy who is “wise, studious, calm, the favourite of the father and has a fragile health.” Sri is “a jokester, unruly, creative and protects his brother.” The first separation the family recounts is the one from the father. He is 18 years old at the times and still lives in Sri Lanka. In the context of war, his initial project is to go to England. A few years after their marriage, in 1999, his wife joins him. She has the project of migrating to France motivated by the idea of liberty that the country represents even if she is afraid of the unknown and of disconnection. A year after moving to France, Jananan is born prematurely at 8 months. The mother evokes symptoms of a post-partum depressive episode undiagnosed because of the language barrier. She describes early abandonment of breastfeeding and developing important concerns about Jananan’s health especially a fear that he would be left with a certain degree of deafness due to prematurity. Was Jananan not interacting normally with his environment in the context of his mother’s depressive episode? Was he himself depressed as a baby? The father for his part says he is the more “fearful” of the family. His role as a father is valued by the team by asking him to speak first during the sessions. The transcultural sessions allowed the expression and transformation of the fears the family shared. It could not be expressed elsewhere than in this specific clinical setting. Jananan is asking for more autonomy and openness from his parents, but the family is afraid to let him go out alone and visit friends. There are also worries about

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the future of the young Anita, about her entry into adolescence, in a world so different than the Tamil world. Issues of respect for parents, sexuality and rites of transition into adolescence (intended to channel anxieties) that can be done in France are addressed. We work with the family reassuringly for them to be progressively less scared of an outside world that they initially considered as hostile. We are relying on the intermingling of culture s (children and parents) by helping each sibling to assert themselves as subjects. During an emotionally charged session, the mother describes tearfully her own “shyness” attributed to the experience of having lived through two migration processes which weakened her self-confidence. She explains that she had to leave the family home to live with her maternal uncle and study in a larger city less affected by war. It is an opportunity to discuss matters of the transmission and legacy of the family history which are important for identity building during adolescence. The mother was still, at that moment, transmitting raw and traumatic elements to her young children, for instance showing them violent images broadcasted by local medias on Sri Lankan television channels. We helped her develop her traumatic account and transform it in a story that could be recounted to the children. In the last consultations, after a year of monthly sessions, the mother tells us that she is able to leave easily the house to take French and sewing classes. At the same time, Jananan has become more integrated at his school.

The Transition to Adolescence Identity Construction Migrant families often leave behind, in the country of origin, any possibility of community support. During adolescence the protective shield function of the community is then damaged. Due to worries about their children successfully integrating in the new country, mainly when the migratory departure has been painful, parents avoid telling their children about their country of origin and about family members that remained there. This brings problems during adolescence, a period in which there is a need of understanding oneself within a family history. Alain de Mijolla maintains that “for a psychoanalyst, the identity question is less a “Who am I,” than a “What and who am I made of?” (1999, p. 1125). Migration also impacts negatively the children’s image of their parents, as they tend to have language difficulties, not speaking the language fluently. Frequently the new country imposes on the children a devalued image of their migrant parents. This feeling of humiliation is more evident among fathers. It is one of the children, conventionally the oldest one, who becomes the link between the family and the new society, giving him a parentified role (Parent-like). The child becomes the family’s spokesperson at school and towards other institutions, a role that is usually attributed to the father; hence, the parental function is weakened. Commonly, during adolescence there is a need to detach from the familial environment. This event is even more complex in the cases of migrant children. The outside environment is

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perceived as hostile and not many adults of the new society can serve as parental substitutes. This environment reinforces the fears of migrant parents towards the outside world. Their children’s adolescence is even more difficult for them. It is a period of personal crisis as well as a period of separation in which memories of other ruptures are evoked, such as that of the migratory process. Additionally, it is the moment when the question of the return to the country of origin, arises. Migrants usually live with the idea of going back to the homeland and the geographical separation from their children depends on the alliance with them. This is usually the moment in which the cultural gap, between parents and children, is more painful. When time comes for the last child to leave home, the mother often endures a strong crisis that sometimes converts into a depression. The loss of the maternal role may be intensified by the trauma of migration. The adolescence process could be built around three main tasks: gaining autonomy from parents and finding other objects to invest; dealing with the aggressive and libidinal drives; and giving up on the “infantile omnipotence” to be confronted with the reality principle. When these three transformations are affected by the change of cultural environment, the first one plays a central role in the difficulties experienced by migrant adolescents. How does an adolescent liberate himself from the dependence to his parents? He opposes their values and rejects their knowledge. In order to achieve this process, the adolescent needs to rely on cultural pillars, particularly on his peer group. Migrant adolescents frequently lack this support from their culture. The latter is essential even when partial or confronted with opposition from the adolescent. When parental nostalgia for the homeland is strong, the adolescent finds himself forced to reject outright cultural references, because it becomes very important to “think by oneself” (Von Overbeck Ottino and Ottino 2001). Conversely, parents’ ambivalence towards their country of origin could prevent the adolescent from maintaining enough traces of identity. In both cases, the adolescent would feel forced to adopt new identifications, diametrically opposed to those from his culture of origin. For the adolescent and his family, leaving their environment poses a risk of losing the creativity provided by the combination of internalized references and the outside world. It is exactly in this field that the migrant adolescent would confront his parents. Far from their own culture, an attack on parents frequently means a radical attack on their culture. Likewise, to be rejected by his parents would hurt his sense of belonging. The rupture caused by the exile, threatens the cultural space for the mediation of the relationship between adolescents and their parents. Great opposition between the new country and the country of origin could lead to a radical polarization of values: either all good/all bad or an idealization of one country over the other or a radicalization of certain patterns (issues like individual freedom). Moreover, when the adolescent is forced to divert too radically from the culture of origin, he or she is exposed to a feeling of a symbolic murder of the parents. It embeds an attack of the essence. The symbolic murder – necessary for the adolescent’s development – is entangled when one or both parents are depressed, when there are social precariousness, and job insecurities that lead to a strong dishonoring

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of the parental figures. Parentification in adolescents hinders the mourning of the infantile omnipotence. Development of identity and identity formation at various stages can be stressful and the adolescences may become vulnerable to anxiety, depression, or behavioral problems. In order to cope with these, they may become hyper-adapting by abandoning the cultures of their parents or the family. This degree of culture conflict may affect second and third generation adolescents. Metraux (2003) concludes four possible outcomes in the process of acculturation for all migrants and particularly for adolescent migrants: • The assimilation within the new society, forgetting ancestral knowledge bequeathed by the elders. • The confinement in their culture of origin and the rejection of any assimilation to the new culture. • The creative integration by constructing a larger identity with references to the original culture and to the new culture. This compromise is the most protective option psychologically. • The rejection of both models by losing filiation with the culture of origin without any assimilation of the new culture. This is perhaps the most difficult and default choice for many adolescents who find themselves unable to braid and bring together both backgrounds. Such difficulty can be generated and maintained by the incompatibility between parents and consultants. As a result of defying the values of both cultures, adolescents can put the two communities back-to-back and be exposed to the risk of becoming lost or even dying. There is, then, a risk for the adolescent of seeking out affiliations to neo-groups: groups of teenagers that share the same codes and language and are guided by someone they can identify with. The strong male figure that is the father is often undermined by migration. What they wish to pass on from their culture is devalued and there is a role reversal with the oldest child of the family who knows better the cultural codes of the host society. Addictions, religion, and mental illness can also represent this other space to define oneself. For example, anorexia nervosa occurring in the context of migration could be likened to a pathology related to acculturation in the sense that it is the stigma of a clash of cultures. Children of migrants who are having difficulties with identity construction, between the culture of their parents and the culture of the host country could express their distress by making use of objects of the host society, such as cultural demands for thinness (Radjack et al. 2013, 2017a).

Suicide and Transcultural Risk Factors Rates of suicide are higher among migrant adolescents than in the general population of adolescents (Cho and Haslam 2010; Plener et al. 2015; van Bergen et al. 2008) and have been attributed to both intergenerational and cultural conflicts. The tensions faced by second generation in the processes of acculturation can contribute to

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assimilation where the adolescents may want to be part of the new culture but the new culture may not accept them as such and their own culture may reject them with the view that they have abandoned their cultural values. Cho has described an “Intergenerational Acculturation Conflict Model” where the conflict relates to cultural problems, notably a feeling of incomprehension as well as difficulties in acquiring a sense of belonging and/or of filiation. Often the tension related to traditions and refusing to follow these can lead to tensions within and with the family. Very often, the children of migrants will have higher levels of educational achievement and attainment than their migrant parents which may further expose the cultural differences between them. The Protective Culture Model includes and embeds religion, social, and family support as protective factors that reduce the stress of acculturation. However, this model decreases over time and generations. The first generation is comparable to the people of the country of origin (considering themselves as privileged) whereas the second generation is compared with the local population (with a feeling of damage and disadvantage) thereby creating a sense of alienation. Durkheim in his study of suicide in France highlighted various types of suicide but also attributed the causes including modernization of the society as a risk factors of suicide. His theories can be applied in the increase of suicide in African American adolescents (Willis et al. 2002). The post-modern society is marked by a decrease in collectivism and an increase of individualism, fewer social values, and less access to support. These changes contribute to personal and social stress, and adolescents may discover alcohol and drugs to deal with this stress.

A Traumatic Confrontation to the World This increase in the usage of alcohol and drugs can be seen as an attempt to cope with the splitting as a result of traumatic experiences through which the two heterogenous worlds are to be traversed. The individual may choose to withhold traumatic experiences in order to manage stress. They may choose to share these with adults or others around them, however, occasionally. the expectation of a healing experience is vain, and the splitting is definitively maintained entailing the constitution of a “false-self”. (Ferradji and Moro 2008)

The adolescent children of migrants may be deprived of the parental role in the establishment of a functional link between the internal cultural frame (executive) and the external cultural frame (executive). In addition, they may also be further confronted by obstruction when trying to access initiation rites which give them a meaningful experience to this rite of passage. As mentioned above, clinically we find that children of migrants suffering from addiction, difficulties in verbalization as well as an absence of a historicizing narrative and an overt drought of speech which affects their engagement in any therapeutic endeavor. These patients can rarely understand and develop a connection between their obvious psychic suffering and

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their addictive behaviors. The therapeutic engagement depends upon weaving links between risk behaviors, substance dependence, and associated pathology on the one hand and the whole individual and family history on the other. The migration trajectory narrative is very important at a number of levels in exploring their inner world, understanding their clinical needs and suitable interventions. One of the working hypotheses in clinical settings indicates that the failure of transmission in migration relates also to a geographic rupture entailing a psychopathological experience of the “past vanishing” which may well be much more problematic for adolescent children of migrants.

Creating Adapted Therapeutic Settings A Second Line Psychotherapeutic Treatment An individual cross-cultural opinion can be made only after discussion with the medical team about the relevance and the temporality of its introduction into the care of the patient. Indeed, a number of situations can also be resolved by a classic approach by a psychiatrist. It is not a question of formulating a cross-cultural opinion for every migrant families, but only when a classic approach has its limits. Neither is it only a question of needing an interpreter. In certain situations where transcultural complexity is brought forward by the patient, specific clinical services are required to allow the construction of that which is usually primary and implicit: the cultural holding of the interaction. The transcultural clinical setting is, most of the time, indicated as a second-line intervention when a classical approach has failed. The professional refers a family to this specific clinical setting either because cultural material which he cannot process is invading therapy sessions or misunderstandings and prejudices emerging in the context of cultural or linguistic differences are impacting the treatment plan. A transcultural approach provides a deeper understanding of a patient’s situation when expression of psychopathology is influenced by migration, representation of the illness in the culture of origin, cultural coding of symptoms and difficulties in blending the original culture with the culture of the new country because of a splitting process that happened during migration. This approach can also be used for patients bouncing between western healthcare services and traditional ones. Transcultural consultations often strengthen therapeutic alliance by allowing patients to share their cultural representations. The therapeutic setting, elaborated to be fluid, is flexible and can take many forms. As stated by Sturm (2016), the goal of transcultural therapy is not to reconstruct preexisting representations or theories, but rather to help patients work on recreating the links between their different cultural universes. It is not about reinforcing a specific cultural identity, but rather accompanying the patient in reflecting on his or her own various affiliations while accepting a more flexible and complex conception of his or her cultural identity.

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A Transcultural and Cosmopolitan Therapeutic Group We receive most children and their families individually, along with a translator when needed. In certain cases the session is provided by a group of co-therapists. The latter constitutes the specificity of our approach, a setting where we have been able to experiment new approaches. This setting raises many challenges, as it is unusual to the common practice in psychotherapy. We work mostly with children and families. We invite the entire family to the session: mother, father, children, other family members and the team that referred the family to us. They settle into a group formed by the main therapist and the co-therapists of diverse nationalities and ethnic groups, speaking a wide variety of languages. Parents are always given the option to speak in their own language. The multiprofessional and polyglot group including psychiatrists and psychologists fulfils three functions for the family and the child (Real and Moro 2004; Moro 2010, 2013): 1. It is made up of diverse representations of otherness-of women and men, of whites and blacks, of neither white nor black, close relatives, close relatives of relatives, and so on to distant relatives. These parcels of otherness embodied by group members and represented in space enable the family to experiment with another form of otherness that is neither monstruous nor threatening or destructive, but on the contrary is an otherness that is representable and creative. 2. Second function: holding space by the group. Once the family is sufficiently “held” by the group, it can in turn “hold” the child. With the child acknowledged in his otherness and effectively held, a relationship based on sharing can then be established. 3. The group provides the materialization of the passage from one universe to the other. The cultural representations surrounding the child can be divided into three levels of complexity: First, there are representations concerning the nature of the infant: the ontological level: What is a child? What does he need? What is a mother? What is the father’s role/place? For example, a child with autism could also be a singular child, the reincarnation of an ancestor, who has something more and not something less (he doesn’t speak our language, but he is able to communicate with the world of the invisible). Second, there are etiological theories concerning the nature of the infant’s disorder, delayed development, sleeping problems or mother-infant difficulties. Such theories may reflect belief systems involving jinx (curses and black magic), witchcraft and attack by spirits. The consultation enables the family to share a culturally acceptable meaning to dysfunction, such as a mother’s sadness, feelings of inability, or unharmonious mother-infant relations. For example, in

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Africa, the child comes from the world of the invisible. To be born is to pass from the world of the invisible to the world of the dead without there being a separation between them. If the child is not “well received” (by cultural protections), he can leave (and die in the world of the visible). Third, there are cultural representations of care. Depending on the ontological and etiological level, parents’ expectations do not necessarily correspond to what is proposed; protection, humanization, divination, breast feeding or bottle feeding, massaging or not, going to a healer or a medical doctor, etc. Sometimes, for example, it can consist in finding another nomination for the child (cf. clinical case of Elavie).

The Theoretical Framework: Ethnopsychoanalysis or Transcultural Approach Since Devereux (1967), ethnopsychoanalysis is based on a complementary method resorting to both psychoanalysis and anthropology in the work with patients from different cultural affiliations. Psychoanalysis aims to understand the individual level and anthropology aims to understand the cultural level of the patient’s discourse. A group of therapists receives the patient and the family (generally about ten co-therapists). In non-Western societies, the individual is interpreted in constant interaction with his/her group of belonging. This explains the importance of the group in therapeutic situations. Additionally, illness and disease are viewed as events that concern not only the individual involved, but also the family and the group. Consequently, illness is cared for according to a group functioning – either by the social group, or by a therapeutic community. The collective treatment of illness or disease enables a compromise between collective and family etiology and individual etiology. Healthcare workers who address the family to our care services generally take part in this consultation, at least for the first session. They have been the first depositories to pieces of the family history. Their active presence within the transcultural therapeutic setting prevents the repetition of disruptions in the long and often chaotic itinerary of these families. The latter have often had a previous therapeutic history fraught with difficulties. In addition to these functions – the culture-sensitive aspect of the exchanges and the therapy, the co-construction of a cultural meaning, the propping of the patient – the group also gives substance to otherness (each therapist being from a different cultural background). It converts this otherness into a therapeutic “lever” according to the meaning attached to this by Devereux (1972), that is to say a basis for the psychic elaboration. The melting pot of men and women, of different theories, and different ways of doing things, is an implicit part of the system (Fig. 1).

The Interpreter: A Major Partner These therapeutic settings have highlighted the need for interpreters with first the generation but also with the second one.

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Family and patient Interpreter Principal therapist

Note-taking or video Table and toys for children

Co-therapists, students, researchers, referral team Fig. 1 A transcultural and cosmopolitain therapeutic group

The interpreter can sometimes be even more useful in his function of mediation: we ask the interpreter to translate word-by-word but also to facilitate the sharing of cultural representations and to allow a narrative to take form. The mediator helps to avoid cultural misunderstandings (for example, on how we carry and hold the child in that specific cultural group, the rituals around traditional naming of a child, etc.). The interview with the help of the interpreter-mediator allows to listen more carefully, to share the representations, and then to negotiate between the two cultural worlds. The interpreter can adopt an active way to create bridges with the country and value the skills of the parents which feel often more supported to express themselves. The presence of the interpreter allows to adapt the clinical frame, making it relevant to use his expertise when a family masters French only partially. Indeed, the interpreter-mediator allows to triangulate the relation between the caregiver and the patient. The dual relation is not natural in various countries. Using the mother tongue facilitates the expression of affects, more than in a second language.

The Children Who Migrate We essentially discussed vulnerability in second-generation migrants. It is also present in first-generation migrants. Sometimes, adolescents join a close relative in the host country for protection or to study. The encounter and adaptation can be difficult because of the separation from the family in the country of origin especially if the migration project was ill-prepared. At times, the child or adolescent migrating with its parents adopts Western cultural codes faster than them. It can lead to an

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emotional distance with the parents as described previously. The child can, in some case, see the parents weakened or depressed by multiple factors related to migration. He can then, in turn, become more vulnerable if he doesn’t have the psychological resources to overcome this issue. Finally, there are instances where the adolescent travels alone. This is the situation of unaccompanied minors. Minors travelling without their parent(s) are an increasing phenomena in Europe and North America. Some of them leave their home countries on their own and find themselves in a new country, separated from their family and cut off of their cultural roots. In addition to those who leave to study, work and pursue a better life, others are escaping war-torn countries. Adequate socio educational and therapeutic spaces are needed for them, in which they can feel entitled to speak. These children are exposed to multiple counter-attitudes of professionals (in regards with the conflicts between immigration policy and child protection laws). Social workers are often asking about ways of understanding to improve their care (coping with trauma and suspicion, handling cultural distance between these adolescents and the social workers, etc.). These singular youngsters have to face a multiplicity of difficulties and paradoxes. Being “isolated” before being “foreign,” they benefit of a legal temporary protection in France. However, at 18, they can be deported to the chaotic environment that they had run away from, often at the risk of their own lives. There is no clinical homogeneity, but most of these teenagers have to live alone through their identity construction period and often experience repeated trauma and multiple bereavements. The brutal and repetitive ruptures that these youngsters suffer may generate mental illnesses, especially attachment or post-traumatic disorders. The clinical descriptions often differ from the usual descriptions of psychological trauma due to culturally bound symptomatic features. For instance, we can identify frequent misdiagnosis, leading to an over-estimation of psychosis in these migrant populations, as well as an underestimation of mood disorders and posttraumatic stress syndromes. Indeed, beliefs, language, and behaviors can contribute to misinterpretation and misdiagnosis of psychosis (Radjack et al. 2017a). For instance, blaming external sources for negative events can be common in traditional societies, and should not be interpreted as paranoid ideation. Nevertheless, we keep in mind that migrant status and ethnic minority position have been associated with an increased risk of psychosis in many European countries in the last decades. A variation of this risk is observed in migrants and their descendants, across countries and different ethnic groups. This risk is modulated by cumulative individual and environmental psycho-social adversity experienced during the migration process and in the new country, such as trauma, discrimination, isolation and inequalities in access to welfare, health care, employment, housing and regular status (Tortelli et al. 2014). A transcultural approach appears to us as a relevant framework to re-activate the construction process of identity. It promotes the emergence of cultural representations and it takes into account pre-migration, migration, and post-migration experiences. Clinical work with these youngsters is often very rich and invokes their relatives’ existence in their narrative, alleviating the feeling of isolation and fostering the feeling of belonging to a group. Indeed, we assist them in their capacity to

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produce an inclusive narrative of a bicultural adolescence, smoothly navigating between two worlds.

Conclusion The therapist’s role is not to show a way of being, or doing, but to allow cultural representations to be elaborated and deployed. The therapists have to “decenter” themselves from their own representations and recognize and elaborate their cultural counter-transference. Clinicians themselves may have stereotypes and implicit or explicit preconceptions. In our consultations, we support parenting skills and the co-construction of solutions. We help children to build their own place into their filiation and lineage, getting themselves ready to make their own choices during adolescence including their alliances to succeed in their inscription in a mixed society. Recently, new issues have surfaced forcing transcultural thought and action to adjust to society as it is with new clinical and epistemological questions. Because of emerging needs, transcultural consultations are complexified at La Maison de Solenn, the “maison des adolescents” (adolescent center) of the Cochin Hospital to allow for a local adaptation of the basic therapeutic setting (Benoit et al. 2018). Various derived clinical frameworks have emerged, including “unaccompanied minors” consultations, “international adoptions” consultations, and intercultural mediation in a hospital setting (Radjack et al. 2017b). Their purpose is to help understand and better care for patients in our multicultural societies.

References Anthony EJ, Chiland C, Koupernik C (eds) (1978) Vulnerable children. Wiley, New York Benoit L, Cottin P, Moro MR (2018) What is a “Maison des Adolescents”? A history of integrated youth health care services in France. Early Interv Psychiatry 1:1–6 Cho Y-B, Haslam N (2010) Suicidal ideation and distress among immigrant adolescents: the role of acculturation, life stress, and social support. J Youth Adolesc 39(4):370–379 de Mijolla A (1999) Histoire et préhistoire psychiques, L’“intergénérationnel” et ses fragments d’identité. Rev Fr Psychanal 58(4):1109–1125 Devereux G (1972) Ethnopsychanalyse complémentariste. Flammarion, Paris Di C, Simon A, Moro MR (2009) Une clinique des métissages pour les enfants de migrants. Soins pédiatrie et puériculture 250:21–25 Dimeo et al (2015) Le mutisme extra-familial chez les enfants de migrants. Le silence de Sandia. L’information psychiatrique 3(91):217–224. https://doi.org/10.3917/inpsy.9103.0217 Ferradji T, Moro MR (2008) Alcool et adolescence, approche transculturelle. In: Huerre P (ed) Alcool et Adolescence. Albin Michel, Paris Gabai N, Furtos J, Maggi-Perpoint et al (2013) Migration et soins périnataux: une approche transculturelle de la rencontre soignants/soignés. Médecine et Hygiène “Devenir” 25(4):285–307 Mahler MS (1979) The selected papers of Margaret Mahler: vol 2. Separation-individuation. Lanham, Maryland, États-Unis: Jason Aronson Inc; 1st edition (1979).

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Metraux JC (2003) La médiation culturelle: favoriser le double deuil des soignants et des familles. European Network of the international association of adolescent health 10th annual meeting, Paris Moro MR (1994) Parents en exil. Psychopathologie et migrations. PUF, Paris Moro MR (2010) Nos enfants demain. Pour une société multiculturelle. Odile Jacob, Paris Moro MR, Nathan T (1989) Le bébé migrateur. Spécificités et psychopathologie des interactions précoces en situation migratoire. In: Lebovici S, Weil-Halpern F (eds) Psychopathologie du bébé. PUF, Paris, pp 683–722 Moro MR, Nathan T (1995) Psychiatrie transculturelle de l’enfant. In: Lebovici S, Diatkine R, Soulé M (eds) Nouveau Traité de Psychiatrie de l’Enfant et de l’Adolescent, vol 1. PUF, Paris, pp 423–446 Moro MR, Sibeoni J, Radjack R (2013) Why should cultural factors be taken into account in child and adolescent development and mental health care ? In J P Raynaud, M Hodes, S Shur-Fen Gau (Eds) From research to practice in child and adolescent mental health. Washington DC (USA), Rowman and Littlefied 2014:199–241 Nathan T (1986) La folie des autres. Traité d’ethnopsychiatrie clinique. Dunod, Paris Nathan T (1987) La fonction psychique du trauma. Nouvelle revue d’ethnopsychiatrie 8:7–9 Plener PL, Munz LM, Allroggen M, Kapusta ND, Fegert JM, Groschwitz RC (2015) Immigration as risk factor for non-suicidal self-injury and suicide attempts in adolescents in Germany. Child Adolesc Psychiatry Ment Health 9:34. https://doi.org/10.1186/s13034-015-0065-4 Radjack R, Guzman G, Bouaziz N, Revah A, Moro MR, Blanchet-Collet C (2013) Approche historique et culturelle des troubles des conduites alimentaires. In: Baubet T, Moro MR (eds) Psychopathologie transculturelle 2ème édition augmentée. Masson, Paris, pp 221–232 Radjack R, Rizzi A, Harf A, Moro MR (2017a) Actualités en psychiatrie transculturelle en France. Ann Med Psychol 175(6):505–592 Radjack R, El Husseini M, Moreno Fernandez L, Moro MR (2017b) Multicultural adolescence. In M Pissacroia (Eds) Textbook of Mental and Behavioral Disorders in Adolescence (2nd edition). Padova (Italia), Piccin Nuova Libraria Editions, 2018: 373–86 Réal I, Moro MR (2004) La consultation transculturelle d’Avicenne (Bobigny, France). In: Moro MR, De la Noë Q, Mouchenik Y (eds) Manuel de psychiatrie transculturelle. Travail clinique, travail social. La Pensée sauvage, Grenoble, pp 217–237 Sturm G, Guerraoui Z, Raynaud JP (2016) Approches transculturelles et interculturelles dans la psychiatrie française. Encyclopédie Médico Chirurgicale. https://doi.org/10.1016/S02461072(16)65114-3 Tortelli A, Craig M, Szoke A et al (2014) Different rates of first admissions for psychosis in migrant groups in Paris. Soc Psychiatry Psychiatr 49(7):1103–1109 Van Bergen DD, Smit JH, Van Balkom AJLM, Van Ameijden E, Saharso S (2008) Suicidal ideation in ethnic minority and majority adolescents in Utrecht, the Netherlands. Crisis 29(4):202–208 Von Overbeck Ottino S, Ottino J (2001) Avoir ou être: tribulations identitaires chez les adolescents migrants. L’autre 2(4):95–108. www.revuelautre.com Willis LA, Coombs DW, Cockerham WC, Frison SL (2002) Ready to die: a postmodern interpretation of the increase of African-American adolescent male suicide. Soc Sci Med 55(6):907–920 Moro MR, Nathan T, Rabain-Jamin J, Stork H, Si Ahmed J (1989) Le bébé dans son univers culturel. In: Lebovici S, Weil-Halpern F. (Eds), Psychopathologie du bébé. Paris: P.U.F.; 683– 750 Moro MR (Ed) (2013) Troubles à l’adolescence dans un monde en changement. Comprendre et soigner. Paris: Armand Colin Devereux G (1967) De l’angoisse à la méthode. Paris: Flammarion; 1980

Migration, Aging, and Mental Health The Chinese Elderly in Singapore

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Ee Heok Kua and Rathi Mahendran

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elderly in the City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elderly in the Suburb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elderly in the Industrial Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Chinese immigrants had arrived in Singapore even before the British established a trading post in 1819. The Chinese diaspora to Southeast Asia in the late nineteenth century and early twentieth century was because of the political and social turmoil in China as a consequence of the civil wars. This chapter discusses the three epidemiological studies on the mental health of Chinese elderly conducted in the last three decades. The first study in 1987 included predominantly immigrants living in the inner city around the Chinatown district. The second study in 1998 comprised immigrants and descendants of immigrants residing in the suburb of Toa Payoh. The third study at the industrial district of Jurong in 2011 included descendants of immigrants and a smaller number of new immigrants. The elderly were all living in public high-rise apartments. A common problem of all the immigrants was loneliness and this was more evident among those in the suburban and industrial districts. There was better social connectivity among the elderly in Chinatown. The prevalence of dementia E. H. Kua (*) · R. Mahendran Department of Psychological Medicine, National University of Singapore, Singapore, Singapore e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_27

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in the three studies varied between 2.5% and 5% and depression rates were from 5% to 9% with a lower rate among the Chinatown elderly. The dementia prevention program launched at Jurong has been very successful to improve the mental well-being and social support of the elderly. Keywords

Immigrant · Chinese · Singapore · Aging · Mental health

Introduction Before the British East India Company established a trading post in Singapore in 1819, Chinese immigrants had arrived in Southeast Asia (Kwa and Kua 2019). The waves of immigrants increased in the late nineteenth century and early twentieth century because of the civil wars in China with the decline of the Qing dynasty resulting in social turmoil, economic upheaval, and poverty. The British colonialists in Singapore had also encouraged immigrants from China and India to work in the pepper, gambier, and rubber plantations in the island. Chinese migration to Singapore was mainly from the southern Chinese provinces of Canton, Fukien, and Hainan. In Singapore, the immigrants were assisted in employment and social activities by their clan associations, which comprised many dialect groups like Cantonese, Hokkien, Teochew, Hainanese, Hakka, etc. The immigrants congregated around Chinatown, which is situated along the Singapore River and near the port. They brought along with them their customs, traditional Chinese medical practice, and social cultural activities. They huddled together in crowded enclaves and there was less integration with other ethnic groups like the Malays and Indians. The mental well-being of Chinese elderly is influenced by tradition and cultural beliefs. For more than a thousand years, Chinese families worship in their homes three deities who personify longevity, happiness, and wealth. Embedded in the Chinese tradition of filial piety is the expectation that children would take care of their aged parents and provide financial, social, and emotional support (Kua 2010; Fischer 2015). Happiness for most elderly people is associated with family relationship and care. There are challenges now in caring for an increasing number of elderly people in Singapore with the social transformation of the family due to the small family size and fragmentation of the extended family. Many elderly people today live alone and although they may achieve longevity and wealth, it is happiness that is more elusive. The authors had conducted three epidemiological studies on the mental health of Chinese elderly in Singapore. They were from three different districts – the inner city (Chinatown), suburb (Toa Payoh), and industrial estate (Jurong). The Chinatown elderly were predominantly immigrants, the Toa Payoh elderly were a mix of immigrants and descendants of immigrants, and the Jurong elderly were mainly descendants of immigrants and a smaller number of new immigrants who came not from China but the neighboring countries of Indonesia and Malaysia.

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Elderly in the City The first epidemiological study on the mental health of Chinese elderly in Singapore was conducted around the Chinatown district, which is at the southern corner of the island. This study in 1987 was part of the World Health Organization global research on dementia. A random sample of 1000 elderly Chinese aged 65 years and more was selected from the electoral roll of the Election Department (Kua 1990). The authors were able to contact only 612 participants and about 92% were immigrants who came to Singapore before World War II, and 8% were descendants of the immigrants who came much earlier in the early twentieth century. The latter group viewed the former group as “sinkeh” or “new arrivals.” The immigrants were from the southern Chinese provinces and settled in enclaves according to their dialect groups. They worked as laborers at the port, plantations, or in small businesses around Chinatown. Because of the crowded accommodations, many of them would prefer to be outside their homes and mingle with friends at the tea houses, coffee shops, or community places. For this study, a nurse would visit their apartments at the Tiong Bahru, Henderson, and Redhill constituencies of Chinatown. Those who were 65 years or more were invited for an assessment at the May Wong Social Centre situated at Henderson constituency. The survey gave us an opportunity to visit the elderly in their homes. They often talked about their joys and sorrows, their hopes and fears living through the tumultuous years during World War II and the poverty of the fifties and sixties. The interview instrument used was the computerized Geriatric Mental State schedule or GMS-AGECAT (Copeland et al. 1976; Copeland et al. 1986) which had been translated into the Chinese language. Every participant had a physical examination and laboratory examinations including brain scan were conducted for those with probable dementia – the diagnosis was according to the WHO ICD-9 (World Health Organization 1978). The results indicated that 5.7% of the study group had depression (Kua 1992, 1994) – this was comparable to a study in China using the GMS-AGECAT (Chen et al. 2005). However, the rate is much lower compared to other GMS-AGECAT studies in the United Kingdom with rates of 8.7–11.2% (Copeland et al. 1987; McDougall et al. 2007). A possible explanation of the lower prevalence of depression is the sociocultural influence on the perception of elderly people in the Chinese community. The emphasis on respect for the elderly and family support for elderly parents may be crucial in elevating the status of old people and minimizing stress in old age. For dementia, the prevalence rate of 2.5% was quite similar to the results of the large-scale study in mainland China (Zhang et al. 2005) and other Chinese studies in Taiwan (Liu et al. 1996) and Hong Kong (Chiu et al. 1998). Overall, the prevalence is comparable with other studies worldwide (Kua and Mahendran 2017). The commonest physical health problems of the Chinatown elderly were musculoskeletal disorders (20.1%), hypertension (12.2%), and diabetes mellitus (9.0%). The authors also studied life satisfaction, which is a subjective perception of one’s overall assessment of life quality and general well-being from comparing one’s

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aspiration to actual life achievement and condition (Kua 2010). About 72% felt satisfied (Kua 1994) and in this group the main reasons were good family relationship (41%), physical comfort (28%), and good health (23%). Most of the elderly in this study preferred to see traditional Chinese healers whenever they were unwell. The traditional healers are popular not only because of the accessibility of their service but also because they share the same sociocultural beliefs about illness and health. A powerful therapeutic factor is the rapport between the patient and the healer, who is able to explain the mental health symptoms using the sociocultural belief system the patient is familiar with. The constellation of symptoms is explained to the patient as due to an excess of “ying” (negative) or “yang” (positive). The traditional Chinese healer understands the ethos of the subculture and consulting one also avoids the stigma of being labeled a “mental patient,” as would happen when they see the doctor in the psychiatric clinic (Kua and Tan 2005).

Elderly in the Suburb The second epidemiological study in 1998 was conducted at the Toa Payoh district in the central region of the island. This project was a collaboration between the Singapore Action Group of Elders or SAGE (a nongovernmental organization) and the Gerontological Society of Singapore (Kua et al. 2004). A day center called SAGE Centre for the Study of Ageing (SAGE-CENSA) was started at Toa Payoh. The elderly living in this suburb were generally more affluent compared to the Chinatown elderly. The study group included 2,907 participants with 62% descendants of immigrants and 38% recent immigrants from China, Malaysia, and Indonesia. Because the allocation of apartments in Toa Payoh was not according to ethnicity, many of the elderly were unfamiliar with their neighbors and many felt lonelier compared to the Chinatown elderly. Our nurses visited their homes and invited those seniors 65 years or more for an assessment at the day center. Compared to the Chinatown elderly, the Toa Payoh residents had more physical health problems – hypertension 34.3% and diabetes mellitus 14.3%. Besides a physical examination, they were screened for cognitive decline using the Elderly Cognitive Assessment Questionnaire or ECAQ (Kua and Ko 1992). The ECAQ is a ten-item scale and the items are culled from the Geriatric Mental State or GSM schedule (Copeland et al. 1976). The ECAQ assesses two aspects of cognitive function, memory and orientation/information, and has a maximum score of ten points. There is less bias on educational status and the questionnaire can be completed in 5 min. For the study on dementia, the authors had a smaller sample size of 296 elderly residents and 18 elderly scored 6 or less points on the ECAQ. Using the GMS-AGECAT assessment, the prevalence rate for dementia was 5% and for those 75 years and older the rate was 8.6%. The screening questionnaire for depressive disorder was derived from the depression scale of the GMS-AGECAT schedule (Copeland et al. 1976). In a previous study (Kua 1992), it was found that those who were diagnosed with depressive

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disorder in the GMS-AGECAT computer program had four or more of these six depressive symptoms, i.e., insomnia, tiredness, poor concentration, feeling sad, inability to enjoy activities or interest, and poor appetite. For this study, those who scored two or more on this six-item scale were interviewed again with the full version of the GMS-AGECAT schedule. In a random sample of 303 elderly subjects, 29 were diagnosed with depressive disorder. The prevalence rate was 9.5% and for those 75 years or more the rate was higher at 14.9%. The prevalence of depression among the Toa Payoh Chinese elderly was higher than the Chinatown study group. At the Chinatown district, the elderly people would tend to congregate daily along the common corridors or void decks of their apartment – they were bonded by clanship ties. The elderly from the Toa Payoh housing estate had come from diverse backgrounds and lacked the “comradeship” of the Chinatown group. The depressed elderly in Toa Payoh reported poor life satisfaction (70.4%) especially in health (48%) and family relationship (28%). A sense of loneliness was a more common complaint among the Toa Payoh elderly than among the Chinatown elderly. Their common worry concerned family relationships – the conflicts were usually with children or children-in-law. These problems were often long-standing and might have been aggravated by the elderly people being forced by circumstances to live together with the children. Most of the elderly in Chinatown and Toa Payoh did not have any pension and were dependent on their families for financial support and care.

Elderly in the Industrial Estate In 2010, a longitudinal study of aging was conducted at the Jurong district, an industrial estate at the western region of Singapore. The catchment area of the Jurong Ageing Study included about 1000 Chinese elderly living around the Jurong Point Shopping Mall where there is a research base called Training and Research Academy or TaRA. In the cohort, about 78% were descendants of the early immigrants and 22% were new Chinese immigrants from Malaysia or Indonesia. This project was funded by the family of a Chinese immigrant who came to Singapore before World War II. The nurses visited 50 blocks of apartments near the shopping mall and invited those 60 years or more to go for a free medical assessment at TaRA. Every elderly person would undergo a thorough physical, mental, and social assessment, including blood examination and neuropsychological tests – MRI brain scan would be ordered for those with mild cognitive impairment or dementia (Kua 2017). From data in the Memory Clinic of the National University Hospital (Kua et al. 1997; Kua et al. 2014), it was noted that the quality of life and life expectancy of dementia patients could be improved if chronic illnesses such as diabetes mellitus and hypertension were stabilized together with lifestyle changes including diet and exercise. Multidisciplinary research has provided evidence supporting the role of vascular and related disorders (e.g., hypertension, diabetes mellitus, and cerebral microvascular lesions) as risk factors and the possible role of psychosocial factors

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(e.g., mentally stimulating activity, social engagement, and exercise) as protective factors in the development of dementia and depression (Niti et al. 2008). The Jurong Ageing Study is a project to ascertain whether psychosocial interventions through group activities together with health education can prevent or delay the onset of depression and dementia. The study examines interventions like mindfulness practice, music, art, and gardening, to improve cognitive, emotional, and functional well-being (Wu et al. 2014). It started with a naturalistic study of a subgroup of 110 elderly who had mild depressive symptoms and mild impairment of cognition. All the elderly attended group meetings once a week for 3 months, fortnightly for 6 months and monthly thereafter. Each meeting began with a 20-min talk in Chinese on health issues, including diabetes mellitus, hypertension, medications, diet, and exercise. After the talk, participants were divided into four groups for art activities, tai-chi exercise, mindfulness practice, and music-reminiscence – this session lasted 30 min. The groups were assessed at the beginning, after a month, at the end of the third month and after a year. The scores on the self-rating Zung Depression and Anxiety scales showed significant improvement in mood after 3 months and continued for a year (Rawtaer et al. 2015). In cognition (memory, concentration, and orientation), after a year only 57% of the elderly showed a decline, 24% remained stable, and 19% improved (Kua 2017). The results were very encouraging because they showed that the health education and psychosocial therapies could improve the mood and cognition of elderly people. More importantly, there was an increase in social connectivity and they had more friends in the neighborhood. Although they came from different parts of Singapore and did not know each other, the psychosocial activities were a common platform for them to interact and build social relationships. The preventive strategies in the Jurong Ageing Study are important not only for their physical and mental health but also social support (Kua et al. 2013).

Future Challenges In recent years there is concern in Singapore about the care of the frail elderly especially among the immigrants with poor social support. The concern is not only because of an increasing number of the elderly but also a diminishing number of care-givers. With the social transformation of the Singapore family, young couples prefer to live away from their parents because of the constraint of space in high-rise apartments. Women are better educated and prefer to work rather than to remain at home. The shrinking family size – most families today have only one or two children – is another factor in the diminishing number of family carers. A previous study showed that about 56% of family caregivers of dementia patients in Singapore had symptoms of anxiety and depression related to the stress of caring (Kua and Tan 1997). Loneliness is a major issue elderly people encounter not just in Singapore but also in most developed and developing countries. Lim and Ng (2010) postulated a model

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whereby the relationship between living alone and psychological well-being is mediated by feelings of loneliness in a sample of 1205 community-dwelling elderly in Singapore. Living alone was associated concurrently with lack of a confidant, both of which predicted more depressive symptoms and poorer quality of life (Lim and Kua 2011). In the three epidemiological studies conducted, it is noted that the mental health of the elderly especially among the immigrants is linked to their social needs such as family and community support. From the encouraging results of the Jurong Ageing Study, a community project called Age Well Everyday (AWE) program was initiated in 2015. The AWE program includes health education, exercise, and mindful awareness practice – all the activities are conducted by volunteers (Kua 2017). There are now eight community centers that have adopted this program and because of the increasing interest among the elderly population, it is hoped that the program will be introduced to more centers around the island. The AWE program hinges on volunteerism and to ensure a steady number of trained volunteers, an on-line training project has been introduced with the collaboration of the Singapore University of Social Sciences. The AWE program will strengthen the social support for many elderly people in Singapore. More new ideas are now introduced to this program, including gardening, art, and choral singing (Kua and Sia 2017; Ng et al. 2018; Mahendran et al. 2018; Lee et al. 2019). Recently, a nature-walk interest group called Nature and Mindful Awareness (NaMA) has started and the program includes mindful walking through the rainforest, learning about the forest ecology and understanding biophilia. Interest in the AWE program has been generated in Asia from the research publications of the authors and they have conducted workshops in Malaysia, Indonesia, and China. The decline in intergenerational cohesion and filial obligations recently has contributed to the older person’s experience of disappointment, alienation, and sadness. We have embarked on a new research called Community Health and Intergenerational (CHI) project, which aims to study intergenerational bonding in the family and explore community support for the elderly. At the Hannah day center, which is at the south western corner of Singapore, a new intergenerational study is now being planned by nurses. It is hoped that values of compassion and empathy will emanate and foster family bond to care for the elderly at home. The nurses will also helm a study on brief integrative personal therapy (Kua 2004) for elderly with mild anxiety and depression. The CHI project has a philosophy that scientific discourse should not just be theoretical but must have an applied agenda of translational relevance that can impact the lives of people living in the community (Becker and Kleinman 2013). Most of the Chinese immigrants in Singapore are now naturalized citizens and many have returned to China to visit the homes of their ancestors. In recent years, a few professors of psychiatry from the National University of Singapore have been invited by the Universities of Beijing, Shanghai, and Chengdu to assist in the training of young psychiatrists. This has led to the formation of the Teachers of Psychiatry (TOP) Club, which includes predominantly psychiatrists who are

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descendants of Chinese immigrants from Singapore, Malaysia, Australia, Canada, and the USA. The TOP Club has now other members from Switzerland, Hong Kong, and Taiwan. The academic exchanges have helped to promote friendship and research collaboration with the Universities in China (Kua 2004; Li et al. 2017).

Conclusion Immigrants who leave their homeland to seek new opportunities in a foreign country often encounter challenges in acculturation, employment, and access to basic needs of housing and health services. Elderly immigrants have other pressing issues – besides their increasing frailty there is the problem of care and social support. The epidemiological studies in Singapore have three important findings of relevance for the healthcare of elderly immigrants in many parts of the world. First, social support and connectivity is vital for the well-being of the elderly as indicated in the Chinatown elderly who although poorer had better social links with friends living close to them – they shared the same dialects and mingled daily. Their depression rate was low compared to the more affluent elderly in the Toa Payoh suburb. Second, lifestyle can certainly affect mental health. The prevalence rates of diabetes mellitus and hypertension were higher for the Toa Payoh elderly who also had higher rates of depression and dementia. Third, the Jurong study showed that it is possible to improve the mental health of the elderly with non-drug strategies, e.g., health education, art therapy, mindfulness practice, music-reminiscence, exercise, and gardening. These strategies can also prevent cognitive decline and promote social connectivity.

Cross-References ▶ Community Engagement and Social Justice ▶ Migration, Globalization, and Mental Health ▶ Resilience, Mental Health, and Migrations

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Mental Health in Refugees and Asylum Seekers

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Meryam Schouler-Ocak and Marianne C. Kastrup

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Illness of Refugees and Asylum Seekers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Healthcare of Refugees and Asylum Seekers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Prospects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

58 million refugees and asylum seekers are currently in the process of fleeing their homes. A high proportion of traumatised people with a serious mental disorder such as PTSD is among this population. Therefore, healthcare systems have to prepare themselves for this very heterogeneous population with different concepts of health and disease and with expectations about treatment depending on cultural background, traditional values, personal experiences and social worlds. To be able to cope with mental health needs among diverse multicultural populations health professionals need sufficient knowledge, competences and training. Furthermore, the legislation should be changed towards including more humanitarian aspects in mental health care. Additionally, data on the mental health of immigrants is scarce, so that it should be filled. Summing up, there is an urgent need for action on different levels.

M. Schouler-Ocak (*) Psychiatry and Psychotherapy, University Psychiatric Clinic of Charité at St. Hedwig’s Hospital, Berlin, Germany e-mail: [email protected] M. C. Kastrup Speciallæge i psykiatri, Frederiksberg, Denmark e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_8

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Keywords

Mental health · Refugees and asylum seekers · Healthcare · Future prospects

Introduction According to the UNHCR, “the terms asylum-seeker and refugee are often confused: an asylum-seeker is someone who says he or she is a refugee, but whose claim has not yet been definitively evaluated” (UNHCR 2015). Asylum-seekers (with “pending cases”) are individuals who have sought international protection and whose claims for refugee status have not yet been determined” (UNHCR Mid-Year Trends 2015, p. 28). “Asylum seekers are individuals who have sought international protection and whose claims for refugee status have not yet been determined, irrespective of when they may have been lodged” (UNHCR 2014, p. 56). Also according to UNCHR, Global Trends, 2014, “refugees include individuals recognised under the 1951 Convention relating to the Status of Refugees; its 1967 Protocol; the 1969 OAU Convention Governing the Specific Aspects of Refugee Problems in Africa; those recognised in accordance with the UNHCR Statutes; individuals granted complementary forms of protection; or those enjoying temporary protection. The refugee population also includes people in a refugee-like situation” (UNCHR 2014, p. 56).

Background According to UNHCR, by mid-2015, the total population of concern stood at an unprecedented 58.0 million persons. Due to differences in delineating the population in question, statistics about its size may differ. The population comprises persons who are forcibly displaced (notably refugees, asylum-seekers, internally displaced persons (IDPs)); those who have found a durable solution (returnees); as well as stateless persons. Millions among them have had to leave their homes for reasons of persecution, armed conflict, strife, generalized violence, or human rights violations. Armed conflicts and persecution forced an average of 42,500 persons per day to leave their homes and seek protection elsewhere, either within the borders of their countries or to other countries during 2014 (UNHCR 2015). This average is much higher than in the previous years, e.g., in 2013 where the average was 32,200 per day and in 2012 23,400. Many of the displaced persons have frequently been subjected to physical, sexual, and/or psychological violence and traumatic bereavement (UNHCR 2015). There are significant geographical differences as the developing regions are host countries for 86% of the world’s refugees – 12.4 million persons – and the Least Developed Countries provide asylum to 3.6 million refugees or 25% of the global total. Other countries also hosted large percentage of refugees. Mentionable, 11% of these refugees were hosted in 2014 by Turkey, 10.5% by Pakistan, 8.0% by Lebanon, 6.8% by the Islamic Rep. of Iran, 4.6% by Ethiopia, 4.5% by

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Jordan, and 54.6% by others (UNHCR 2015). Syria (3.88 million), Afghanistan (2.59 million), and Somalia (1.11 million) are the three countries, which sent out more than half (53%) of all refugees worldwide. Syria, Iraq, Afghanistan, Serbia/ Kosovo and Eritrea are the top five countries/region from which the asylum seekers registered for asylum in the 44 industrialized countries in 2014 (UNHCR 2015). According to UNHCR 2015 (UNHCR Mid-Year Trends 2015, p. 9), close to one million individual asylum applications from at least 190 nationalities were registered in 155 countries or territories during the first half of 2015, significantly more than during the corresponding period of 2014 (558,000). UNHCR offices registered 115,200 individual asylum applications, out of the provisional total of 993,600 (12%). “The statistical picture of the number of people seeking international protection in Europe is partially distorted because of the reported instances of the same individual being registered as asylum seeker multiple times across the continent. The actual number of individuals lodging asylum applications in Europe is thus likely to be lower than described” (UNHCR Mid-Year Trends 2015, p.10).

Mental Illness of Refugees and Asylum Seekers As described by several authors (Rasmussen et al. 2010; Neuner et al. 2004; Roberts and Browne 2011; Mazur et al. 2015), the loss of loved ones/caregivers and/or livelihood, the destruction of property, deprivation, persecution, insecure living conditions, war, torture, imprisonment, terrorist attacks, abuse, and sexualized violence are among the traumatic experiences of refugees and asylum seekers. Most of them will experience defenselessness and disorientation, conditions of cold or heat, hunger and thirst, lack of medical care, robbery, assault, and discrimination during the process of flight. Furthermore, many women may be subjected to different kinds of sexual assaults and violations. After the arrival to the host countries, the stress continues. According to Heeren et al. (2012), stress factors, e.g., induced by residence in mass accommodation facilities, difficulties dealing with the authorities because of language and cultural barriers, being allocated to specific municipalities only, lack of working permit, and dependence on social security (subsistence-level poverty) all influence their health situation. Further, stress factors like lack of future prospects, uncertain residence status (asylum or temporary “toleration”), and the threat of exportation, despite sometimes having resided in the country for years, have also an impact on their health situation. Added to that come the short-term and uncertain residence status and lack of opportunity to work or undergo training. Traumatic experiences like the killing or unnatural death of a family member or friend, attacks by strangers, not having a roof over one’s head, near-death experiences (Heeren et al. 2012) are all related to common mental disorders. These authors (Heeren et al. 2012) diagnosed major depression (31.4%) and PTSD (23.3%) in groups of asylum seekers and found that the number of experienced traumatic event types was highly correlated with psychiatric morbidity. They further observed that the rates of psychiatric morbidity in refugees and asylum seekers in the first two years after arrival were

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high, but with no indication of a decrease in mental distress subsequently over time. They suggest that traumatic experiences seem to play a major role in morbidity during the time after arrival in the receiving country. When people have been traumatized by “man-made disasters” the rate of posttraumatic stress disorder (PTSD) is higher in comparison to the rate of PTSD when people have experienced fateful events such as natural disasters or traffic accidents. According to Flatten et al. (2011), the prevalence rates show that not everyone who experiences traumatic events develops a trauma-induced disorder. Thus, the percentage among victims of traffic accidents is only 10%, whereas more than 50% of the victims of rape, war, displacement, and torture develop PTSD (Flatten et al. 2011). Schock et al. (2015) studied in Germany the stressful impact of the asylum interviews on traumatized refugees. Their data showed a significant increase in posttraumatic intrusions and a significant decrease in posttraumatic avoidance and hyperarousal symptoms. The authors discussed that the asylum interview might decrease posttraumatic avoidance and trigger posttraumatic intrusions, thus highlight the importance of ensuring that the already vulnerable group of traumatized refugees needs to be treated with empathy during their asylum interviews. Therefore, it is very important that mental health professionals are culturally competent. Cultural competence is necessary in clinical practice whereby the mental health professional see each patient in the context of the patient’s culture as well as their own cultural values and prejudices. Cultural competence deals with the skills that a clinician can employ to understand the cultural values, attitudes, and behaviors of patients, especially those whose cultural background differs from that of the mental health professional (Schouler-Ocak et al. 2015; Bhugra et al. 2011, 2014; Qureshi et al. 2008). Hocking et al. (2015a) reported that the impact of industrialized host nations’ deterrent immigration policies on the mental health of forced migrants has not been well described. In an Australian study, the authors investigated the impact of Australia’s refugee determination process on psychiatric morbidity in community-based asylum-seekers and refugees. They found that psychiatric morbidity was predicted to be greater in asylum seekers than refugees and to persist or increase as a function of time during the refugee determination process. The authors investigated also the effect on mental health of demographic and socio-political factors such as health coverage and rights to work. They pointed out that psychiatric morbidity in asylum seekers significantly decreased and was no longer greater than that of refugees after an average of 15.7 months. They reported also that psychiatric morbidity, like PTSD, and demoralization reduced in asylum seekers who gained protection. Those who maintained their asylum-seeker status also had a significant reduction in depression and posttraumatic (PTS) symptom severity. Interestingly, reduced PTS symptoms and demoralization symptoms were associated with securing work rights and health cover. Hocking et al. (2015a) underlined that living in the community with work rights and access to health coverage significantly improves psychiatric symptoms in forced migrants irrespective of their protection status (Hocking et al. 2015a). Hocking et al. (2015b) found in an Australian study that the prevalence of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) was 61% and 52%, respectively, among adult asylum seekers. Factors like unemployment

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and greater numbers of both potentially traumatic events and rejection of the refugee determination process were predictors of symptom severity. Unemployed asylum seekers were more than twice as likely to have MDD. The authors found that asylum seekers with the refugee determination process resulting in at least one rejection were 1.35 times more likely to develop PTSD for each additional rejection. A main result of this study was that reducing the asylum claim rejection rate and granting work rights are likely to reduce the rate of PTSD and MDD in community-based asylums seekers (Hocking et al. 2015b). Sundvall et al. (2015) found in a Swedish study that asylum seekers registered for suicide attempts were more traumatized, had different social risk factors, and received different diagnoses than the controls, who were suicide attempters with Swedish personal identity numbers. At the same time asylum seekers were referred to less specialized follow-up after- treatment, in spite of their health history and previous and current clinical pictures indicating similar or – in the case of the female asylum seekers – more serious mental health condition. The authors reported that female asylum seekers also received more intense and prolonged inpatient treatment than female controls. Interestingly the authors pointed out that asylum seekers appeared to have social networks more often than the control group. Among the asylum-seeking men, there was less documentation of an impact on their mental health of social context, previous suicidal behavior, or suicide in family or close environment. They also found that information on suicidal intent was lacking in a majority of both groups. In their conclusion, they summarized that there was a lack of early and thorough exploration of suicide intent for both groups and of contextual and subjective factors for the asylum seekers. Differences in treatment, less documentation, etc., follow-up were seen as indicator for unequal access to care (Sundvall et al. 2015). Nakash et al. (2015) examined the association between acculturation patterns and mental health symptoms among a convenience sample of Eritrean and Sudanese asylum seekers who accessed health services at the Physicians for Human Rights Open-Clinic in Israel. Their findings showed that acculturation predicted depressive symptoms among asylum seekers beyond the effect of history of detention and reports of experiences of traumatic events. Thus, assimilated compared with integrated asylum seekers reported higher depressive symptoms. These findings draw attention to the paradox of assimilation, and the mental health risks it poses among those wishing to integrate into the new culture at the expense of their original culture (Nakash et al. 2015). Mazur et al. (2015) observed in their French study that 60% of the asylum seekers suffer from psychopathological disorders with an important comorbidity of PTSD and depression (64.2%). Furthermore, they found that the seriousness of the symptoms is correlated with less adaptive defense mechanisms (like a higher incidence of defense mechanisms such as acting-out and distorted self-image). Furthermore, the study participants tend to resort to defense mechanisms such as projection, low selfesteem, withdrawal, acting-out, and hypochondria. These results underlined the importance of the affiliation mechanism, which holds the potential to facilitate adaptation and resilience in these vulnerable groups (Mazur et al. 2015).

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Goosen et al. (2011) found in a study that the suicide rate was higher in male asylum seekers than in males in the reference population. The incidence of hospitaltreated suicidal behavior was higher in several subgroups of asylum seekers than that in the reference population. Laban et al. (2005) identified clusters of postmigration living problems: family issues, discrimination, asylum procedure, socioeconomic living conditions, socioreligious aspects, and work-related issues. They noted a significant relationship between all clustered postmigration living problems and psychopathology, except for socioreligious aspects. Lack of work, family issues, and asylum procedure stress had the highest odds ratios for psychopathology. Consistently, it is important to shorten the asylum procedures, allow asylum seekers to work, and give preference to family reunion. According to these authors, the mental health workers should recognize the impact of postmigration living problems and consider focusing their treatment on coping with these problems instead of traumas from the past (Laban et al. 2005). In another study, Laban et al. (2008) examined the influence of the length of the asylum procedure on quality of life. They found that a long asylum procedure went along with significantly lower quality of life, higher functional disability, and more physical complaints. Particularly, the length of stay is the strongest predictor for a low overall QoL. The authors reported that lower QoL was predicted by psychopathology, higher age, adverse life events in the Netherlands, and the postmigration living problems: family issues, socioeconomic living conditions, and socio-religious aspects. They reported also that disability was predicted by psychopathology, higher age, and the postmigration living problems. It was underlined that physical complaints were predicted by length of asylum procedure, psychopathology, female sex, adverse life events in Iraq, and PMLP-family issues (Laban et al. 2008). These findings are very important because they show the impact of the integration process. In another study, the same group Laban et al. (2007) found that a long asylum procedure is not associated with higher health service use, except for mental health service use and drug use. These authors reported that the use of mental health services is, however, low compared to the actual prevalence of psychiatric disorder in this group. One of the important observations was that low quality of perceived general health and functional disability are the most important predictors of services use. Another result was that psychopathology predicts the use of a medical specialist (nonpsychiatrist) but does not predict mental health service use (Laban et al. 2007).

Mental Healthcare of Refugees and Asylum Seekers According to Fenta et al. (2007), the first consultation that takes place in case of psychiatric illness is more frequently a general medical consultation rather than a consultation with trained psychiatric/psychological professionals. There are several reasons for this. This may be because physical symptoms are easily recognizable. It may also be due to the fact that psycho-somatic symptoms may well be more prevalent and explanatory models may well use physical ascriptions. These individuals may well see doctors as dealing with only physical problems so may choose not

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to express psychological distress. In most places however not even the acute medical care is assured. Data about mental health services for refugees and asylum seekers are frequently missing, which makes it difficult to monitor and subsequently improve migrant health of refugees and asylum seekers (Rechel et al. 2012). The most fundamental barriers for refugees and asylum seekers in accessing health services are inadequate legal entitlement and, where entitlement exists, mechanisms for ensuring that they are well-known and respected in practice (Pace 2011). According to Karl-Trummer et al. (2010), the problems are greatest for asylum seekers and undocumented migrants. Mladovsky et al. (2012a) reported that by 2009, only eleven European countries had established national policies to improve migrant health. Kluge et al. (2012) conducted structured interviews with health service providers located in areas with high immigrant populations in 16 European countries. The focus of this study was to analyze the availability of data on service use by immigrant patients, the provision of interpreting services, and immigrant staff members. One of the results was that data on service use by immigrants were recorded by only 15% of services. Another main result was that more than 40% of services did not provide any form of interpreting service and 54% of the services reported having no immigrant staff. The authors pointed out that there is a great need to improve the availability of data on service utilization of asylum seekers and refugees worldwide. Rechel et al. (2013) confirmed that across the world, huge differences exist in national asylum policy regimes. Mladovsky et al. (2012a) compared and contrasted the content of policies and analyzed their strengths and limitations. Their analysis suggested that most of the national policies target either migrants or more established ethnic minorities. According to these authors, undocumented migrants in many countries are restricted in utilization of mental health services (Mladovsky et al. 2012a). Therefore, they constitute a particularly vulnerable group, many likely to being exposed to further trauma in the host country; certain groups such as trafficked women may be kept under highly degrading and traumatizing circumstances (Schouler-Ocak and Kastrup 2015). Lack of familiarity with rights, entitlements, and the overall health system, gaps in health literacy, social exclusion, and direct and indirect discrimination are other barriers (Mladovsky et al. 2012b). Stigma, social exclusion, perceived discrimination, and self-discrimination are also barriers to access (Küey 2015; Rose et al. 2007; Lederbogen et al. 2011; Veling 2007; Veling et al. 2008). Additionally, exposure to individual social adversity – such as markers of disadvantage – and area-level factors like ethnic density (Schofield et al. 2011), neighborhood deprivation, and social strain (Stafford et al. 2008) are further barriers. According to Bhugra et al. (2014) and Schouler-Ocak et al. (2015), further barriers include a lack of employees’ knowledge on different concepts of health and ill health, the treatment expectations of refugees and asylum seekers, and the lack of intercultural competence of the staff members system. In many countries, voluntary organized doctors, nurses, social workers, and other volunteers are carrying out the treatment of refugees and asylum seekers. Only a minimal level of care can be provided, and it does not ensure comprehensive medical care. Uncontested,

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refugees, and asylum seekers need regular medical care. The aim to reduce the barriers so that refugees and asylum seekers reach the same level of service use as the background population is often not attainable due to lack of or limited funding for interpreting or other special services (Bhugra et al. 2011; Schouler-Ocak and Kastrup 2015). For all this, there is an urgent need for action.

Future Prospects Industrialized countries are likely to receive increasing numbers of refugees and asylum seekers, because more than 58 million people are currently in the process of fleeing their homes. There is a high proportion of traumatized people with a serious mental disorder such as PTSD among this population. Therefore, health care systems have to prepare themselves for this very heterogeneous population with different concepts of health and disease and with expectations about treatment depending on cultural background, traditional values, personal experiences, and social worlds (Bhugra et al. 2005, 2011, 2014; Schouler-Ocak and Kastrup 2015). There is an urgent need for action on different levels. On the political level, changes must be realized for legal entitlement for everybody. Furthermore, the legislation should be changed towards including more humanitarian aspects in mental healthcare. On the level of policy maker and service provider, it should be a must that institutions are culturally open and that cultural competence training is available for all professional staff. The use of the Cultural Formulation Interview (CFI) during a mental health assessment to obtain information about the impact of culture on key aspects of a patient’s clinical presentation and care should be integrated in the daily work (Aggarwal et al. 2015, 2016). On the level of data on mental health of immigrants, which is scarce, the gap should be filled.

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The Untold Story of Mental Health and Resilience of Internal Migrants in India

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Raghu Raghavan, Jonathan Coope, Brian Brown, Muthusamy Sivakami, Saba Jamwal, and Tejasi Pendse

Contents Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gap in Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Pune Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sketches of Three Participants from Our Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sketch 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sketch 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sketch 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk and Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Migration is an integral part of population dynamics. Migration is a matter of emerging importance for Low- and Middle-Income Countries (LMIC), with international debate stepping up on the linkages between migration, development, and poverty. Migration is the process of social change whereby an individual moves from one cultural setting to another for the purposes of settling down either permanently or for a prolonged period. India is the nation with the highest R. Raghavan (*) · J. Coope · B. Brown Mary Seacole Research Centre, De Montfort University, Leicester, UK e-mail: [email protected]; [email protected]; [email protected] M. Sivakami · T. Pendse Centre for Health and Social Science, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India e-mail: [email protected]; [email protected] S. Jamwal Asoka University, Haryana, India e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_43

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proportion of internal migrants among its population, with more than 300 million internal migrants reported in the census of 2001 Our aim is to develop our understanding of how a participatory and coproduction model with internal migrant communities in India can help us to coconstruct knowledge of resilience for mental health and wellbeing in the context of global public health. We draw on the findings from a Global public health research funded by Global Challenges Research Fund. We will explore the stresses of three slum dwelling internal migrants in Pune, India, and the way in which they construct resilience for mental health and wellbeing. We portray how the characters in our three narratives each exemplify the “urge to live” via their ongoing confrontation with mental distresses and their ongoing capacity to construct resilience in the socioeconomic and cultural context of India. Keywords

Mental health · Resilience · Migration · Poverty · Global public health

Background The Chapter draws on a study of the mental health resilience of internal migrants in India. The selection of India for the location of the study is particularly apt, given that it has the highest proportion of internal migrants among its population of any country in the world, with internal migrants numbering some 326 million (UNESCO 2013, pp. 4,7). Given that a high proportion of urban migration growth is occurring towards fast growing megacities in developing countries such as India, Brazil, and China where relatively little is currently known about the mental health challenges of migration, internal migration appears to merits particular attention from mental health researchers (Li and Rose 2017, p. 21). Moreover, such megacities can, frankly, often be harsh, hazardous, and unwelcoming: for the vast majority, cities are polluted, unhealthy, tiring, overwhelming, confusing, alienating. They are the places of low-wage work, insecurity, poor living conditions and dejected isolation for the many at the bottom of the social ladder daily sucked into them. (Amin 2006, p. 1011)

There has been a long tradition of counter-modern critiques of the distinctive psychopathologies. In the west, for example, Georg Simmel’s famous account from 1903 suggested that urban environments perpetuate and exacerbate the strains on mental health inflicted by modernity itself: The psychological basis of the metropolitan type of individuality consists in the intensification of nervous stimulation which results from the swift and uninterrupted change of outer and inner stimuli . . . [some of them] tearing the nerves so brutally hither and thither that their last reserves of strength are spent. . .

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Simmel’s suggestion was that the only way to thrive and avoid “being levelled down and worn out” by modernity and the city is for each person to develop “an organ protecting him against the threatening currents and discrepancies of his external life which would uproot him” (Simmel 1964, pp. 409–414). Of course, in Simmel’s day, the global urban population was a mere 220 million; by 2014, that figure had risen to some 3.9 billion and the proportion of the population that is urbanized globally only continues to rise (UN Department of Economic and Social Affairs 2014, p. 1). Although the mental health risk factors confronting internal migrants can often be manifold and grave, several strong arguments have emerged for why mental health research on migration may need to start looking beyond risk factors alone. Firstly, there has arguably been something of a paradigm shift away “from the pathological focus to the positive aspect” in health and mental health studies (Chen et al. 2016, p. 533). For example, Aaron Antonovsky’s salutogenesis model was one pioneering example of such an approach, which gave much greater emphasis to factors that cause health rather than factors that cause ill-health or disease. The latter approach is sometimes described as a pathogenesis approach. Proponents of salutogenesis argue that research focusing on risk factors all too often overlooks the sometimes hidden resources people and their communities may possess for mediating risk and achieving positive health (Becker et al. 2010). Secondly, and relatedly, critics of deficit models of health have sometimes noted that such approaches also have negative political implications, by tending towards a technocratic style typified by top-down, expert-driven interventions that can reduce citizens to mere passive recipients of care (Hammond and Zimmerman 2012, p. 2). By contrast, it is suggested, assets-based approaches to health care are more likely to engage people and communities as co-producers and co-designers of their own wellbeing and flourishing (Pattoni 2012, p. 2). For the purposes of our study (and this chapter), we chose to focus on “resilience” for our asset-based study of mental health for several reasons. Firstly, concepts of resilience have been attracting increasing attention in positive assets-based studies of mental health. In this context, resilience can be defined as the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitation this capacity for adaptation and ‘bouncing back’ in the face of adversity. Across the life course, the experience of resilience will vary. (Windle 2011, p. 163)

Moreover, this growing interest in mental health resilience can be seen against a growing interest in themes of resilience across a range of fields. Indeed, in 2015, the number of academic papers concerned with resilience was estimated at some 30,000 in one year: a remarkable rise from practically zero articles on resilience in 1997 (Lovell et al. 2016, p. 4). Resilience also features significantly in post-2015 international development agreements including the 2015 Sendai Agreement, endorsed by the United Nationals General Assembly. Drawing on that agreement the GCRF have defined resilience for development purposes as

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about making people, communities and systems anticipate and be better prepared to withstand catastrophic events – both natural and man-made – as well as more able to absorb and bound back more quickly and emerge stronger from these shocks and stresses. (Global Challenges Research Fund 2016)

Gap in Knowledge Most of the international mental health literature on internal migrants has tended to focus on such risk factors as loneliness, low socioeconomic status, poor social resources and friendships, separation from family members, and alcohol abuse. Lu, for example, notes how many of the same stressors that affect transnational migrants also impact upon internal migrants – such as stress and feelings of isolation (Lu 2010, p. 5). For Wen et al., loneliness and perceived stress are among the most significant factors influencing negative mental health (Wen et al. 2017, p. 459). Meanwhile, Firdaus finds adult migrants who are single, widowed, divorced, or separated to be significantly more likely to suffer poor mental health (Firdaus 2017, p. 164). For Hu, separation from family, separation from familiar surroundings, low socioeconomic status, and high mobility are among the most significant stressors on internal migrants (Hu et al. 2008, p. 1718). Exploring the Indian context, a recent study of a Mumbai slum area finds the range of stressors to include having to sleep sitting up or outside one’s home and frequent exposure to rats and insects cause stress in and of themselves, they may also serve as markers of underlying structural deprivation – such as extreme housing density, living next door to a solid waste dump, or having a home built of low-quality materials that provide poor barriers against rodents. Also, there is a complex interplay among some stressors, such as income poverty, having a loan, the cost of water, and food security. The qualitative data suggest that the poor experience great stress from trying to decide which basic need (e.g., food or water) should be prioritized, in situations of limited monetary means and sometimes severe debt. (Subbaraman et al. 2014, p. 160)

Thus, as we argued above, the stressors and risk factors for mental ill-health among internal migrants are manifold and often severe. Meanwhile, empirical studies of how migrants might mediate such risks and construct resilience for positive living appears to be an untold story thus far: a lacuna which appears all the more remarkable given the aforementioned increase in prevalence of notions of “resilience” in mental health and development studies. Calls for more studies of mental health resilience among vulnerable communities include the suggestion from Davydov et al. that. For the purposes of public health interventions, resilience research should not only identify those members (countries, social groups or individuals) of a surveyed ‘at risk’ sample who demonstrate resilience, but also identify the specific characteristics of resilient groups or individuals. Failure to investigate these factors will hamper our ability to . . . promote good mental health. (Davydov et al. 2010, p. 488)

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The Pune Study With this in view our aim is to understand risk and resilience for mental health and wellbeing in internal migrants in India. According to the 2011 Census of India, more than two-thirds (69%) of India’s 1.21 billion people live in rural areas, but the country is rapidly urbanizing (Abbas and Varma 2014). Provisional 2011 census data show that India’s urban population has grown faster than its rural population for the first time since census in 2001. Thirty-one percent of India’s population is now classified as urban, up from almost 28% in 2001. In 2007–2008, the National Sample Survey measured the proportion of migrants in urban populations at 35%. Shrinking agriculture in rural areas and industrialization and increasing urbanization leads to ever-increasing internal migrants in search of livelihood for cities. Development and employment opportunities have reached saturation in many Metro cities. However, the next tier cities continue to expand and provide employment opportunity for migrants. Pune in the state of Maharashtra is an old city is now home to many knowledge-based industries which has also spilled over to increase in construction and related industry. Pune is eighth in India in terms of GDP (Mckinsey Report 2010) and its per capita income is higher by 50% than the country’s PCI (PMC Environment Status Report, 2007–2008). At the same time, urban poor make up 50% of the city’s population and there are 564 slums in Pune (2011 Census). These urban inequalities underscore the rift between the rich, burgeoning middle class, and the people from the low socioeconomic group in the city. Most of the population in these slums consists of migrants from rural areas in search of employment. We used participatory methodology embracing the principles of coproduction to use community theatre for engagement and data collection. Participatory research methods are geared towards planning and conducting the research process with those people whose life-world and meaningful actions are under study. Our approach is based on the work of Fals-Borda and Rahman (1991) on action and knowledge where they argue that participatory research is conducted directly with the immediately affected persons; where the aim is the reconstruction of their knowledge and ability in a process of understanding and empowerment of marginalized groups whose views are seldom sought, and whose voices are rarely heard for public health awareness and support. Our aim was to develop life stories using a method of biographical interviewing and interpretation popularized by Chamberlayne and Wengraff (e.g., Chamberlayne et al. 2000) where the researcher starts with a single question to elicit a person’s life story: “Tell me the story of your life” where the aim is to get the participant to talk in an unprompted way, from their earliest memories to the present. In this case such question might include “why did you decide to move to the city?” or explorations of important experiences, for example, “you said you missed your family.”

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Sketches of Three Participants from Our Study In this section we will present the narratives of three participants who have consented to take part in our study. We have modified details to conceal their identity. We will do two things: first offer a brief sketch of the participants as they have become known to us through our engagement and interviews; second re-examine these sketches to consider (1) examples of risk and resilience; and (2) how they are mitigating risk and constructing resilience for leading a purposeful life despite the socioeconomic adversities constantly challenging their mental health and wellbeing. The three sketches we have chosen to concentrate on are not presented as representative of the study population as a whole or of wider slum dwelling community. Neither are they examples of particular forms of resilience models. They are presented to explore how far even a small portion of the interview data can be interrogated to illuminate our concerns of risk and resilience in global public mental health context.

Sketch 1 Gan is a 31-year-old man staying here in the basti (slum). He came to Pune when he was 11 or 12 years old, then left for Mumbai, then to Goa, then to another town, and back again to Pune. He left his home because of his stepmother. When he was trying to get back to Pune, he did not have any money, so collected garbage on the way, selling it immediately to get some money for food. By doing so, he finally managed to get to Pune. He worked as a laborer in a construction site and used to get 25 rupees per day. Then one day he was asked if he could work as a watchman, and he did that work for 6 months. At the moment, he is working as a mason. When he was in Mumbai he spent 4 years sleeping at a Mumbai railway platform; he had to hide his money under the rails. Then an opportunity came up to work on a ship and that’s how he ended up moving to Goa. He worked in Goa for 8 months and earned 40 K rupees. After Goa, he went back to his native village and got married there. He now has a daughter and two sons from the marriage. But the marriage didn’t last very long partly because of discord with his mother-in-law. But Gan also ended up having an affair with someone from work who has now become his second wife. She is a Muslim and he is Hindu; the only support either of them have from their families is from his wife’s brother. Gan and his wife have decided not to have any more children. Gan does drink a lot; and often fights when he is drunk. If he gets upset, he also gets angry. But when he isn’t upset, he usually sits by the canal, watching the water or talking to passers-by. If something upsets him badly, Gan goes to visit the hospital where his father was admitted for cancer treatment: seeing the hospital patients and their pain and suffering helps Gan gain perspective making his own problems seem trivial by comparison. Gan regards his wife as his greatest support. It seems she would never leave him, come what may. But for Gan, she also seems like a mother to him, whose love and attention he has been craving, though this sometimes makes him feel childish.

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Whenever he earns money now, he saves half of it for the next day and spends the rest. Gan believes that by finding satisfaction in the things we have, we can achieve happiness; and then nothing can break us. He says he doesn’t have any expectations and that he is satisfied. He constantly experiences sorrow, as if old wounds are reopening and causing pain. He recollects his wife said she used to have only two sarees: one was for wearing and the other was used as a bedsheet to cover both of them. And when either of them was awake, the other slept. When there was nothing to eat they would have to beg for food; yet they never resorted to stealing.

Sketch 2 Suni is a 23-year-old woman. When she entered the basti (the slum community), she was shocked to see her room burnt in a fire. She remembers thinking then that it would have been “better if I’d stayed at my small village.” She simply hadn’t realized she would end up staying in the slum, with its tiny rooms. It took her a long time to adjust to living there. She has two children, a son and a daughter. When they first arrived, there were no proper facilities for water, sanitation, or electricity, though these facilities were eventually installed a couple of years ago. Some things still make her feel anxious and distressed, particularly for her husband and children. For one thing, she feels the slum community is not a safe place for them: the people here are not good and she would prefer them to move and live somewhere else. Suni remembers when her son was 6 months old and she was pregnant for the second time, her husband didn’t return home from work one night. She waited and waited for him the whole night but still he didn’t return (they were then staying in a different part of the city). Finding herself all alone, she decided to visit some of her relatives who took her to her parents’ home. After 11 days her husband was eventually found at a temple nearby. When Suni asked her husband what had happened, he claimed he simply didn’t remember. She thought it did seem as though someone has cast some black magic on him. Her husband still sometimes disappears for days on end and without explanation, which leaves her feeling constantly unsettled and fearful. Suni has various ways of dealing with this ongoing distress, e.g., by talking to neighbors, stitching clothes, or just sitting outside her room. She would love to travel and see different places. But it’s difficult. Suni often talks with a friend, who is also a neighbor, about the things that upset her. According to Suni, one can be happy when all is well. But her unhappiness and sorrow make life uncomfortable.

Sketch 3 Roopa and Vit have been married for 14 years. Roopa is 30 and Vit is 40 years old. They migrated from Mumbai to Pune. Because they were related to each other, neither of their families could accept their marriage and that’s the reason they ran away from their native village. They have been staying in the basti, in their own

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house, for the past 3 years. They arrived in Pune 8 years ago and have rented several different homes in the city during that time. After arriving at the basti, Vit worked on various jobs including as a stone mason. However, he wasn’t able to earn enough money from any one job to support both himself and his family. However, after some years, Roopa’s sister told them about Swachh Bharat Abhiyaan [A Government of India employment program], where, one has to carry a small cart-like box to each household or building. Because this job is a government job, it pays enough to support them both and it takes up less time than previous jobs. Both of them currently work there from 6 am to 12 noon. But Vit then works afterwards as a plumber and earns extra money that way. Consequently, they now feel their life has now become quite relaxed. Some years back, Roopa was diagnosed with a brain tumor and the doctor has told them the risks involved if they operate. She is delaying the operation because the cost would be quite huge and she might need to sell her house: “But if I sell my home, my family will again be on roads and I don’t want my family, especially my children, to be without any shelter.” Roopa also gets seizures at times. Thinking about the risks involved in her operation, Vit comments: “if she is no more, there is no question of me living. I will leave everything and I don’t know what I shall be doing. Because I don’t have anyone else.” She also has a disability in her lower body which was caused when she was pregnant with her second child. At the time she was hospitalized for 3 months. Roopa recalls that previously, whenever they used to stay anywhere, people would eventually have to ask them to leave the community because they used to quarrel with each other. Also, if Vit got drunk he used to hit Roopa. They were forced to move home several times. They worked very hard and at that time, if they were working together, they used to get 300 rupees per day. But when they didn’t find any work, they suffered a lot: they went without food on those days, just had water and tried to sleep. One thing that has helped them survive these hardships, when there was no-one else to support them, has been having each other’s support. And so, in spite of their many conflicts, they do still love each other. On one occasion, when Vit, under the influence of alcohol, failed to return home, Roopa became really frightened. She tried to phone him but couldn’t get any answer. Vit didn’t return home until the next day but wouldn’t say where he’d been. Roopa still gets frightened whenever Vits goes off like that. But she now feels more confident that he will return: usually by midnight, or by next morning at the latest. Their relatives didn’t used to speak to either of them. But now their financial outlook has improved and they have their two boys, their relatives have started speaking to them again. Roopa and Vits would like to have their own home, somewhere on the hill with two or three goats and have a complete family, with their sons getting married and everyone staying together. Vit would also like to buy a new auto rickshaw for his sons, because he feels that he doesn’t have that much financial capacity to give them higher education. But with a rickshaw, they could ride it in two shifts and both earn a living.

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Risk and Resilience These three sketches inform us about the powerful and intricate ways by which the internal migrants experience psychological distress in their lives and how they mediate these risk factors in constructing resilience for mental health and wellbeing. They illustrate how internal migrants are able to identify the stressors in their lives, and the most powerful of these is the way in which they confront poverty by taking up the job opportunities available to them – however menial it may appear to be, and then changing them for better prospects. These are jobs on daily wages and the way in which they are going about looking for work on a daily basis demonstrate their motivation and inner strength in confronting hunger and poverty at all costs as in sketch 1 when Gan says we had nothing to eat and had to beg for food. . . but never resorted to stealing. Family is a major stressor for migration to an unknown urban area in all these sketches and it is the conflict with their own immediate family members or their “mother-in-law” which has forced them to migrate from their villages in search of better family prospects. The migrants are aware of the risks posed by living in the slum environment, the lack of basic amenities for family life, and the anxiety and distress due to the insecurity of the area – not being a safe place to life with their young children. These fears are haunting them every day and yet continue to live there as it offers them a “place to live” to earn enough money to fulfil their dreams and aspirations. Alcohol intake of men, arguments, and domestic violence pose major distress for their partners in all three sketches. What we see here is that regardless of the domestic violence and quarrels as a consequence of alcohol abuse, their relationships with their wives are intact and caring. There is also forgiveness of their husbands’ behavior under the influence of alcohol. Connected with this is the issue of the “disappearance of their husbands,” i.e., the men returning home from work a day late, which is major cause of anxiety and distress for their wives. No explanation is provided by the men for their temporary (mostly overnight or few days) disappearance from home. Does it mean that men are taking a break from their families? Is this a way of managing their distress? In sketch 3, Roopa experiences seizures and disability as a result of her brain tumor. Surgery is possible but they are unable to afford the cost for this. They have the option of selling their dwelling to raise some of the funds required for the surgery, but the fear of losing their home for their children is a sacrifice that she makes to keep the family together despite her serious health risks.

Resilience Despite these sometimes seemingly insurmountable challenges, many urban migrants are nevertheless able to negotiate them. How do they do this? We will thus briefly consider the assets and resources for resilience indicated in our three sketches.

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First, as already noted, caring and intact relationships between wife and husband is clearly important in all three narratives. As Roopa (sketch 3) puts it, “One thing that has helped them survive these hardships . . . has been having each other’s support.” Secondly, we might consider Gan’s distinctive outlook on life in sketch 1. This outlook seems to help Gan pre-empt many of the life challenges he faces by managing his own expectations. Indeed, he claims “he doesn’t have any expectations and that he is satisfied.” And for Gan, managing expectations goes hand-in-hand with the belief that happiness can be achieved provided that we choose to find satisfaction in the things we already possess. If we can do that, he suggests, “nothing can break us.” Gan also re-frames his stressors, putting them in perspective by visiting a hospital to remind himself there are always others less fortunate than him. Gan (sketch1) and Suni (sketch 2) seem to find benefits from simply talking. Indeed, Suni, explains that talking with a friend or with neighbors is one of several strategies she uses to deal with problems. Something else she finds helpful is stitching. Gan, on the other hand, seems to value finding space away from other people – sometimes simply sitting “by the canal, watching the water.” Such apparently activities as stitching or sitting and watching water might easily be overlooked as too ordinary to be worth mentioning. Nevertheless, they appear to have a role in these migrant’s strategies for resilience. And it is worth noting that in western mental health care therapeutic communities have long highlighted the potential benefits of what is sometimes termed “therapeutic ordinariness” (Pearce and Haigh 2017, p. 302). Similarly, there is a growing recognition among mental health practitioners of the therapeutic benefits of such apparently “ordinary” activities as handicrafts as well as relationships with the natural world. A further resilience asset apparent in this basti is “jugaad” – a Hindi, Urdu, and Punjabi word roughly meaning “frugally improvised.” Thus, when Gan (sketch 1) was sleeping on a Mumbai railway platform, his improvised hiding place for money is an example of jugaad. But in this basti, jugaad is evident at the community level as well. Dwellings, including multistory dwellings, together with electrical supplies have often clearly been frugally and cunningly improvised. And it is not inconceivable that, although wholly practical, such examples of jugaad might also contribute to mental well-being through the satisfactions of skillful achievement and a job well done.

Conclusion The mental health resilience of internal migrants appears to have been an untold story for two reasons. Firstly, the majority of international research about the mental health of migrants has tended to focus on transnational rather than internal migration, despite the fact that internal migrants outnumber transnational migrants globally by a factor of some three to one (Skeldon 2017). Secondly, such studies tend to draw on deficit models of mental health which emphasize negative risk factors for mental ill-health, rather than the possibilities and resources for positive mental health that more asset-based enquiries – including those relating to resilience – explore.

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Possibilities and potential for mental health resilience among internal migrants internationally has thus been largely overlooked hitherto. Definitions of resilience vary, though they almost always include three features: (a) identification of risks or adversity, (b) identification of sources or resources to help offset the effects of that adversity, (c) avoiding the effects of the adversity or adapting positively to it. In our three sketches, we see examples of Truffino’s (2010) characterization of resilience as the ability to grow and develop under difficult conditions and the importance of being alert to a range of sometimes very ordinary resources for resilience, including family members and inner strength. The sketches indicate some of the stressors and mental health challenges that typically confront internal migrants and how that they are able to deploy mature coping strategies, such as problem solving rather than self-blaming. And research undertaken by indicates how precisely these kinds of strategies can help migrants significantly reduce their likelihood of experiencing mental ill-health. Optimism is another key factor for constructing resilience and Wen et al. have noted the importance of optimism for good mental health among internal migrants: they argue optimism seems to enhance a person’s hardiness and sense of coherence. Such psychological traits appear predictive of better health and life outcomes especially among individuals who have suffered extremely traumatic life hardships, including many who survived Nazi concentration camps. Optimistic people tend to see, or believe in, “light at the end of the tunnel,” and appear equipped with a greater intrapersonal capacity to rebound from crisis (Wen et al. 2017, p. 17). We might say that the characters in our three narratives each exemplify the “urge to live” via their ongoing confrontation with mental distresses and their ongoing capacity to construct resilience in the socioeconomic and cultural context of India. And while we acknowledge the important point highlighted by Martilla et al. (2013): that resilience is a relative, culturally and contextually dependent, concept (thus, resources for resilience such as self-esteem or self-efficacy may be valued quite differently in different settings). Nevertheless, and echoing Davydov, we argue that a more holistic approach to the mental health of internal migrants may now be needed: one that fully acknowledges material and risk factors but which is also alert to potential positive, assets-based factors for mediating risk including sources and resources of mental health resilience. A caveat must be raised here about resilience. In exploring resilience in these three sketches, we by no means wish to under-estimate the material or risk factors for mental ill-health. To do so would be to make precisely the same mistake that excluding resilience and positive mental health can sometimes make: namely, it would be under-dimensioned. Indeed, as a recent ODI report rightly warns us: “emphasising resilience can depoliticise by indicating that vulnerable populations confronted by stressors should largely be responsible for their own wellbeing” (Tanner et al. 2017, p. 1). Nevertheless, we suggest our three preliminary sketches here indicate the need for a more holistic approach to mental health of internal migrants. One that acknowledges material factors and other risk factors but which is also alert to the capacities of people and communities to coproduce and participate in their own good health, care,

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and well-being, and in ways that may reduce perhaps their need for top-down, expert-driven interventions. Acknowledgments This research is funded by the Medical Research Council (MRC), Arts and Humanities Research Council (AHRC), and the Global Challenges Research Fund (GCRF) UK. Grant Ref: AH/R006148/1

References Abbas R, Varma D (2014) Internal labour migration in India raises integration challenges for migrants. Migration Information Source. Retrieved from http://www.migrationpolicy.org/ article/internal-labor-migration-india-raises-integration-challenges-migrants Amin A (2006) The good city. Urban Stud 43(5–6):1009–1023 Becker CM, Glascoff MA, Felts WM (2010) Salutogenesis 30 years later: where do we go from here? Global Journal of Health Education and Promotion 13(1):25–32 Chamberlayne P, Bornat J, Wengraf T (2000) The turn to biographical methods in social science: comparative issues and examples. Routledge, London Chen X, Wang Y, Yan Y (2016) The essential resilience scale: instrument development and prediction of perceived health and behaviour. Stress and Health 32(5):533–542. https://doi.org/10.1002/smi. 2659 Davydov DM, Stewart R, Ritchie K, Chaudieu I (2010) Resilience and mental health. Clin Psychol Rev 30(5):479–495 Fals-Borda O, Rahman MA (1991) Action and knowledge: breaking the monopoly with participatory action research. The Apex Press, New York Firdaus G (2017) Mental Well-being of migrants in urban center of India: analyzing the role of social environment. Indian J Psychiatry 59(2):164–169. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_272_15 Global Challenges Research Fund (2016) Global challenges research fund: building resilience. Retrieved 11 May, 2018, from https://ahrc.ukri.org/funding/apply-for-funding/archivedopportunities/gcrf-building-resilience/ Hammond W, Zimmerman R (2012) A strengths-based perspective. A report for resiliency initiatives Hu X, Cook S, Salazar MA (2008) Internal migration and health in China. Lancet 372(9651):1717– 1719. https://doi.org/10.1016/S0140-6736(08)61360-4 Li J, Rose N (2017) Urban social exclusion and mental health of China’s rural-urban migrants - a review and call for research. Health Place 48:20–30. https://doi.org/10.1016/j.healthplace.2017. 08.009 Lovell E, Bahadur A, Tanner T, Morsi H (2016) Resilience: the big picture. Top themes and trends. Oversees Development Institute, London Lu Y (2010) Mental health and risk behaviours of rural urban migrants: longitudinal evidence from Indonesia. Popul Stud 64(2):147–163. https://doi.org/10.1080/00324721003734100 Martilla A, Johansson E, Whitehad M, Burstorm B (2013) Keep going in adversity- using a resilience perspective to understand the narrtives of long-term social assiatnace recipiants in Swden. International Journal of Equity In Health 12(8):1–12 Mckinsey Global Institute (2010) India’s urban awakening: building inclusive cities, sustaining economic growth. Mckinsey & Company Pattoni L (2012) Strengths-based approaches for working with individuals. The Institute for Research and Innovation in Social Services (IRISS), Glasgow Pearce S, Haigh R (2017) The theory and practice of democratic therapeutic community treatment. Jessica Kingsley, London

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Mental Health of Irish Travellers An East London Perspective

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges Facing the Irish Traveller Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthcare Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe Mental Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Irish Travellers are a minority group who often move from place to place. Their patterns of migration are of interest. Although they originate from Eire, there are under-reported census figures. They have very strong patriarchy and family connections which affect help-seeking and it is crucial that families are engaged in a culturally appropriate and sensitive way to deliver services which will be acceptable. There is no doubt that Irish Travellers among other nomadic groups face high levels of social discrimination which can contribute to poor acceptance and rejection which in turn affects their help-seeking. The challenges faced by them are complex and often contribute to low socioeconomic status and poverty which affects their wellbeing. Additional factors like globalization, changing employment markets, financial insecurities, and altering gender roles can add to F. Cullenbrooke City and Hackney Rehabilitation and Recovery Service, London, UK e-mail: fi[email protected] S. Gupta (*) Early Intervention of Psychosis, East London NHS Foundation Trust, London, UK City and Hackney Early Intervention Service, Donald Winnicott Centre, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_31

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further stress in these groups thereby marginalizing them further. Lack of stable and reasonable accommodation can add to stress. Keywords

Irish Travellers · Migration · Mental health · Stigma · Discrimination

Introduction Irish Travellers form a distinct group with specific mental health needs. Sometimes they are on the move whereas at other times, they settle down in one place and maintain their community with often restricted access to outsiders. Travellers are found in many countries such as the group described as Roma. They have their own networks and pathways into healthcare seeking. In this chapter, we focus on Irish Travellers and their mental health needs and the challenges in delivering services. There are recordings of them as a distinct group in Ireland from as early as the fifth Century (Common Ground Report 2006). Irish Travellers have lived in various parts of Britain since the early nineteenth century. They are often included in the wider description of gypsies and Travellers. Irish Travellers, along with Gypsy Roma Travellers, are recognized as a distinct ethnic groups under the UK Race Relations (Amendment) Act 2000.

Definitions In order to better understand their needs as a group it is useful to explore some definitions and the wider context of the United Kingdom “Gypsy Traveller.” The umbrella term “Gypsy Travellers“ is used colloquially and in the literature to include Welsh and English Romanichal or Romany Gypsies, Irish and Scottish Travellers, and in recent years European Roma (Francis 2010). There are other traveller groups outside of these including New Travellers, Fairground people, and Bargees. The Commission for Racial Equality (CRE) in the UK identifies the nomadic tradition as a key cultural common-ground between Irish Travellers and Gypsies while recognizing “these two groups differ in family size, economic activity, travelling patterns, language and certain cultural traditions” (Common Ground Report 2006). However, Irish Travellers have their own distinct cultural identity, and are ethnically and genetically similar to the mainstream Irish population and different from the Romany Gypsies. Almost all Irish Travellers follow the Roman Catholic religion and therefore place strong importance on the sacrament of marriage (Allen 2012). Their culture is marked by very close-knit families. The family unit offers exclusive social support and security within the community. Being physically close to family is so important that Irish Travellers will accept poor accommodation options to ensure close proximity rather than endure distance from kin or the prospect of living on different housing estates (All Ireland Traveller Health Survey 2010; Walker 2008). The last Census (UK Census 2011) indicates that Gypsies and Irish Travellers make up 0.1% of the English and Welsh population, and that they are widely

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dispersed geographically. It recorded 58,000 people as self-identifying as a Gypsy or Irish Traveller. It is likely that there are actually between 200,000 and 3000,000 but completion rates of census forms are thought to have been low due to poor literacy rates and a feeling of disenfranchisement and disconnectedness with society, (Marc Willers QC, Traveller Movement Conference 2019). There were only 8,196 recorded in London, which was far less the earlier estimates. It is estimated that 600–800 Irish Travellers (nearly 10%) live in the East London borough of Hackney. These figures are acknowledged as an underestimation of the size of the Gypsy Traveller community because they account only for individuals and families who were accessing or were known to those services. In addition, some of them were forced to move from Newham to Hackney during development of the Olympic site in 2012, after losing a High Court battle launched under the Human Rights Act (Guardian 2007).

Challenges Facing the Irish Traveller Communities The Irish Travellers like other nomadic groups face high levels of social discrimination. Anti-Irish feelings in the UK have been prevalent for a number of years and their migration patterns have created same kind of discrimination as faced by East Europeans in the past decade or so. Being Irish and being a Traveller thus contributes to what can be described as “double jeopardy.” Thus their social determinants of health become even more complex and challenging with poverty, overcrowding and poor educational levels. Factors related to globalization with consequent changing markets and market economies thereby influencing and altering gender roles. Gypsies and Travellers risk being pushed further into poverty, social exclusion, and “cultural shock” (Cemlyn et al. 2009), thus setting up a vicious cycle. Many are now settling down in one place of their choice and that has brought about a change in their way of life and a pressure to assimilate. There is often a lack of appropriate accommodation available to these communities; accommodation that is in keeping with their culture and traditions. Many individuals find that councils do not permit planning for Traveller sites as general principle of NIMBYism (Not in My Back Yard) as a result of stigma and discrimination which then can lead to an enforced nomadism or an enforced “settling” into what is referred to in the community as “bricks and mortar.” This discrimination therefore, directly affects dynamics within communities and a sense of belonging which often disrupts the close physical and social relationships and bonds that are embedded into these cultures. Despite many Travellers now being settled, out of force or choice, in one place, there is still a strong identity with nomadism which is extrapolated by Traveller activist Michael McDonagh (1994): When Travellers speak of travelling, we mean something different from what country people [settled people] usually understand by it. . .. Country people travel to get from A to B. But for Travellers, the physical fact of moving is just one aspect of a nomadic mind-set that permeates every aspect of our lives. Nomadism entails a way of looking at the world, a different way of perceiving things, a different attitude to accommodation, to work and to life in general.

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The Irish Traveller community has a low literacy rate (Race Disparity Audit 2017) and they are economically vulnerable (UK Census 2011) both possibly as a result of nomadism. The children often experience bullying at school due to stigma and discrimination and consequently often have poor academic achievement, have high exclusion rates, and are most likely to be eligible for free school meals (Cemlyn et al. 2009; Race Disparity Audit 2017). The rate of unemployment is also high in this community and many travellers work in the informal cash in hand economy. This can make them economically and socially vulnerable and leads to negative contact with police and locals, thereby feeding into further discrimination. There is a process of accelerated criminalization at a young age, leading to negative experience of contact with the criminal justice system and further marginalization (Cemlyn et al. 2009). With high unemployment, many of them can become reliant on statutory social security and benefits but some may struggle to access these forms of support due to lack of stable accommodation.

Healthcare Challenges Other than the socio-economic determinants and factors(?) there are significant issues around access to healthcare. The rates of physical morbidities in most Gypsy and Traveller communities are higher than the general population, and they are less likely to receive effective and continuous healthcare (Cemlyn et al. 2009). Infant and child, as well as maternal mortality rates are reported to be high (Parry et al. 2004). Many Irish Travellers can also have large households with high birthrate and early marriages leading to large families and consequently poor physical and mental health in women. Issues related to poverty and poor housing including overcrowding can contribute to chronic health conditions, infections and complex co-morbidities. In some Traveller community’s higher alcohol and other substance misuse may contribute to health and social issues (Cemlyn et al. 2009). Studies have highlighted that life expectancy in Gypsy and Traveller groups is 10 years lower than the UK average and that child mortality is 20 times higher than the rest of the population (EHRC 2009; Cemlyn et al. 2009). Access to healthcare can be affected by lack of trust from both sides. Real and perceived discrimination and racism experienced by such a marginalized group can prevent positive helpseeking, and may be compounded by negative attitudes held by health-care professionals and providers (Facione and Facione 2007; Francis 2013).

Mental Health Needs The rates of mental health problems are reported to be high as with other socially marginalized groups. Rates of depression and anxiety seems to be disproportionately high in Irish Travellers and other nomadic groups (Appleton et al. 2003). Presentation of mood and anxiety disorder can be quite culture- specific, and needs understanding by healthcare workers or may get misdiagnosed and untreated. Factors such

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as experience of bullying, violence, discrimination, negative self-image, stigma around identity and mental illnesses can all lead to increased anxiety and other common mental health disorders (Cemlyn et al. 2009). The use of alcohol and other substance abuse or over use in men can contribute to such mental disorders, and can contribute to domestic violence. Rates of suicide is reported to be high (Appleby et al. 2006). Stigma and secrecy within the community are barriers to seeking appropriate help (Parry et al. 2004; Treise and Shepherd 2006). Such studies have indicated that there is greater reliance on medication and poor uptake of talking therapies, that can contribute to poorer outcome. It is entirely possible that they are less likely to be offered talking therapies due to similar reasons to other marginalized groups such as BAME communities.

Severe Mental Illnesses There are very few studies looking at the actual rates of severe mental disorders in the Irish Traveller community. A recent service evaluation from the Hackney Early Intervention Service suggests a disproportionately high rate of referral of young male patients from this community – mostly via primary care. They often present with non-specific psychotic symptoms characterized by high levels of anxiety, agitation, low mood, insomnia, and complaints of auditory hallucinations at night that are distressing in nature. First rank symptoms, such as thought interference and passivity phenomena, tend to be less prominent. Many of the patients report previous history of physical and psychological trauma, and negative experience of contact with the Police and criminal justice system. Paranoia seems to be a feature in presentations, but it is hard to establish if this is pathological or based on past negative experiences with services. Male patients often struggle to verbally communicate with professionals and tend to rely on their female relatives and carers to facilitate this. Eye contact tends to be very poor and Irish Traveller men during appointments will often sit quietly, head bowed, wearing a hood, cap or hat. The service evaluation highlighted greater reliance on psychotropic medication and poor uptake of psychological therapies and family interventions. They are also less likely to access vocational and occupational therapies, as well as education and employment support aimed at improving social functioning and economic independence. There is high dropout rate from treatment and follow-up, along with low rates of inpatient admissions or the use of home treatment team. This unusual presentation does not quite fit more accepted psychological paradigms of psychosis, and appear to be distinctly culture-bound and specific to this community. There is palpable lack of trust in professionals with patients often refusing to interact directly with professionals. It is possible that the high dropout rates reflect a variance in explanatory models between the travellers and the healthcare professionals an area which deserves further exploration. The role of perceived and real stigma against them and their psychiatric condition and the humiliation of having mental health problems are factors that affect the way they engage with treatment. Family members have cited a reluctance to have home

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visits from mental health care professionals due to concerns that others in the community will judge them. They are also less represented in peer-support and carers’ support groups. Scambler’s definitions of “felt-stigma” and “enactedstigma,” from his work on epilepsy, are a helpful paradigm to view the complex engagement of this group with mental health services. Felt-stigma refers to a sense of shame and in-built expectation that others will discriminate against them and therefore stops help-seeking behaviour; this could explain late presentation to services. Enacted-stigma is the experience of direct discrimination from others in society (Scambler 1998). In addition, with a strong value placed on the family unit, bringing shame or dishonour is reprehensible. While Irish Traveller communities try to fulfil the needs of and manage the healthcare for dysfunctional family members, there is often a likelihood of experiencing what Walker (2008) describes as the potential for “social deaths” and exclusion of members who are seen to bring particular shame to the family and the community. There is urgent need for further exploration of these presentations, their pathways to care including explanatory models as well as actual suicide risk of this vulnerable population. Some consideration needs to be given to understanding the assignment of the “sick role” to such patients and how that labelling and allocation affects their longer-term outcome and recovery. If not handled sensitively such presentations run the risk of maintaining symptoms and prolonged reliance of disability-benefits that can further marginalize individuals and their families socially and economically. This can only be properly tackled through appropriate and culturally sensitive care. Wider social issues such as those brought about by “culture-shock” and conflict (related to stress and distress), social defeat, as well as in-group “social-death,” can contribute to both the etiology and perpetuation of such psychiatric morbidities. Conversely, the local data in Hackney, London, also shows very low rates of referrals to the Early Intervention Service for Psychosis among Irish Traveller women. This phenomenon also needs further exploration. Possible reasons for this may be that the women have more gender-specific roles and identity within the community and are less likely to come in direct conflict with wider society thereby acting as a protective factor. Their culture is marked by patriarchy and strong gender role demarcations (AITHS 2010; Allen 2012; Walker 2008). Traditionally, Irish Traveller women marry at a young age and join their husband’s extended family network. They are responsible for childcare and the home environment and rarely have paid employment outside of this. It may be that, gender role expectations also play a role thereby discouraging both men and women from seeking help-men because of their patriarchal role and women as keepers of family honour and respect. It is possible that women may have better adaptability and social resilience which needs to be explored and verified in future work. On the other hand, the possibility of poor healthcare seeking behavior influenced by such factors such as stigmatizing social factors around marriageability and ostracization within the community needs to be considered. Women’s roles as primary carers need to be explored along with what factors are successful in contributing to their social resilience. Women may care not only for large households, but also for those who are physically and mentally unwell within these

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units –thereby leading to high-levels of burden of care in the absence of wider family or community support. However, it appears anecdotally that there is often support from wider family and from within the community. Supporting women and carers is possibly crucial in any initiatives aimed at improving physical and psychological health in this group at the local level. Reports of violence within the community and interpersonal violence on the one hand and violence perpetrated against them by the wider communities may go unreported to the police due to possible lack of trust in authorities and thus remain undealt with thereby adding to chronic difficulties as well as chronic stress. Anxiety around the role of children social services interventions can also lead to avoidance of seeking help, and also potentially poorer outcome of any such interactions. A recent Salford University paper examines child protection practice in the UK Traveller and Romani communities. They write that the number of children of Irish Traveller heritage living in state care in England has increased by 400% since 2009. This is compared to an average increase of 19% across society (Allen and Riding 2018). Thus a stress diathesis model may explain higher than expected levels of common mental disorders. Insecurity of accommodation and moving from one place to another as internal migrants may further contribute to distress and poor acceptance. In recent times there has been a few initiatives focusing on improving the physical health care of this vulnerable group such as the City and Hackney-based Traveller Health Reference Group. There needs to be greater involvement from within the community in the form of advocacy and internal support. This has to be in conjunction with training of health and social care staff in sensitive trans-cultural issues.

Conclusion and Recommendations The impact of the change in way of life for the Irish Travellers possibly has a major factor in destabilizing them as with other previously nomadic communities. These factors can exacerbate existing physical health, mental health and psychosocial challenges faced by them thereby creating multiple complex comorbidities. Youngsters may lack support with education and might be subjected to bullying and discrimination in school and resulting early criminalization; all of which can contribute towards long-term common and severe mental illnesses. The psychiatric presentations of Irish Travellers in the clinics are likely to be due to manifestation of distress experienced by them. The presentations may be misleading if not put in context of this specific group’s cultural experiences and specific idioms of distress and help-seeking. The initial generations of Travellers may struggle to assimilate and integrate with wider society and fear losing their own cultural identities and heritage. There also have to deal with in-group (host) and out-group (Irish Travellers) conflict. Within the group there might be clan-based or kinship-based conflicts and ostracization of highly vulnerable individuals who may be considered to bringing the community into disrepute. With increased settlement there is likely to be greater and perhaps better degree of contact with local healthcare and social services. The absence of

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mutual trust and cultural sensitivity, can become a barrier to access and delivery of health and social care, and risks further alienation of the community. The staggering 400% increase in Irish Traveller children in state care, since 2009, could be an example of this (Allen and Riding 2018) example. This can primarily be a reflection of greater contact than actual escalation of child neglect, but if not handled with care and sensitivity it can appear punitive and becoming highly counter-productive in outcome. Social problems need to be tackled too from both sides through true partnership, development of advocacy, greater cultural awareness of service providers and confidence-building measures. Strategies to change complex issues such as the confidence and self-image of the community and perceptions due to past poor experience of engagement with services needs to committed involvement all stakeholders. If there are a number of community members then cultural mediation or cultural broker models can be used where a member of the community can act as honest broker and educate both the team and the community about their respective expectations. Another important factor is the lack of actual estimate of numbers for this group. This is partly due to people within the community fearing discrimination as well as poor sensitivity and methodology of recording such information. This then makes it difficult to understand the scale of their health needs and to create targeted strategies to support them. However, again having a culture broker may enable this barrier to be overcome especially when trust has been established. The local strategies by local authorities, starting to form in places like Hackney is a positive step forward but there is need to improve interactions with primary and secondary healthcare providers for improved outcome of mental and physical health challenges of the Irish Travellers within these communities.

References All Ireland Traveller Health Survey (2010) p 125. https://www.ucd.ie/t4cms/AITHS_ SUMMARY.pdf Allen M (2012) Domestic violence within the Irish Travelling community: the challenge for social work. Br J Soc Work 42(5):870–886 Allen D, Riding SA (2018) The fragility of professional competence: a preliminary account of child protection practice with Romani and Traveller children in England. University of Salford Institutional Repository, Wicklow County Council Appleby L et al (2006) Avoidable deaths: five year report by the national confidential inquiry into suicide and homicide by people with mental illness. University of Manchester Centre for Suicide Prevention, Manchester Appleton L et al (2003) Smails’s contribution to understanding the needs of the socially excluded: the case of Gypsy Traveller Women. Clin Psychol 24:40–46 Cemlyn C, Greenfields M, Burnett S, Matthews Z, Whitwell C (2009) Inequalities experienced by Gypsy and Traveller communities: a review. New University, Buckinghamshire. https://www. equalityhumanrights.com/sites/default/files/research_report_12inequalities_experienced_by_ gypsy_and_traveller_communities_a_review.pdf Common Ground Report (2006). https://www.lancsngfl.ac.uk/projects/ema/download/file/ commonground_report.pdf

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Equality & Human Rights Commission (2009) Gypsies and Travellers: simple solutions for living together. https://www.equalityhumanrights.com/en/gypsies-and-travellers-simple-solutions-liv ing-together Facione NC, Facione PA (2007) Perceived prejudice in health care and women’s health protective behaviour. Nurs Res 56(3):175–184 Francis G (2010) Traveller voices: FAQ on the cultural identity & health needs of Gypsy Travellers. Department of Health. http://www.gypsy-traveller.org/wp-content/uploads/2010/08/TravellerVoices.pdf Francis G (2013) Developing the cultural competence of health professionals working with Gypsy Travellers. J Psychol Issues Organ Cult 3:S1. https://doi.org/10.1002/jpoc.21074 Guardian article (2007). https://www.theguardian.com/society/2007/may/04/communities. olympics2012 Mcdonagh M (1994) Nomadism in Irish Travellers’ identity. In: McCann M, O’Siochain S, Ruane J (eds) Irish Travellers: culture and identity. Institute of Irish Studies, the Queens University, Belfast Parry G et al (2004) The health status of Gypsies and Travellers in England. University of Sheffield, Sheffield Race Disparity Audit (2017). https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/686071/Revised_RDA_report_March_2018.pdf Race Relations Amendment Act (2000). http://www.legislation.gov.uk/ukpga/2000/34/pdfs/ukpga_ 20000034_en.pdf Scambler G (1998) Stigma and disease: changing paradigms. Lancet 352:1054–1055 The Traveller Movement National Conference, Thursday 21st November 2019 – Marc Willers QC Treise C, Shepherd G (2006) Developing mental health services for Gypsy Travellers: an exploratory study. Clin Psychol Forum 163:16–19 UK Census (2011) Census analysis: what does the 2011 Census tell us about the characteristics of Gypsy or Irish travellers in England and Wales? https://www.ons.gov.uk/peoplepopulationand community/culturalidentity/ethnicity/articles/whatdoesthe2011censustellusaboutthecharacteris ticsofgypsyoririshtravellersinenglandandwales/2014-01-21 Walker MR (2008) Suicide among the Irish Traveller community 2000–2006. Wicklow County Council, p 48

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Aspects of Arab Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding and Addressing Barriers to Accessing Mental Health Care . . . . . . . . . . . . . . . . . . . Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shame and Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Labeling Distress as a Mental Health Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Power Dynamics and Expert Position of Helper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Language Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural and Religious Modes of Coping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Islamic Constructs and Faith Adapted Psychological Therapies for Arab Muslims . . . . . . . . . . . Culturally Adapted Psychological Interventions for Arabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

A large proportion of global refugees come from the Arab region due to multiple recent and ongoing conflicts. This chapter is a resource for people wishing to take a culturally informed approach to working with Arab clients, with guidance on adapting mental health care, and draws on the available literature and clinical expertise. We provide an overview of shared characteristics in Arab culture that J. Hammad (*) School of Psychology, University of East London, London, UK e-mail: [email protected] A. Hamid Research Department of Clinical, Educational and Health Psychology, University College London, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_37

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contribute to different conceptualizations, experiences, and processes relevant to the provision of mental health care for this population. We also summarize attitudes, barriers, and access to, and engagement in, help-seeking among this population, while discussing religious and cultural modes of coping. Finally, we summarize culturally/faith adapted and/or sensitive psychological interventions with this population. Keywords

Arab · Muslim · Culturally adapted therapy · Barriers to access mental health care · Culturally sensitive mental health care

Introduction Explanatory models of distress are often rooted in local cultural and/or religious beliefs, in turn influencing help-seeking behaviors (Fernando 2014; Kleinman 1980; Littlewood 1990). Understanding the cultural context and their influences when providing mental health care is likely to lead to better outcomes (Gaytandjieva and Bontcheva 2013; Fernando 2014). A number of national and international policy bodies promote the use of culturally appropriate mental health care (National Institute for Health and Clinical Excellence [NICE] 2011; World Health Organization 2013). We hope that this chapter is a useful resource for anyone wishing to take a culturally informed approach to working with Arab clients. In this chapter, we focus on Arab migrants in the West and Arab refugee people. We take a position that is informed by critical community psychology approaches that contextualize mental health problems throughout the chapter. We start by introducing some of these cultural aspects that would be helpful for mental health professionals (MHPs) to be aware of when working with this client group. Although there is large variability throughout the Arab region, we will focus on the influence of shared characteristics of Arab culture that contributes to differential conceptualizations, experiences, and processes relevant to mental health provision. We then summarize factors that contribute to attitudes, access to and engagement in mental health services, as well as help-seeking behaviors. Following this, we will discuss religious and cultural modes of coping. Finally, we summarize culturally/faith adapted and/or sensitive psychological interventions that have been used with this population, and where there are gaps we will draw on clinical experience. Guidance and suggestions for MHPs on how to adapt mental health care to improve access and engagement, on the basis of the available literature and our clinical experiences with this group, are discussed throughout this chapter. The Arab region, defined in this chapter as the collection of states making up the Arab League (see Table 1), has experienced an unprecedented number of international migrants, with an estimated 38 million migrants in 2018 (United Nations and International Organization for Migration 2019). A significant proportion of this migration is due to pull factors such as economic betterment; the Arab region hosted around 29 million migrants, in 2017, most migrating to Gulf states. The remaining

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Table 1 22 Member states of the Arab League Algeria Bahrain Comoros Djibouti Egypt Iraq Jordan Kuwait Lebanon Libya Mauritania Morocco Oman Qatar Saudi Arabia Somalia State of Palestine Sudan Syrian Arab Republic Tunisia United Arab Emirates Yemen

nine million are refugees, representing 43% of the global refugee population (United Nations High Commissioner for Refugees 2018). This comes as no surprise given the multiple past and ongoing conflicts in the region causing civil unrest, political persecution, and resulting economic instability. Recently there has been an overall increase in awareness of mental health in the Arab region (e.g., Sweileh 2018), yet there remains a need for adequate provision of mental health services, further increasing awareness and reducing stigma. For example, there were 70 psychiatrists registered in Iraq for a population of 30 million (Knaevelsrud et al. 2015) and in Syria, even before the conflict, 70 psychiatrists served some 21 million people (Gavlak 2016). Halaj and Huppert (2017) provide an overview of historical and current provision of mental health care services across the majority of the Arab region. In the West, Arabs are underrepresented in literature pertaining to the mental health of minorities. In a review of six leading American Psychological Association journals, less than 1% of all samples were from the Arab region (Arnett 2008). A recent study found that American MHPs demonstrated high levels of general multicultural knowledge and awareness yet their specific knowledge of the Arab American population was very low, with most indicating that they barely knew anything about beliefs, norms, and values of Arab Americans (Basma et al. 2020). This current gap in knowledge may pave the way for misconceptions and assumptions

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informed by dominant politicized discourses surrounding perpetual violence, Islamophobia, and, more recently, rising anti-migrant sentiment across the world.

Key Aspects of Arab Culture It is impossible within this scope to fully capture cultural aspects within a region encompassing 22 countries made up of over 400 million individuals, with a vast array of dialects, beliefs, practices, denominations, sects, political ideals and tribal, familial, national, and socioeconomic identities. Despite such complex variations, as with any group, there are commonalities and shared characteristics that unite individuals and are widely recognized as part of Arab culture. We recognize that the Arab region is not ethnically homogenous; there are Arabic speaking populations who do not identify as Arab, for example, Amazighs in North Africa (Maghreb), Phoenicians in Lebanon, and Kurds. We also recognize the diversity of the religious beliefs, practices, and denominations across the Arab region including Islam, Christianity (e.g., Coptics, Maronites), Judaism, Baha’i, Druze, Yazidism, and Zoroastrianism. In this chapter, we have decided to focus on Arab Muslims given that 93% of those from the Arab region are Muslim (Skirbekk et al. 2015), the high levels of Islamic religiosity reported across Arab countries (Lugo et al. 2013), and the strong interlinking of Islam and Arab culture across history and its place in the conceptualization and experience of mental health problems. Harb (2015) outlined a number of shared characteristics between Arabs that are recurrent in polls and ethnographic studies; religiosity, hospitality, and family. Islam’s strong influence has led to Islamic moral values becoming strongly intertwined with Arab culture, particularly justice, fairness, generosity, respect for the individual’s privacy and humility (Abu-Rida 1998). There are two important annual religious feasts for Muslims; family and community bonds are typically strengthened during these times of year. Eid al-Fitr (festival of breaking the fast) is celebrated at the end of Ramadan to mark the month of fasting; and Eid al-Adha (feast of sacrifice) is celebrated two months after and at the same time when Muslims perform the Hajj pilgrimage. Hospitality is of strong cultural importance and value in Arab societies. It is not unusual to hug and kiss strangers in same-sex greetings, ask about their family, and to offer food and drink. Gift giving is part of Arab and Islamic customs. If, in therapy, there is no choice but to decline a client’s invitation or gift as it goes against the professional policies of a service, for example, it is important to do so delicately and with care while showing appreciation for the meaning of their gesture, taking time to explain reasons that would not allow for its acceptance. Arab clients may engage in general conversation with their therapist at the beginning of a therapy session. The use of nonsignificant disclosures by the therapist may help to cultivate warmth and therapeutic bonding. In a study of displaced Syrian MHPs working with displaced Syrian clients in Turkey, MHPs found it helpful to make disclosures to reduce perceived power imbalances (Hamid et al. 2020). Beginning a therapy session with conversation about, for example, topical issues can help to externalize and normalize the experience of therapy, rather than asking about mental health

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which may exacerbate any feelings of shame and stigma. In Muslim culture, etiquette and social interaction may be prioritized over time keeping (Ezenkwele and Roodsari 2013). This is true of Arab culture also and Arab clients’ concept of time may be different to that of their care provider. Arab culture is collectivist in nature, where greater emphasis is placed on the family or community than on individual interests and needs (Hofstede 1980; Hofstede et al. 2010), and often family and social networks function to protect individuals particularly in conflict settings where there are no social security systems in place (Giacaman et al. 2007). Arab individuals’ self-construction is most prominently connected to and shaped by the family (Harb and Smith 2008), and “family” was the most highly endorsed identity category beyond all others (including self, professional, national) in Lebanese youth (Harb 2010). This conceptualization tends to encourage interdependence over independence, leading to cooperation and a group decision-making process rather than an individual decision-making process, particularly where family members are seen to be in crisis. Arab family members may want to attend the client’s therapy sessions, and it is considered culturally appropriate for parents to have very close relationships with their children, and this may sometimes be misinterpreted as ‘enmeshed’ by MHPs (Utz 2012). In the West, intercultural gaps between first-generation immigrant parents and their second-generation children may come up, as young people may have less awareness of these traditional boundaries (Utz 2012). As with any religion, people will vary widely in their beliefs, interpretations, and levels of religious observance. In this chapter, our discussions on Islamic aspects focus on what is outlined in the Qur’an and what are considered general consensus and widely accepted norms and beliefs among Muslims. In Islam, women are not expected to contribute financially to maintain the family; if a woman works, she is under no obligation to spend her income on her family, although she can if she chooses to. In contrast, men are mandated to financially support their family, and an inability to do so is likely to create a sense of vulnerability and shame in Arab Muslim male clients (e.g., Utz 2012). The importance of haya, or modesty, in Arab culture and Islam, also implies a type of sexual modesty, where individuals are taught early on to guard their chastity (Jalal et al. 2017). This may make talking about sex a sensitive topic. Questions about sexual relations aimed at unmarried clients should be asked only if necessary, and it may be helpful to incorporate a caveat before asking such as the fact that all clients would be asked this question. Where there has been sexual abuse, emphasizing the placing of responsibility on the perpetrator is key. Shame may be heightened when working with Arab clients given the notion of haya and so it is vital to stress that one does not lose one’s haya after sexual abuse and that one is not to blame (Jalal et al. 2017). Depending on the level of religious observance, some Arab Muslims may feel more comfortable with a therapist of the same gender. This may affect access and engagement in this group of clients, given that gender concordance is not always possible. One way to overcome this may be to bring in another MHP to sessions but this is resource intensive and may compromise the therapeutic relationship and confidentiality (Alqahtani and Altamimi 2016). If interpreters are necessary,

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ensuring that they are gender concordant in cases where there is gender discordance of the MHP and client may resolve this. Some clients in this group may not feel comfortable to discuss sensitive, vulnerable, and personal information with the opposite gender. In a study of forcibly displaced Syrian MHPs in Turkey providing mental health care to Syrians, Syrian MHPs working with Syrians noted that initially all MHPs tried to offer mental health care to all clients given the intense demand and reduced resources, but had to resort to gender concordant care, as clients were not engaging, particularly when talking about trauma (Hamid et al. 2020).

Understanding and Addressing Barriers to Accessing Mental Health Care The underutilization of mental health services has been found among Arab migrants in the West (Kayrouz et al. 2015a; Youssef and Deane 2006), as well as Arab refugee populations in the Middle East (e.g., United Nations Population Fund and Norwegian FAFO Institute of Applied International Studies 2009). In this section, we discuss barriers to accessing mental health care.

Surveillance Many countries within the Arab region are characterized by being a police state. Routine surveillance is common practice, particularly in conflict-affected areas. Unsurprisingly, then, those within the Arab region have been found to be suspicious and mistrusting of MHPs (Al-Krenawi and Graham 2000; Eapen and Ghubash 2004; Gearing et al. 2013). It is also common in such settings for governments to tap phone and internet connections (e.g., Tawil-Souri 2012). In an online intervention in Lebanon, Syrians were skeptical when asked to provide contact details and mentioned that they may put in fake contact information for fear of being spied on by certain agencies (Abi-Ramia et al. 2018). In such ongoing and postconflict settings, hypervigilance of the motives of those seeking personal information is a protective mechanism key to one’s survival. Such concerns should not be dismissed as paranoia because it is likely that many Arab clients and their families have had experiences of repressive regimes, where surveillance is the norm and thus understandably find it hard to trust authorities. Given that assessment and therapy for mental health problems requires highly personal and vulnerable client self-disclosure, clinicians should keep the experiences of the client in mind, take time to establish trust and a therapeutic relationship, and emphasize confidentiality and its limitations throughout. Arab migrants in the West were also found to mistrust MHPs (Aloud and Rathur 2009; Hammad et al. 2020; Kayrouz et al. 2015a; Tobin 2000; Youssef and Deane 2006), and confidentiality concerns have been reported as barriers (Hamid and Furnham 2013; Youssef and Deane 2006). This may lead to an underutilization of services (Tobin 2000) and understandable difficulties in engagement. Anti-Arab and Islamophobic political rhetoric are on the rise in the West, with consequent hate crimes against Arab Americans seen to rise by 219%, the highest since 9/11

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(Levin and Grisham 2016). Additionally, ethnic minority people (Mind 2013 cited in Arday 2018) and Muslims (Younis and Jadhav 2019) are increasingly subject to surveillance in public spaces in the West. Concerns about surveillance within the health sector have also been raised (e.g. Heath-Kelly and Strausz 2018). Muslims in the West have been disproportionately impacted by governmental counter-radicalization measures such as Prevent, including in health care settings (e.g. Younis and Jadhav 2019). Arab and Muslim people have reported fears of being negatively stereotyped and misunderstood linguistically and culturally (Erickson and Al-Timimi 2001), and such fears are likely to be enhanced as a result of these recent measures and racialized political discourses, likely impacting on access to and engagement in mental health services. Chung, Bemak, and Grabosky (2011) use the term “political countertransference” to define the negative reaction towards migrant and refugee populations amidst the array of political messages fuelling fear around terrorism. Reflection and supervision can help clinicians to be aware of conscious and unconscious emotions, biases, and assumptions that may impact on empathy and therapeutic alliance.

Confidentiality In a sample of Arabs in the United Kingdom (UK), confidentiality concerns played a more significant role in shaping attitudes towards seeking mental health care than shame-focused attitudes (Hamid and Furnham 2013). In Arab culture, the behavior of an individual is perceived to be a reflection of the family’s upholding of social values, expectations, and norms (Erickson and Al-Timimi 2001). Therefore, as well as being linked to surveillance, confidentiality concerns are compounded by the importance of protecting the family’s honor, and in particular, preserving the family’s name, as many Arab families are large and their names are well-known by many (Scull et al. 2014). Some Arab clients may prefer to see a clinician who does not come from the same community or country as them due to confidentiality concerns (e.g., Scull et al. 2014). While it is not always possible to meet client preferences for clinician, the assurance of confidentiality and privacy policies is an essential requirement when working with this group, and flexibility in provision, such as out-of-hours, home visits, and anonymous call services accessible from home where possible, may help to maintain privacy (Youssef and Deane 2006) and increase engagement (Al-Krenawi et al. 2003). Where clinicians need to write down or store information, they should inform clients of the purpose and protection of their data, while providing a space for clients to share their concerns. If confidentiality concerns are likely to be an issue, it can be helpful to revisit this more than once during the beginning phases of assessment and therapy to reinforce confidentiality.

Shame and Stigma Stigma is a major barrier to accessing mental health care reported by Muslim Arab migrants in the West (e.g., Abu-Ras 2003; Alhomaizi et al. 2017; Aloud and Rathur 2009; Hammad et al. 2020; Kayrouz et al. 2015a; Youssef and Deane 2006). Similar

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findings were found in the Arab region (e.g., Bruno et al. 2019; Gearing et al. 2013; Rayan and Jaradat 2016). British Arabs were found to have less favorable attitudes towards seeking professional psychological help than their White British counterparts (Hamid and Furnham 2013). In the United States, 70% of Arab women reported shame and 63% reported embarrassment associated with seeking help from formal services (Abu-Ras 2003). High levels of stigma may be attributed to the strong cultural prohibitions on exposing any family or personal matters to outsiders (Youssef and Deane 2006). A diagnosis of a mental health condition or receiving mental health care can affect the family’s social standing and the individual’s and their siblings’ marriage prospects (Al-Krenawi et al. 2009; Jabr et al. 2013); therefore, avoidance of mental health care may occur (Hassan et al. 2016; Jabr et al. 2013). Labeling distress as a mental health problem is likely to be considered a source of embarrassment, shame, and can lead to fear of scandal in Arab cultures (Hassan et al. 2016; Kayrouz et al. 2015b). Individuals who experience mental health problems may be labeled with the derogatory term “majnoon,” meaning “crazy” or “insane” (Hassan et al. 2016; Jalal et al. 2017; Kayrouz et al. 2015b). Ninety seven percent of Arabs in Australia associated mental health problems with being “majnoon” and that psychiatry was considered the “end of the line” (Youssef and Deane 2006). Negative attitudes may be influenced by mass media’s depictions of mental health problems as unpredictable and dangerous or linked to spiritual possession, perpetuating stigmatizing ideas (e.g., McCrae et al. 2019; Overton and Medina 2008). Mental health care is typically associated with being locked up in an asylum in the Arab region (e.g., Amri and Bemak 2013; Youssef and Deane 2006). From the ninth century, mental health care in the Arab region emphasized a humane approach consisting of psychotherapy, support, and reassurance (Mohit 2001). In the nineteenth century, asylums modeled on European approaches to psychiatry were introduced in the Arab region during periods of French and British colonialization and lacked a good standard of psychiatric care (Fernando 2014; Mohit 2001). Youssef and Deane (2006) found that a large majority of Arab Australians assumed psychiatric care and institutions in Australia would resemble those in their native countries. Strong held beliefs were found regarding psychiatric hospitals being reserved for people who are violent, ostracized by society and therefore locked up (Youssef and Deane 2006). The perception of mental illness as a threat to social order was found to be managed by segregation and physical isolation of psychiatric facilities in Egypt (Coker 2005). Offering embedded interventions to help improve mental health, where there is no labeling of mental health, may be less stigmatizing (Inter-Agency Standing Committee [IASC] 2007). The labeling of mental health services as “mental health centers” discouraged Arabs from using them because it was experienced as unapproachable and threatening (Youssef and Deane 2006). The integration of mental health services into primary care (e.g., Bruno et al. 2019; Marie et al. 2016), and delivering mental health care in nonclinical settings, such as in community centers and places of worship (British Psychological Society [BPS] 2018; Hassan et al. 2016), have been recommended as a way to address stigma and improve access to mental health care. Coproducing psychological interventions with community members and faith leaders may help to address the barriers reported. Lane and Tribe (2010) recommend the use of

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food in community engagement interventions, as it helps to create a relaxed informal atmosphere, an example could be services hosting coffee mornings.

Labeling Distress as a Mental Health Problem In Arab cultures, overt expression of strong emotions is typically considered as socially acceptable and emotional suffering is conceptualized as an inherent part of life (Hassan et al. 2016). The large majority of countries in the Arab region are or have been affected by political conflict, the Arab Spring, socio-economic issues, political instability, and unrest. The reframing and medicalization of normative distress and suffering as psychological disturbance have been heavily criticized by many (e.g., Giacaman et al. 2011; Hammad and Tribe 2020a; Summerfield 2000). Research has found that Palestinians consider trauma-related stress and feelings of depression as normative social suffering associated with the injustice and violence of the military occupation, rather than individual pathology or mental dysfunction (Giacaman et al. 2011; McNeely et al. 2014). Avoiding the labeling of distress as mental health problems is recommended for Arab clients according to Hassan et al. (2016). Instead of psychiatric labeling and psychological jargon, clinicians can use culturally familiar nontechnical or nonpathologizing language, local expressions, and idioms of distress with Arab clients to help reduce stigma and shame (Hassan et al. 2016). We recognize that some clients may find it helpful to have a diagnosis to access required support and make sense of their symptoms. It may be normalizing for them to know that others may share similar mental health related experiences. If mental health labels are to be offered, it is important that this is done in a nonstigmatizing manner where the meaning of each word and concept is explained and is done so in a way which fosters a sense of hope. When collective trauma has taken place, individuals from Arab cultures typically would interpret this in respect to specific collective meanings rather than individual experiences (Hammad and Tribe 2020b, c; Marie et al. 2016). In addition, experiences of distress consistent with psychiatric disorders are not necessarily perceived as intra-psychic conflict because the understanding of the self from an Arab-Islamic perspective differs from Western psychology’s conception of the self (Riyami et al. 2009). In Islam, there is also the concept of “ummah” – a single global community that connects Muslims and transcends linguistic or ethnic differences and national and local boundaries (Walters et al. 2019). Therefore, it is common for Muslims to be distressed by world events and share in the collective suffering, even if they have no connection to that geographical part of the world, other than shared faith (Walters et al. 2019).

Power Dynamics and Expert Position of Helper The majority of displaced people and refugees experience a lack of control and power over multiple aspects of their lives (e.g., Hassan et al. 2016). A report for the

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United Nations High Commissioner for Refugees (UNHCR) on mental health and psychosocial wellbeing for Syrians affected by armed conflict highlighted concerns regarding power dynamics in the helping relationship (Hassan et al. 2015, 2016). The report highlights how many clients may experience the expert position of the MHP as disempowering and disregarding their sense of agency (Hassan et al. 2016). The power imbalance in the helping relationship can leave clients in a subordinate position (Hassan et al. 2016). Caution is needed to ensure professionals do not create dependency on their expertise and resources (Hassan et al. 2016), and access to and engagement in therapy is likely to be affected if clinicians took a formal, expert position that drew attention to the power imbalance. A service evaluation with Arab Muslims in the UK found that barriers to accessing mental health care included formal delivery of therapy and hierarchical relationships between MHPs and service users; participants reported wanting informal delivery of therapeutic support where the MHP does not take an expert position (Hammad et al. 2020). Adopting a gentle approach and taking time to build trust, and warmth during the therapeutic encounter is recommended with Arab clients (Abi-Hashem 2014). Abi-Hashem (2014) highlights how the majority of Arabs expect the therapeutic exchange to be friendly and warm and would not respond well to formal, mechanical, business-like relationships, which may lend themselves to interrogative-type of evaluations. Some earlier studies suggest that a directive approach or interventions emphasizing a medical model is preferred by some Arabs living in the Middle East (e.g., Al-Krenawi et al. 2000, 2001). However, this may reflect the skepticism about the usefulness of mental health services (Eapen and Ghubash 2004), negative attitudes held of MHPs (Aloud and Rathur 2009), and the greater respect and trust placed in Arabic speaking medical doctors, with difficulty in discerning the varied roles of MHPs, including psychiatrists (Youssef and Deane 2006). In addition, Arabs may conceptualize somatic symptoms associated with psychological distress as medical in origin and therefore may expect medical treatment to address somatic symptoms (Hassan et al. 2016). If ailments are attributed to social stressors or the body, in these instances clients may prefer brief directive interventions with rapid results, to regain control over their lives (Hassan et al. 2016).

Language Barriers Language has been reported as a barrier to accessing mental health care for migrant and forced migrant Arab populations (Abu-Ras 2003; Gearing et al. 2013; Hammad et al. 2020; Hassan et al. 2015, 2016; Kayrouz et al. 2015a; Youssef and Deane 2006). In the Middle East, language was a barrier to accessing mental health care when health-care providers and clients were from different cultures (Gearing et al. 2013). Arabic speaking countries have their own accents and dialect of Arabic, sometimes even regional dialects within the same country. Ideally clients should be offered the choice of therapy in their native dialect, although some may prefer to work with an interpreter or clinician from a different Arabic speaking country due to

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confidentiality concerns. Collaborating with Arabic speaking colleagues or a professional interpreter familiar with mental health terminology is recommended and informal or ad hoc use of interpreters from the family/community networks should be avoided (Hassan et al. 2016). The British Psychological Society’s (BPS 2017) guide to working with interpreters provides further detail.

Mental Health Awareness Reduced awareness of mental health, measured by mental health literacy, is found to be a barrier to accessing mental health care for Arab migrants in Western countries (Aloud and Rathur 2009; Kayrouz et al. 2015a; Youssef and Deane 2006) and the Middle East (e.g., Gearing et al. 2013), including knowledge of services available and how to find them (Youssef and Deane 2006). In Western countries, this has been attributed to poor advertising and promotion of mental health care in Arabic (Youssef and Deane 2006). Religious leaders are seen as important sources of help for some Arabs in the West; religious leaders are well trusted, and Arabs were more inclined to seek advice and counseling from a respected religious leader than from MHPs (Youssef and Deane 2006). Although most clients and carers in Saudi Arabia and Bahrain described biopsychosocial causal factors of mental health problems, with only three clients describing spiritual factors as the cause, most still emphasized the need for prayers and reading the Qur’an as additional interventions (Algahtani et al. 2019). Working with faith leaders and respected community members may help to increase mental health awareness in a culturally sensitive way. For example, in the UK, some Imams have been delivering sermons (khutbahs) on mental health to their congregation during Friday prayers to help increase mental health awareness and reduce stigma.

Cultural and Religious Modes of Coping Culture and religion underpin the formation of beliefs about mental health and illness and healing methods (Fernando 2010, 2014). Religious rituals and cultural traditions can have a protective function. Traditional coping resources, such as religion, prayer (Aloud and Rathur 2009), and family and community, are often used as alternatives to formal mental health care (Aloud and Rathur 2009; United Nations Population Fund and Norwegian FAFO Institute of Applied International Studies 2009). Khan’s (2006) research found that a large number of Arab American Muslims always sought comfort in prayer and from the Qur’an. The use of Islamic rituals (e.g., praying and ablution) was found to help Arab Muslims elevate their mood and relax in areas experiencing ongoing conflict (Marie et al. 2017). Several studies with Arabs living in conflict-affected areas have found that religion is a primary strategy to cope with collective trauma and loss and is a source of resilience (e.g. Hammad and Tribe 2020c; Marie et al. 2017; Nuwayhida et al. 2011; Thabet

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et al. 2013, 2015). Meaning-making of painful experiences from a cultural and religious framework was found to help Arabs in ongoing conflict settings in the Middle East (Afana et al. 2018; Hammad and Tribe 2020b, c). Studies with Arab populations in ongoing conflict settings have found that social support is a method of coping with collective trauma and loss, and conflict related stressors (e.g., Afana et al. 2018; Hammad and Tribe 2020c; Joma’a and Thabet 2015; Khamis 2013; Shalhoub-Kevorkian 2014) and is a source of resilience (e.g., Marie et al. 2017; Thabet et al. 2013, 2015, 2016). Social support helps maintain family and community survival and wellbeing (Giacaman et al. 2007; Hammad and Tribe 2020b). Numerous studies have documented the importance of community solidarity, mobilization, and support among Arab populations affected by political conflict (e.g., Atallah 2017; Hammad and Tribe 2020c; ShalhoubKevorkian 2014), and have found that during times of acute war (e.g., Hammad and Tribe 2020c; Nuwayhida et al. 2011) and shared collective suffering (Marie et al. 2017), social support and cohesion increases. In addition, shared collective suffering and identity was found to protect against negative affect and facilitated coping (Afana et al. 2018). Cultural healing practices/collective cultural coping strategies in the Arab culture include communal gatherings over food (Abi-Hashem 2006; Zarifi 2015), oral storytelling – “hikaya” (Atallah 2017; Zarifi 2015), and traditional arts connected to cultural heritage, such as communal embroidery (Zarifi 2015) and “dabke” (traditional Middle Eastern folk dance), which are discussed in greater detail below. These traditional forms of healing have been found to be therapeutic (Hammad et al. 2020) and can be comforting and serve to strengthen community and family bonds and coping, as well preserving important cultural traditions. Particular attention is drawn to the informal collective methods used to respond to and process distress and difficulties. The processing of distress and collective trauma and loss is often not done in isolation but in a collective setting, in an informal manner focused on a concrete shared activity connected to their cultural heritage and which all can participate in. Preserving cultural healing practices can be of particular importance to Arab populations who are displaced and/or exiled and describe experiences of ethnic cleansing or erasure of their culture because it can help them to connect to and preserve their cultural heritage. Local cuisine and music are also key ways to promote wellbeing and preserve cultural heritage and identity among migrant and displaced Arabs. A therapeutic group that incorporated traditional drumming and nasheed (Islamic spiritual songs) singing was found to improve wellbeing, mental health, emotional expression, and mood for Arab Muslims in the West (Hammad et al. 2020). The IASC (2007) guidelines on mental health and psychosocial support in emergency settings, developed by the United Nations and over 200 humanitarian organizations, encourage the utilization of cultural and faithbased resources that help promote wellbeing and coping and encourage the implementation of culturally appropriate interventions. Hospitality and communal gatherings to share food is an indigenous strategy that many Arabs use to cope with the pains of war, collective trauma, and loss, taking turns to uplift each other, show solidarity and empathy, and bond together, where

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food shows love, preserves memories, and reminds people of home (Abi-Hashem 2006; Zarifi 2015). Communal gatherings over food, particularly the evening meal, are a common part of everyday life in Arab cultures where families come together to discuss, and support each other through a wide range of difficulties. If someone is distressed or in difficulty, a typical response is to invite and host the person for a meal or tea/coffee and offer support in an informal casual setting. In the context of political conflict and exile in the Middle East, the harvesting of fruit trees and the use of indigenous food produce was used as a source of empowerment and to cope with historical trauma (Atallah 2017). Arab cultural healing practices of “hikaya” (oral storytelling) are used to cope with collective trauma and loss (Atallah 2017; Zarifi 2015), as well as other emotional pains and difficulties. Oral storytelling involves people sharing tales of joys, sorrow, life, and memories of sacred places, linking the past to the future; people bear witness to each other’s stories in a supportive environment (Zarifi 2015). Elders often are the guardians of oral storytelling (Zarifi 2015). Oral storytelling among Arabs is often vital in promoting resilience in settings of ongoing political conflict, as cross-generational families share strategies of coping with political violence and oppression (Atallah 2017). Another indigenous Arab cultural healing practice, popular among some exiled Arab female communities, is the communal embroidering of motifs unique to their village/region; the embroidery occurs in a group setting, where an informal space is created to remember their homeland, share stories of exile, collective trauma and loss, and to support each other (Zarifi 2015). When the dress is first worn, drums play and singing and dancing take place (Zarifi 2015). Each dress is intimately connected to their native land and the embroidery is the signature of their native village (Sousa et al. 2014; Zarifi 2015). For disaster-affected populations, cultural healing practices have been found to improve psychosocial wellbeing (Hammad et al. 2020), whereas ignoring or marginalizing these cultural and religious healing practices can have an adverse effect, prolonging distress and causing potential harm (IASC 2007). Thinking systemically and offering systemic therapy to families, or collective interventions (e.g., therapeutic groups) that utilize cultural healing practices, are suggested ways to promote community engagement and offer culturally sensitive mental health care. In the context of civil war or intergroup issues, careful consideration is needed regarding offering group interventions and its suitability. Capacity for emotional selfregulation and social connection can be built by utilizing these rituals (Hobson et al. 2018). Most disasters cause significant disruption to family and community networks. Even where this is not the case, disaster-affected people will benefit from help with the activation and reinforcement of social support networks (IASC 2007). This can be promoted by the establishment of activity groups that share a common interest, for example, cooking groups (IASC 2007). Working with community organizations to coproduce culturally sensitive interventions, which utilize culturally linked creative arts, faith and culture based rituals, can help promote resilience, social and psychological wellbeing, and can help with processing distress and difficulties in a culturally familiar way (Hammad and Tribe 2020c). Emerging research indicates the benefits of collaboration and co-production

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of psychological interventions with clients and community organizations to improve access to, and experiences of, mental health care (e.g., Hammad et al. 2020; Nagel et al. 2009). For further detail, see the IASC (2007) guidelines on mental health and psychosocial support in emergency settings, Lane and Tribe (2010), and the BPS (2018) guidance for psychologists on working with community organizations.

Islamic Constructs and Faith Adapted Psychological Therapies for Arab Muslims Religion is a central part of MENA societies (e.g., Al-Krenawi 2005). In many African and Middle Eastern countries, less than 0.1% of the populations are nonreligious people (Koenig 2009). Numerous studies indicate that religious faith is associated with improved mental health, stress management, recovery, and wellbeing (Bonelli et al. 2012; Bonelli and Koenig 2013; Koenig 2012; Webb et al. 2011). Religion can provide a cognitive framework of meaning making to interpret difficulties, as well as providing strategies to promote resilience, positive coping (Hammad and Tribe 2020c; Peres et al. 2007), and emotional relief (Tedeschi 1999). There are two types of religious coping. Negative religious coping is when a person feels abandoned or punished by God, or they do not feel supported by their religious community, and is associated with increased psychological distress, depression, and anxiety (Ano and Vasconcelles 2005; Dein 2018; Dew et al. 2008; Koenig et al. 2001; Pargament et al. 2001). In contrast, positive religious coping (e.g., benevolent religious appraisals) is an internalized spiritual belief system that can offer hope and resilience enhancing strategies, and is associated with reduced levels of distress, depression and anxiety, and better mental health and psychological adjustment to stress (Ano and Vasconcelles 2005; Dein 2018; Koenig et al. 2001; Pargament et al. 2001). There is a rich historic legacy of Islamic psychotherapies dating as far back as the eighth century (Mohit 2001; Haque 2004), for example, Al-Balkhi, a ninth-century Muslim physician who developed a cognitive behavioral therapy model outlining strategies to promote resilience and psychological heath, including addressing issues of depression, specific-phobias, obsessive compulsive disorder, and anxiety (Awaad and Ali 2015, 2016; Badri 2013). Developments in the field of Islamic psychotherapies based on indigenous Islamic psychology/counseling are growing in the West. As discussions of Islamic psychotherapies are beyond the scope of this chapter, we refer readers to Al Karam (2018) for further detail. For the purposes of this chapter, we provide a brief overview of key Islamic concepts and aspects of Islamic psychology for consideration, and adaptations to Western therapies for religious Arab Muslim clients who would like their faith to be incorporated into therapy. It is important to be aware that while clients may identify as Muslim, clients will differ in their practice, beliefs, and attitudes, and therefore, it is paramount to ask clients about their faith, enabling conversation about how it interacts with their conceptualization, experience, and coping with distress.

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Ilm al-nafs (“knowledge of the soul or self”) is the Arabic term for psychology. Islam places a strong emphasis on self-awareness, personal introspection, and development, which is relevant to the goals of psychotherapy. An eleventh-century Islamic scholar called Al Ghazali conceptualized the Islamic model of the self/soul as described in the Qur’an (Rothman 2018). The four key components of the self are the nafs (lower self), qalb (heart), aql (cognition – rational faculty encompassing reason, logic, and acquired intellectual beliefs), and ruh (spirit; Haque 2018; Rothman 2018). Each component has its unique mechanisms and attributes, which are interconnected and collectively make the inner working of the human soul (Haque 2018; Rothman 2018). The heart is considered to encompass the psychospiritual processes which manifest in human behavior (Haque 2018). Using these specific terms with clients as outlined by historical Muslim psychologists may help provide insights and challenge perceptions that therapy is of no value and foreign (Haque and Kamil 2012). Islamic approaches to psychotherapy can aid the reframing of clients’ struggles in the context of spiritual growth (Rothman 2018). Rothman (2018) highlights how working with religion in therapy is not about projecting religious beliefs onto clients, which is both unethical and un-Islamic, but focuses on what is most congruent with the clients’ own fitra, known as inherent knowledge combined with the human soul, which is considered fundamental to human behavior (Haque 2018). All humans are believed to be born with a positive state of fitra and a pure soul (Haque 2018). According to Al Karam (2018), the purification of the soul (tasawwuf/tazkiyat al nafs) is considered Islam’s version of psychotherapy, as it is central to Islamic spirituality. Muslims may not necessarily be aware about purification of the soul; although it is part of Islamic traditions within most schools of thought, it is strongly associated with Sufi practices. The purification of the soul contains strategies to address various issues that are considered symptoms of mental health problems which differ from Western conceptualizations of mental health problems (Haque 2018). These include addiction to fame, status, wealth, arrogance, envy, cruelty, ignorance, cowardice, avarice, deceit, etc. (Haque 2018). According to Haque (2018), positive mental health from an Islamic paradigm pertains to positive behaviors and character traits. Some Muslims may attribute mental health or life problems to supernatural causes (e.g., Haque and Kamil 2012; Lim et al. 2018). Beliefs in the evil eye (al-’ayn or nazr), envy (hasad), angels, magic (sihr), jinn (nonhuman supernatural beings), and satan/devil (shaitaan) are part of Islamic beliefs; there are many references discussing this in the Qur’an (Haque 2018; Haque and Kamil 2012). Understanding such beliefs may prevent misinterpretation or misdiagnosis relating to delusions, and this may enhance Muslim clients’ trust in the mental health system (Haque and Keshavarzi 2014). Although these are religious beliefs, they feature more prevalently as an explanatory model for mental health problems in some Arab cultures compared to others. Whispering into the heart (waswaas) from the shaitaan is believed to negatively influence the individual’s thoughts and feelings (Haque 2018; Haque and Kamil 2012). The concept of waswaas and how to protect against it (e.g., recitation of prayers seeking refuge from the shaitaan) can provide a way to

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explore, understand, and manage anxiety and negative thoughts in a faith sensitive way. It can also help to externalize and challenge the validity of negative thoughts. Preventative methods to protect against negative unseen forces include reciting the last three chapters of the Qur’an and ayat al kursi (verse in the Qur’an) before sleeping and after morning prayers (Haque 2018). Ruqyah (recitation of Qur’an) is used as a treatment for people believed to be afflicted by the jinn (Haque 2018). Clients may feel reluctant to talk about these beliefs with non-Muslim clinicians. If these idioms of distress and explanatory models are adopted, traditional healers or Imams are also likely to be approached first before MHPs (Gearing et al. 2013; Riyami et al. 2009). Common held Islamic beliefs include that this world is temporal and that life primarily consists of tribulations and tests with times of enjoyment and ease (Haque and Kamil 2012). Trials and tribulations are conceptualized from an Islamic paradigm as a test of faith, purification of the soul, elevation of rank in heaven, expiation of sin, and/or a reminder to draw closer to God, which are considered to benefit the believer in the afterlife. A common held Islamic belief is that it is better to be tested and tried in this world, rather than in the afterlife, so it may not necessarily be considered as a punishment but an invitation to gain more reward that would benefit the believer in the next life. Exploration of Islamic perspectives on trials and tribulations with religious Arab Muslim clients may help to reduce psychological distress and negative religious coping. Religious constructs that inform Islamic psychological resilience include iman (faith in God), tawakkul (reliance on God), and sabr (patient perseverance), which were found to aid resilience and adaptive coping for Muslim Arabs affected by protracted political conflict and chronic adversity (e.g., Hammad and Tribe 2020c). Exploration of rituals (e.g., reading Qur’an, prayers, dhikr – remembrance of God) and strategies that support these constructs may be helpful to explore with religious Muslim clients and can be incorporated into behavioral activation. The Seerah (life story) of the Prophet Muhammad is considered a helpful pathway to model resilience (Marie et al. 2017). Malik (2018) describes her use of Qur’anic stories in systemic therapy to integrate Muslim clients’ beliefs and Islam. A primary way to enhance the effectiveness of cognitive interventions with religious clients is the integration of religious cognitions into therapy (Utz 2012). Exploration of Holy Scriptures (e.g., verses from the Qur’an and hadiths – sayings of the Prophet) relevant to the clients’ presenting issues is an example of how psychological interventions can be culturally adapted to incorporate the client’s belief system, which may help with cognitive restructuring by reframing and challenging negative thoughts, reducing distress, and promoting behavioral activation. The integration of relevant Holy Scriptures into therapy lends itself well to Eye Movement Desensitization Reprocessing (EMDR), narrative and cognitive behavioral approaches, and cognitive behavioral therapy (CBT) may be congruent with a number of aspects of Islamic beliefs and Arab culture (Amer and Jalal 2012; Hodge and Nadir 2008). The use of Qur’anic metaphors was helpful in encouraging war-affected Arab clients with trauma-related distress to challenge unhelpful thoughts and to take a different perspective (Knaevelsrud et al. 2015). Normalizing

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emotional expression using examples from Holy Scriptures was reported to aid emotional expression for disaster-affected Arab Muslim clients (Hammad et al. 2020). Several other studies have found that religious Muslim clients who received psychotherapy with a religious perspective (e.g., encouragement of prayers and reading verses of the Qur’an and hadiths) in a collaborative cognitive behavioral approach had faster recovery and better mental health outcomes (e.g., improved symptoms of depression and anxiety) compared to clients who received secular therapy (e.g., Azhar and Varma 1995; Azhar et al. 1994; Razali et al. 1998, 2002). Hook et al. (2010) similarly found spiritually/religious informed psychological interventions improved depression outcomes for Muslim clients. Mir and colleagues (Mir et al. 2013, 2015, 2019) culturally adapted a behavioral activation (BA) intervention for depression for Muslims. The intervention focused on utilizing positive religious coping as a resource for clients and integrating religious scriptures to enhance BA concepts and strategies. The study found that it improved access to mental health services and reduced depression for Muslim clients in the UK (Mir et al. 2019). We refer readers to Mir et al. (2013) for an outline of the culturally adapted BA intervention in English and Arabic. The UNHCR also incorporates religion into their psychological interventions for Arab refugee people (Quosh 2013). Ibn Seerin was a seventh century Islamic scholar well known for his pioneering contributions to dream interpretation and etiquettes based on Islamic traditions (Al-Akili 2006). Although there may be differences of opinion, a brief discussion on dreams based on Ibn Seerin’s work (Al-Akili 2006) is provided below for consideration. There is also diversity within Arab cultures regarding approaches to and sharing of dreams. According to Islamic traditions, there are three types of dreams: (1) a false dream which may come from the shaaitan; (2) a true dream considered to come from God; and (3) a meaningless everyday dream. Islamic dream etiquettes stipulate not to share bad dreams with others; therefore, clients may be reluctant to share their dreams in therapy. Generally the sharing of dreams regardless of type is not encouraged according to Islamic dream etiquettes; although good/true dreams may be shared with select trusted people. If important to the therapy to discuss dream content, for example, in trauma work, explaining the rationale behind asking and gaining informed consent to discuss this is helpful. Islamic dream interpretation differs from Western dream interpretation. Seeing the deceased in a dream is of particular significance, as it is considered to be a communication regarding the state of the deceased in the afterlife, and in addition it is believed that what the deceased says in the dream is true. Adaptations for trauma work (e.g., EMDR) will be discussed in light of the collective trauma and loss many Arab Muslims experience due to political conflict; the adaptations discussed can also be used in other therapies. The use of religious resources in therapy can be helpful for religious Muslim clients. In the case of traumatic bereavement(s), it can be helpful for the client to imagine the deceased in heaven utilizing Holy Scriptures to describe heaven; this may help them to tolerate distressing traumatic material regarding imagined or real suffering during the

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desensitization stage, as well as helping to emphasize that the deceased is no longer suffering. It is suggested to have this resource tapped in before starting trauma therapy, so that it can be used as part of the closing down of a trauma therapy session if needed. Forced disappearances in armed conflict and life in exile means some clients may not have had the chance to say goodbye to their loved ones, have no body to bury, or are unable to attend the funeral. In these instances, it can be helpful to invite the client to imagine saying goodbye to their loved one and fulfilling the burial rites to help them process their loss; EMDR can be used in this context to help support the processing of the loss, which can be helpful in complicated/ traumatic grief presentations, etc. People are able to offer prayers and sadaqah jariyah (ongoing charity) for the deceased, which is believed to directly help the deceased in their afterlife and elevate their spiritual rank. Engaging in these religious practices can help clients to find a productive and meaningful way to help the deceased and can help with the mourning process. The religious concept of shaheed refers to believers who are considered to be in heaven as they have died in certain ways. Categories of shaheed include death caused by a collapsed wall/building, drowning, childbirth, stomach ailments, and war, etc. An awareness of this concept can bring comfort to religious Arab Muslim clients. Qur’an can be played in the session to help ground clients, be tapped in as an EMDR resource/safe place, create dual awareness, or as part of a relaxation exercise; it can also be used during EMDR flash technique (e.g., Manfield 2017). Inviting clients to share verses from the Qur’an or hadith that are meaningful to them, which help them to find relief and make sense of their difficulties, are helpful ways to open up dialogue; it can also be tapped in as a resource as part of the EMDR preparation phase. Integrating relevant religious scriptures during trauma processing can be helpful if the process feels stuck. Reflecting on Allah’s (God’s) 99 names/attributes and the qualities of the prophets (e.g., compassion) can be used as a religious resource generally, or tapped in as a resource during the EMDR preparation phase, as well as a religious resource figure in attachment-focused EMDR (Parnell 2013). Abdul-Hamid and Hughes (2015) outline how religious practices associated with Sufi dhikr can be integrated into EMDR for Sufi Muslims. The EMDR “blind 2 therapist” protocol (Farrell et al. 2020) is suitable when the client does not want to disclose the content of their difficulties/trauma and/or due to feelings of shame and stigma. Narrative Exposure Therapy is also considered a culturally appropriate trauma therapy, as it involves the narration of the individuals’ life story, which is compatible with cultural traditions of oral storytelling. The examples and research outlined regarding the use of religious scriptures and resources in therapy are those used with religious Muslim clients. As we noted earlier, some Arabs do not identify as Muslim, and those who do identify as Muslim may not identify as religious or see their faith as relevant to their difficulties or their recovery. It is also important to note that practices such as Sufi dhikr are usually specific and acceptable to Sufi Muslims. In many cases, non-Sufi Muslims may not find this an acceptable approach. A careful assessment of a client’s faith and how it may or may not interlink with their presenting problems and notions of healing is key to ascertain whether an integration of religious resources would be a helpful approach.

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Culturally Adapted Psychological Interventions for Arabs Countries in the Arab region have been increasingly turning to evidence-based mental health care, with the majority of available empirical evidence originating from Europe and North America. There is a notable gap in the literature in the adaptation of interventions specific to the Arab context (Gearing et al. 2013). Several meta-analyses showed that adapting interventions to the local culture increases their effectiveness (Hall et al. 2016; Shehadeh et al. 2016) and adapted interventions show higher effect sizes than nonadapted ones (Benish et al. 2011; Griner and Smith 2006). Cultural adaptation involves the systematic modification of interventions to consider culture, context, and language while ensuring compatibility with the client’s cultural patterns, meanings, and values (Bernal et al. 2009). Researchers have argued that interventions for this population need to consider the value placed on family membership, stigma associated with mental health problems, indigenous healing, and the lack of available interventions in most Arab countries (Al-Makhamreh and Hundt 2012; Al-Makhamreh and Libal 2012). Gearing et al. (2013) outlined therapy recommendations drawn from a systematic review of 22 studies conducted in the Middle East. These included connecting with and understanding local and cultural beliefs and values and how these may influence mental health care, incorporating stigma reduction strategies, psychoeducation, and incorporation of locally accepted approaches, such as those that incorporate community discussions through a group, with a focus on specific concrete skills such as relaxation and stress management. Since then, a number of studies have culturally adapted interventions for this population (Algahtani et al. 2019; Brown et al. 2020; Burchert et al. 2019; Jalal et al. 2017; Kayrouz et al. 2016; Shehadeh et al. 2020; Spanhel et al. 2019). The majority of these studies adapted online or face to face cognitive and/or behavioral therapy with Arabs. There has been increasing interest in iCBT for Arab populations (Kayrouz et al. 2018), with suggestions that it may improve access and reduce barriers faced by Arab clients such as stigma, lack of flexibility, and lack of translated and culturally appropriate services (Gearing et al. 2013; Kayrouz et al. 2015a). In a study of the adaptation of an online intervention for Syrian refugees, many commented positively on the feature of anonymity and that they would feel less shy, afraid, embarrassed, or ashamed to use an app instead of seeing a professional (Burchert et al. 2019). Three of the studies provided detailed, comprehensive information of the adaptations made. Brown et al. (2020) used a top-down process, Bernal’s et al. (1995) framework Ecological Validity Model, to adapt an intervention for Lebanese youth, and Shehadeh et al. (2020) used a bottom-up process (Hwang 2006), outlined in Abi-Ramia et al. (2018). Jalal et al. (2017) described their adaptation of culturally adapted-CBT (Hinton et al. 2012) for Egyptians with trauma-related distress. Recommendations from this study showed that a culturally sensitive assessment should frame the intervention as addressing complaints of concern to create positive expectancy about therapy. Additionally, clinicians would benefit from learning the local psychological and somatic experiences associated with the presenting difficulty, the client’s understanding of how symptoms arise, and the local understanding of

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symptoms in terms of syndromes. When discussing therapy with clients, clinicians may ground the descriptions in terms of locally salient practices and metaphors, a term described by Jalal et al. (2017) as cultural grounding, where they used the example of using mahshi, a special local dish involving time, patience, and multiple processes as an analogy for therapy. Proverbs and culturally bound metaphors encapsulate a collective wisdom and are important in the Arab tradition and language (Barakat 1993). Clinicians can draw on metaphors and analogies and culturally grounding these where possible. Interpreters and community workers can be sought as cultural advisors in this capacity. In addition, the use of local cultural expressions for the distress that clients are experiencing is a means to normalize, an important aspect given the stigma surrounding the experience of mental health problems in this population. Asking clients to name their own distress and then using their words rather than diagnostic labels at assessment and throughout therapy can help clients to feel more at ease. Where a formal diagnosis is necessary, for example, in an assessment letter, it can help to explain the need for this to access services. An important adaptation found in a number of interventions was the addition of context and local understanding of mood problems including financial problems, stressful work conditions, and violence as prominent issues that may lead to feelings of depression (e.g., Abi-Ramia et al. 2018; Brown et al. 2020). Clinical research among conflict-affected and forcibly displaced populations would benefit from a social ecological lens (Bronfenbrenner 1977; Salo and Bray 2016), where distress stems not only from the violent and traumatic experiences endured, but also the stressful daily social and material conditions following these experiences, or following displacement (Hammad and Tribe 2020a; Miller and Rasmussen 2010, 2017; Schafer et al. 2014). Risk factors can be seen at multiple levels (individual, family, community, society) and therefore intervention can be placed at multiple levels. Using such a theoretical framework allows for more comprehensive research and intervention reflecting the reality of individuals’ experiences. Wells et al. (2018) developed an ecological model of adaptation to displacement among Syrian refugees in Jordan to help guide community-intervention to widen the scope of an individual pathology formulation. There is a dearth of research on interventions that take into account the effect of multiple daily stressors and address the broader needs of conflict-affected individuals such as torture survivors (Hamid et al. 2019). This is important given that international consensus calls for a greater emphasis on community-level interventions with a hierarchy of need prioritizing basic safety, security, and dignity prior to the provision of specialized mental health services (IASC 2007). While suffering stemming from conflict and civil unrest affects all civilians, there are gendered experiences of conflict to consider. Rape is a common weapon of war inflicted against females across the globe. Like other parts of the globe affected by political conflict and civil unrest, females are vulnerable to gender-based violence. For example, during the Arab Spring, sexual violence and gender-based violence by security forces against female protestors were heightened (e.g., Kato 2017). The use of sexual torture afflicted upon female political prisoners is also salient; male

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political prisoners are also subjected to sexual torture. In Meari’s (2015) study of female Palestinian political prisoners in Israeli prisons, she illustrates how interrogation strategies are informed by static orientalist/colonial perceptions of Arab women’s sexuality regarding dignity and honor. Interrogation strategies reported included strip and body searches, threats to disseminate photos of naked bodies, undressing of females, unveiling of veiled women, threats to rape, rape, and deprivation of feminine hygiene products (Meari 2015). Mass political imprisonment and torture in prisons is a common strategy used by governments and dominant armed groups to suppress civilian resistance, which disproportionately affects Arab males in this region (e.g., State of Palestine 2020). Contextualizing the distress of individuals is key by way of linking distress to the circumstances that are producing it. When working with Arabs with multiple social needs, it is key to validate, and where possible, address clients’ practical problems and frustrations regarding access to services and resources such as those related to housing, financial, legal, social services, medical care, language training, and employment. Guidelines on implementing culturally sensitive interventions with refugees describe taking a broader approach to not only cultural adaptation, but contextual adaptation taking into account structural barriers (Hinton and Jalal 2014). Supporting, signposting, and advocating for these where possible should be seen as a component of therapy while promoting cultural empowerment, defined as the client’s ability to connect with their own power to advocate for themselves and overcome barriers (Solomon 1976).

Case Study The following case study refers to the ‘Hand of Hope’ therapeutic group intervention and is based on the work of Hammad et al. (2020). Following a major disaster (Grenfell Tower fire) in the UK, some sections of the Arab Muslim community who had lost loved ones and were affected by trauma were reluctant to engage with the mental health services on offer, despite appearing to be in need of additional support. First, community consultation and partnership working between services were established, recognizing that local community organizations hold valuable knowledge and cultural expertise (e.g., Lane and Tribe 2010). A collaboration was established between statutory services and a local community organization, that specialized in working with the Arabic speaking community to address the psychological needs of the Arab Muslim community who were reluctant to engage with services. Second, affected community members known to not be engaging with mental health services were invited by a MHP representative from each service, to join them for an informal conversation over lunch, to establish what their needs were, and if they experienced any barriers to access mental health services. The women reported numerous barriers to accessing mental health care, including shame and stigma associated with mental health and seeking therapy, formal delivery of mental health care, MHPs taking an expert position, language barriers, confidentiality concerns, mistrust of all

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statutory services, and a lack of culturally sensitive and faith informed therapeutic support. They were asked what their needs were and they requested informal culturally appropriate support that focused on their religion. It was important to understand the barriers and their needs in order to make adaptations to the therapy offered. Third, after consultation with the community members, they coproduced a therapeutic intervention with the MHPs. The women designed the intervention and decided the topics discussed. The group decided they wanted to cook a meal together, connect with other bereaved women, and focus on their religion. Following the fire, there was large scale displacement and many people had to live in hotels for a period of time and did not have access to kitchen facilities. Their request to cook a meal together reflects Arab and Islamic customs to cook for the bereaved, which they had been unable to fulfill. Collective communal gatherings over food is a culturally appropriate strategy to deal with collective trauma and loss. The intervention focused on utilizing cultural healing practices to help promote safety and stabilization, remembrance and mourning, and reconnection in line with Herman’s (1992) trauma recovery model. The intervention also aimed to improve access to mental health services, increase mental health awareness, challenge the stigma associated with mental health and accessing support, support the women to process their trauma and loss, and strengthen social support networks. The group facilitators addressed the reported barriers by making various cultural adaptations to their approach and practice. The group facilitators set up the group to resemble a social gathering like in their native countries and hosted the group in a community center. The group was not labeled as a mental health intervention and the group facilitators used culturally familiar nontechnical language. The group facilitators did not take an expert position and spent time building trust and focused on creating a warm and inviting environment, recognizing that the engagement process will take longer. Food was used to create an informal environment. The intervention was designed to focus on cultural healing practices of communal gatherings over food and oral storytelling “hikaya”; the latter involved drawing on Qur’anic stories about coping with calamities, trauma and loss, as well as the life narratives of the women. The therapeutic intervention was delivered in an informal manner; therapy was delivered in conversation with the women during cooking and eating sessions. It was observed that by restoring cultural healing practices the women used the space to process their trauma and loss collectively in a culturally familiar nonthreatening way. Community consultation, partnership work, and coproduction of a culturally sensitive faith informed therapeutic group intervention were found to improve access to mental health care for Arab Muslim communities, who previously held negative attitudes towards therapy, and it reduced the stigma associated with mental health and accessing services. The women reported that it improved their attitude towards therapy and half of the women went on to access individual therapy and their children also accessed mental health care. The women also reported improved trust, emotional regulation, mental health awareness, stabilization, wellbeing, and the strengthening of social support networks. See Hammad et al. (2020) for further detail.

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Summary and Conclusion The aim of this chapter was to discuss key aspects of the Arab culture that may impact on mental health care, and suggest adaptations that can be made to improve access to and experience of mental health care that is culturally sensitive to the needs of Arab Muslim migrant and forced migrant populations. The large variation within and between Arab cultures, and constantly evolving norms, as with any culture, mean that universal cultural guidelines do not exist. Instead, these guidelines should be used generally and applied on an individual basis. When working with any population, ongoing reflection and learning about the culture and faith from reliable trusted sources is encouraged. We note the rising anti-Arab, antimigrant, and Islamophobic political discourses that prevail in the mass media in some countries and how this may inadvertently impact on MHPs understandings about Arab and Muslim cultures. Political countertransference (Chung et al. 2011) was discussed and the need to be mindful of unconscious and conscious biases when working with this client group. We suggest utilizing supervision to explore process issues, and cultural consultation from Arab colleagues and interpreters and community organizations that specialize in working with Arab communities to enhance cultural awareness. We also note that Arab psychology is neglected in research, and mental health care in the Arab region adopts a Western model. The emphasis on the universal application of the Western mental health model particularly in the Global South is problematic because it neglects indigenous understandings of mental health and wellbeing and the practices that support healing, wellbeing and health (Fernando 2014). For example, we note that indigenous Islamic psychology conceptualizes mental health problems and what is considered good mental health differently to Western understandings of mental health. We also draw attention to how trauma is experienced on a collective level not an individual level in Arab cultures because of meaning-making processes and how the self is constructed and embedded within the collective. Cultural and religious modes of coping for Arab Muslims emphasized the importance of social support from family and community networks, and religion, which informed help-seeking behaviors and was found to be a source of resilience. Cultural healing practices in the Arab culture emphasize that the processing of collective trauma and loss is not done in isolation but as a group, in an informal manner focused on a concrete shared activity connected to their cultural heritage and which all can participate in. We contextualized the barriers to accessing mental health care for this population, which includes: experiences of surveillance from the state, confidentiality concerns, mistrust, shame and stigma associated with mental health and accessing mental health care, lack of mental health awareness, language, labeling of normative social suffering and distress as mental health problems, hierarchical relationships between service users and healthcare providers, and the expert position of the helper. Recommendations of cultural adaptations to improve access to and experience of mental health care were discussed throughout this chapter and include: informal delivery of mental health care in nonclinical settings; taking time to build trust; using

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nontechnical culturally familiar language which avoids psychiatric labeling and psychological jargon; offering embedded interventions to help improve mental health, where there is no labeling of mental health; utilizing cultural healing practices; community consultation; and coproducing culturally sensitive psychological interventions with the community. A brief overview of Islamic psychology concepts and aspects of the Islamic faith that are relevant to mental health care were discussed. We discussed research on religious and culturally adapted therapies and suggestions on how to make faith/cultural adaptations to therapy with this client group; a case study was provided as an example of how a culturally sensitive intervention was co-produced with this population. The importance of addressing socioeconomic and political issues was also discussed. Community consultation, coproduction of psychological interventions, and partnership work between statutory services, community members/service users, and local community organizations have been recommended ways to address barriers to access mental health care and to improve the provision of culturally sensitive mental health care that meets the needs of diverse groups (e.g., BPS 2018; IASC 2007; Lane and Tribe 2010; Hammad et al. 2020). Emerging research indicates the benefits of coproduction of psychological interventions with clients and community organizations to improve access to and experiences of mental health care (e.g., Hammad et al. 2020; Nagel et al. 2009), faith informed therapeutic interventions for religious Muslim clients (e.g., Hammad et al. 2020; Hook et al. 2010; Mir et al. 2013, 2015, 2019), and providing culturally sensitive psychological interventions to ethnic minority groups (e.g., Bhui et al. 2015; Hall et al. 2016; Soto et al. 2018).

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Jeyda Hammad, Zaynab Hammad, and Rachel Tribe

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History and Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Palestinian Mental Health Under Military Occupation and Chronic Warlike Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The majority of Palestinians have lived their entire lives as refugee people in poor living conditions and protracted political conflict. The research conducted in the occupied Palestinian territories (oPt; Gaza Strip, West Bank, and East Jerusalem) has primarily focused on the impact of direct acute violence in the form of military attacks (e.g., airstrikes, shelling) and physical violence from military personnel and settlers, and typically adopts a Western biomedical model. In this chapter, a literature review of research studies on Palestinian mental health in the oPt will be provided, with a particular focus on exploring local expressions and idioms of distress, contextualized accounts of mental health, and emerging research examining different features of protracted conflict that impact on

J. Hammad (*) School of Psychology, University of East London, London, UK Z. Hammad Faculty of Life Sciences and Medicine, King’s College London, London, UK R. Tribe School of Psychology, University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London, London, UK © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_35

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civilians, such as structural violence, economic oppression, and conflict induced humiliation. The findings revealed the pervasive negative impact the military occupation, structural violence, and protracted conflict has on Palestinians’ mental health and various domains of their life. An apparently unique type of mental suffering connected to the oppressive economic and political conditions experienced was identified in the oPt. Research indicated that humiliation induced by conflict constitutes an independent traumatic event and that Palestinians who experienced persistent humiliation reported significantly worse psychological, health, political, and economic functioning, compared to those who experienced periodic exposure to political violence. Unique insights regarding how continual, systemic, and structural oppression can be potentially more psychologically detrimental than specific incidents of conflict and violence were reported. The implications and relevance of these findings to mental health and disaster relief are considered. Keywords

Refugee · Occupied Palestinian territories · Political conflict · Mental health · Oppression

Introduction History and Context The Israeli-Palestinian conflict began over 70 years ago. The state of Israel was founded in 1948, on approximately three quarters of the land that had been, up to that point, known as Palestine (Barber et al. 2014). Described as the “Nakba” (catastrophe; Afana et al. 2018), the war in 1948 led to the mass displacement of over 700,000 indigenous Palestinians who became refugees after being forced to flee their homes (United Nations Relief & Works Agency [UNRWA] & United Nations High Commissioner for Refugees 2007). Since then, the Palestinian people have experienced ongoing oppression and collective trauma and loss, as well as socioeconomic and political strife (Afana et al. 2018). In 1967, following an Arab-Israeli war, Israeli forces took control of further Palestinian land, including occupying the West Bank, East Jerusalem, and the Gaza Strip, resulting in a second Palestinian exodus, with half a million Palestinians displaced from Palestine (United Nations 1985). The Israeli military occupation of the West Bank, East Jerusalem, and the Gaza Strip (referred to as the occupied Palestinian territories [oPt]) has been ongoing for more than 50 years (Amnesty International 2018). The military occupation impedes on basic human rights of Palestinians (United Nations Office for the Coordination of Humanitarian Affairs [OCHA] oPt 2015), and involves Israeli control over the land, access to resources, employment, and the free movement of people (Amnesty International 2018; Amnesty International UK et al. 2010).

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The Gaza Strip is a 25-mile-long coastal enclave and has a population of approximately 1.9 million people of which 1.4 million are registered refugee1 people; approximately 73% of the Palestinians in the Gaza Strip are refugee people (UNRWA n.d.b). Since 2007, the Gaza Strip has been under an illegal Israeli military blockade (by sea, air, and land) contrary to international law (Amnesty International 2018). With only rare exceptions permitted, Palestinians are refused the freedom of movement to work, travel, study, or make visits outside of the Gaza Strip (B’Tselem 2017; Gisha 2018; United Nations 2015). The United Nations predict that Gaza will become uninhabitable by 2020 due to rapidly deteriorating living conditions (United Nations Country Team in the oPt 2012). Gaza receives two to four hours of electricity usage per day, on average (Amnesty International 2018), and lacks essential infrastructure (e.g., water and sanitation systems) (United Nations Country Team in the oPt 2012; United Nations Development Fund 2017; UNRWA 2018). Under the blockade, severe restrictions are imposed on the movement of people and goods entering and exiting the Gaza Strip, and its inhabitants are struggling to survive in these conditions (United Nations Office for the Coordination of Humanitarian Affairs [OCHA] oPt 2010). This has led to severe poverty and food insecurity (Amnesty International 2016; OCHA oPt 2020; UNRWA 2018) and high levels of unemployment throughout the Gaza Strip (Amnesty International 2016; UNRWA 2018). Findings of situationally induced malnourishment were reported in the Gaza Strip (Gilbert 2014). Between 2007 and 2014, the Gaza Strip experienced four wars: in 2007 there was a civil war between two Palestinian political factions; there were three wars between Israeli military forces and Gazan forces, in 2008/2009, 2012, and 2014 (lasting 22 days, 6 days, and 51 days, respectively) (Barber et al. 2014). These four wars resulted in the deaths of more than 3500 Gazans and up to 100 Israelis (Barber et al. 2014). There are over 800,000 refugee people currently registered as living in the West Bank (UNRWA n.d.c). The conditions faced by Palestinians in the West Bank are similar (i.e., poor living conditions, poverty, unemployment) though not to the same severity as in Gaza. A barrier in and around the West Bank constructed by the Government of Israel has led to further fragmentation of the oPt (OCHA oPt n.d.a). The barrier impedes on access to resources and services, disrupting livelihoods and social and family life (OCHA oPt n.d.a.). A complex system of control comprising of bureaucratic barriers (e.g., closure of areas, permits) and physical barriers (e.g., military checkpoints, roadblocks, and the barrier wall) impede on the right to freedom of movement for Palestinians in the West Bank (OCHA oPt n.d.b). Palestinians in the West Bank also experience expanding Israeli settlements, home demolitions, forced evictions, raids and violence from settlers and Israeli military

The United Nations, define Palestine refugees as “persons whose normal place of residence was Palestine during the period 1 June 1946 to 15 May 1948, and who lost both home and means of livelihood as a result of the 1948 conflict” (UNRWA n.d.a). Descendants of Palestine refugee males, including adopted children are included in this definition by the United Nations (UNRWA n.d.a).

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(Amnesty International 2018). Ongoing safety concerns, displacement, and political imprisonment are common experiences for Palestinians living in the oPt (e.g., Amnesty International 2018). Since the Israeli occupation of Palestine in 1967, approximately 20% of the total Palestinian population and 40% of the male Palestinian population in the oPt have been incarcerated in Israeli prisons (State of Palestine 2020), and thousands are unlawfully detained without charge or trial (Amnesty International 2018). Torture and other ill-treatment of detainees, including children, is common (Amnesty International 2018).

Methodology The authors conducted a review of the peer-reviewed and gray literature, with an aim to determine and assess the current research knowledge on the impact of protracted conflict, war, military occupation, and exile on Palestinians’ mental health in the oPt. The PubMed and PsycINFO databases were used to survey the peer-reviewed literature, which also included that which had been gathered as part of the first author’s doctoral research. The inclusion criteria (search terms) used in the literature searches were: (mental health) OR (wellbeing) AND (“Palestine” OR “occupied Palestinian territories” OR “Palestinian” OR “Gaza” OR “Gaza Strip” OR “East Jerusalem” OR “West Bank”). Studies were filtered for relevance to mental health in the oPt by article title and abstract, and then full article. Articles were excluded if they were unrelated to mental health, adults, and Palestinians living in the oPt, due to differing challenges and contexts. Analysis of the included studies involved considering the key findings, aims, data collection, sample, methodology, and limitations.

Findings Palestinian Mental Health Under Military Occupation and Chronic Warlike Conditions Research has documented various forms of suffering and issues stemming from the occupation, including the deep mourning and psychological pain of life in exile, forced migration and the Nakba, displacement, feeling dehumanized, loss of childhood, poverty, and transgenerational trauma (Alzaroo 2005; Nguyen-Gillham et al. 2008; Serhan and Tabari 2005). Giacaman (2019) highlights how the past – the Nakba – informs the future for Palestinians because it is imprinted on their collective consciousness. The threat and fear of expulsions, eviction, dispersion, and dispossession prevails in everyday life, due to the Nakba in 1948 and also the 1967 Arab-Israeli war, which led to some Palestinians becoming refugees twice (Giacaman 2019). Several studies have documented the high levels of fear and concerns about human insecurity. In a study of 1008 representative Palestinians from the West Bank and the Gaza Strip, Mataria et al. (2009) found high levels of fear, with the

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large majority of Palestinians fearing for their family’s safety in daily life, and the majority of people worrying about their future and the future of their family, and worrying about threats to family and personal safety. The study found that, at the time, close to one in two Palestinians lived with worry, grief, distress, and anxiety, and more than one in three were fed up with life. Other studies have found that fear for the safety of one’s family and fears of attack pervaded Palestinians’ experiences (McNeely et al. 2014). Home invasions, surveillance, and actual or threatened destruction of one’s home was found to create fear, grief, humiliation, anxiety, and helplessness, particularly among mothers who struggled to protect their children, according to Sousa et al. (2014). The lack of safety, protection, and stability appears to contribute to human suffering because the environment is insecure and unpredictable, and people have to contend with constant threats to their property and their own and their family’s survival. Kira et al. (2014) found collective identity trauma (oppression) was the highest trauma type occurrence among Palestinian adolescents from the West Bank. Oppression directly predicted collective annihilation anxiety and was significantly associated with psychological distress (Kira et al. 2014). Abu-Rmeileh et al. (2012) conducted a large-scale study in Gaza six months after the end of the 2008/2009 war, and reported findings of distress, insecurities, and threats. The study method involved use of a cross-sectional survey and the World Health Organization (WHO) quality of life (QoL) instrument, and used random and cluster sampling of one adult from each household – 3017 households were included in total. The findings revealed high levels of suffering and human insecurity: 88% of participants reported that suffering is a routine aspect of their life. The ongoing blockade was highlighted as the main cause of suffering (93%), along with the recent war (87%), and violence between Palestinian political factions (83%). Moderate to high levels of human insecurity (87%) and individual stress (49%) were also reported. Significant associations were found between a low health related QoL and factors related to war, namely distress, suffering, and human insecurity. A lack of basic and essential needs was reported by over 50% of participants and includes clean water and an uninterrupted supply of electricity. The majority of participants (74%) reported that their most essential need was that of employment and livelihood. This study highlighted the high prevalence of distress, human insecurity, and suffering faced by the civilians in Gaza, and the lack of basic and essential needs brought about by the war and occupation. Research studies in the oPt have found that the issues in meeting basic and crucial needs stemming from the occupation create distress. During the second intifada2 period, Giacaman et al. (2004) investigated the impact of the Israeli army invading five Palestinian towns in the West Bank in 2002. Two-stage cluster sampling was used to collect data, first strata and then stratified random sampling of houses were conducted; a total of 761 household surveys were conducted. The study found that psychological distress was directly related to the degree of destruction and the

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Intifada in Arabic refers to uprisings against oppression.

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interruptions in medical and food provisions. In a later study, Giacaman et al. (2007a) conducted a qualitative study using group interviews with 150 Palestinians living in the Gaza Strip and the West Bank to explore QoL. The data was collected in 2004, prior to Gaza’s blockade. The Israeli military occupation and its measures (closures, blockade, checkpoints, and the separation wall), and the instability and insecurity associated with this, were unanimously identified as constraining a variety of basic freedoms which negatively influenced QoL and mental health (e.g., continuing feelings of fear) and led to a loss of dignity. The study found that the political constraints on daily life led to Palestinians experiencing feelings of “incapacitation” and “imprisonment.” Other studies focused on restrictions on movement due to Israeli securitization have found the detrimental impact it has on wellbeing. Giacaman and Johnson (2013) found that mothers and wives of Palestinian political prisoners saw a continuum between prison and Palestinian life outside of prison as reflected by Israeli securitization and geographical incarceration; visiting prisons in Israel from the West Bank was reported as an ordeal that pervaded and structured their daily life. Their study also found that women describe a triple captivity – of the Israeli colonial system, the Israeli prison, and the post-Oslo Palestinian political landscape with its isolating effects in their own communities. McNeely et al. (2018) found that Palestinians in the oPt being barred from travel for medical care was associated with poor health as long as 25 years later. Nagamey et al. (2018) explored the psychological experience of Palestinians who daily cross an Israeli checkpoint controlled by soldiers to reach their schools or places of employment. The study found deep feelings of distress and desperation which included humiliation, dehumanization, nonexistence, and helplessness. Participants drew parallels between their relationships with the soldiers and the relationships between detainee and jailer, describing the crossing of checkpoints as a “prison” and “cage,” thus conveying experiences of entrapment. Similarly, civilians living under military blockade in the Gaza Strip reported feeling like they are living in a “big prison” and feel trapped and incarcerated (Hammad and Tribe 2020a; Joma’a and Thabet 2015; Thabet and Thabet 2015). The average QoL of Palestinians is among the lowest of any population in the world according to the WHO environmental, physical, and psychological domains (Abu-Rmeileh et al. 2012; Mataria et al. 2009; Ziadni et al. 2011). The low QoL in the oPt has been attributed to the chronic and entrenched conflict spanning several generations (Mataria et al. 2009). Later studies have confirmed that conflict-related trauma predicts psychological distress. Khamis (2013) investigated the impact of intifada-related trauma among 624 Palestinians, and found that political stress predicted psychological distress. Traumatic experiences relating to war and political violence have repeatedly been found to adversely affect mental health in the short term and long term (Thabet and Vostanis 2011). Giacaman et al. (2011) describe an ease–disease continuum on which social suffering is placed and which ranges from mental wellbeing to mental disease. This approach links mental health with indicators of QoL and social wellbeing. According to Giacaman et al. (2011) the majority of Palestinians are thought to

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oscillate in the gray areas between ease and disease, on account of the chronic warlike conditions and the trauma and suffering they have sustained. Local expressions and idioms express a holistic state of health, including both physical and mental aspects, and convey the nuances related to various disease states. These expressions include: low energy (habet); wilted (dablan); not able (mish qader); broken or achy (mkasswar); not happy (mish mabsut); sick (marid); tired (ta’ban); down (kayes); ill (ayyan); and no energy to complete daily activities (ma fish mrueh) (Giacaman et al. 2011). Afana et al. (2010) found that many idioms of distress used by Gazans were related to their social context: qalaq described being anxious or apprehensive of the future/unknown; assabiah referred to feelings of anxiety, nervousness, or jitteriness; azma nafsiah describes a psychological crisis due to the ongoing daily stressors encountered; dagt nafsi refers to psychological pressure related to repetitive and cumulative daily stressors which are overwhelming and hinder daily activities; araq refers to interruptions in or inability to sleep, and is also used to describe thinking about an unknown and insecure future; sarih al fikr is used to mean absent-minded, where there is no psychological comfort; and kaufa is related to many physical symptoms including fever, general fatigue, and headache. In a follow-up study with Palestinians in the Gaza Strip, Afana et al. (2018) found further expressions and idioms of distress: fear (khoufa); irritability (arak nafsi); sadness (hazeen); and psychological persecution (idehad nafsi). In the context of economic oppression, the following idioms were newly identified: “akser ine” (humiliation) describes the self/soul as humiliated and psychologically broken by the humiliation; and “sallam awraqoh” (the individual gave up their cards) refers to a surrendered position and absence of power due to their lack of money (Hammad and Tribe 2020a). The use of economic oppression is a common feature of political conflict, yet there is little research examining the impact of economic oppression, politically induced poverty and restricted employability opportunities, and structural violence in this context (Hammad and Tribe 2020a). Barber’s (2013) review of the literature on political conflict highlighted how disruptions in access to key resources can create more difficulty than exposure to violence. Disruptions were found to occur in various domains, such as the economic domain (e.g., food insecurity, hunger, reduced economic self-sufficiency, reduced diet, collapse of basic services, house demolitions, electricity cuts, imprisonment, access to healthcare) and the social domain (e.g., displacement, separation, loss of life, loss of social support, reduced social networks). Prior to the blockade, Thabet and Abuteya (2005) found that for young Palestinians in Gazan refugee camps, life was arduous and unbearable due to the difficult living conditions, poverty, unemployment, and their complete reliance on donations from the United Nations. The psychological impact included trauma, stress, anxiety, and tension. The uncertainty of what their future would be like created stress. Overcrowded living conditions elevated stress and anxiety. Many young people reported emotional pain, helplessness, and stress due to watching and/or directly experiencing violent events. The study’s findings also indicated that

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young people were leaving school and working due to poverty; therefore the pursuit of higher education was also impeded by poverty. Thabet and Abuteya’s (2005) findings highlight the importance of understanding the psychological impact of poor living conditions, poverty, and unemployment stemming from the conflict and occupation, and the impact of the occupation on different aspects of people’s lives. A qualitative study conducted with professional Palestinian university graduates living under military blockade in the Gaza Strip found that they were trapped in inescapable politically imposed poverty, and were denied the opportunities to work their way out of poverty and raise their standard of living (Hammad and Tribe 2020a). Economic oppression and structural violence were found to create multiple losses, human insecurity, psychological, social, and existential suffering, injuries to dignity, experiences of humiliation and debasement, poor wellbeing, and resulted in life experienced as though it were “on hold.” Poverty and political oppression intersected and were found to have a detrimental impact on multiple domains of life and impeded on autonomy, independence, and ability to exercise choice and control over their lives. Poverty was found to impede on their current and future plans, such as their career, development, and being able to get married and establish a family and independent household. Participants linked their distress and psychological wellbeing to the economic and political domains. Findings in Hammad and Tribe (2020a) contributed to unique understandings of how systemic, structural, and ongoing oppression may be more psychologically detrimental than individual events of conflict and violence. These findings challenge the conventional notion that violence relates only to the direct use of physical force or damage (Bulhan 1985). Oppression in conflict settings often utilizes economic, systematic, ethnic, social, and structural oppression as part of the strategy of violence, and rarely comprises of physical force or physical damage alone (Bulhan 1985). Despite the paucity of research specifically investigating the impact of high unemployment and poverty in the Gaza Strip, there are a number of studies in the oPt which have described an association between low income and lower QoL, poorer mental health, and greater stress and distress (Bseiso and Thabet 2017; Khamis 2008, 2013; Mataria et al. 2009; Thabet and Thabet 2015). A study conducted in the oPt showed that Palestinians with the fewest resources were more likely to be distressed and insecure, with suffering linked to greater insecurity (Ziadni et al. 2011). Deprivation of material and psychosocial resources in the oPt was linked with greater levels of distress (Hobfoll et al. 2011). The World Bank (2011) found that for Palestinians in the oPt, poverty is conceptualized as resulting from unemployment and an absence of productive work due to the Israeli occupation. For Gazans, poverty is associated with humiliation, desperation, indignity, and frustration (Hamad and Pavanello 2012). In the West Bank, Kira et al. (2014) found that poverty intersected with political oppression and had significant negative effects on mental and physical health. In more recent years research has begun to increasingly expand its focus beyond incidents of direct acute political violence to consider other issues stemming from the occupation that impact on civilians. Barber et al. (2014) carried out a qualitative

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study in the oPt (Gaza, West Bank, and East Jerusalem) with 68 Palestinian adults to investigate human functioning in conditions of chronic adversity. The study found that the political conditions governed and negatively impacted various aspects of people’s lives including education, family, identity, employment, economic conditions, and psychological wellbeing. The study found that life under occupation was marked by violations of justice and equality, economic dependence, perceived intent of Israel to divide Palestinians (identity control, displacement), territorial fragmentation, property control (demolitions, land and home confiscations), building restrictions (fines, taxes, etc.), movement restrictions (border controls, checkpoints, separation wall, travel bans, spontaneous closure, etc.), specific actions of Israeli security or security forces (e.g., bombings, arrests, detentions, special forces operations, imprisonment, incursions), and resistance/political activism to the occupation (Barber et al. 2014). These findings were supported by other research studies (e.g. McNeely et al. 2014). Barber et al.’s (2014) findings revealed that it was rare to find references to mental health that did not also cite the political context. The study also found that participants experienced psychological tension and stress from life under occupation – they felt trapped and controlled by the occupation. The participants had continuous concerns for their safety and lived in fear of being arrested, or made subject to shelling, shootings, and raids. The study revealed a marked absence of safety, stability, and security, with some participants describing feeling defenseless. Some of the Gazan participants reported a lack of fulfillment and described themselves as “not living like humans” due to the violations of their dignities. Following on from Barber et al.’s (2014) study, some of the same authors carried out a second study with a larger sample size (McNeely et al. 2014). In their research, conducted in the West Bank, Gaza, and East Jerusalem, they surveyed a representative sample of 508 Palestinians aged between 30 and 40. The study found that a lack of resources (inadequacy of food, housing, household amenities, clothing, transportation, recreation) and human insecurity (fears regarding safety for one’s self, family, and home) were associated with feelings of depression, trauma-related stress, and low functioning due to poor health. Human insecurity was a strong predictor of suffering, both emotional and physical, and along with resource inadequacy was also associated with unemployment or underemployment. Direct exposure to political violence (hearing/feeling the effects of a bomb, verbal/physical abuse, witnessing the humiliation of a person close to them) was only associated with trauma-related stress. These findings lend support to the growing notion that human insecurity and long-term economic restrictions jeopardize the wellbeing of those living in the oPt, maybe more so than even direct exposure to violence. Similar findings were reported by Hammad and Tribe (2020a) in their study examining the impact of economic oppression and structural violence on civilian mental health in the Gaza Strip. Findings from recent research by Barber et al. (2014, 2016a, b) and Hammad and Tribe (2020a) have highlighted that Palestinians in the oPt display an apparently unique type of mental suffering which is linked to the oppressive political and economic conditions: emotional and psychological exhaustion; a feeling that one’s

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life, morale, spirit, and/or future was broken or destroyed; feeling tired, crushed, and shaken up. Barber et al. (2014, 2016a, b) found that suffering in these aspects was found to be distinct from depressive feelings and trauma-related stress and was more commonly experienced. Depressive feelings and trauma-related stress were also found. Humiliation is pervasive in conflict settings, and is typically experienced on a collective and individual level (Giacaman et al. 2007c). However, there is a lack of research exploring the impact of humiliation induced in the context of political conflict on mental health and wellbeing (Barber et al. 2016c; Giacaman et al. 2007c; Hammad and Tribe 2020a). Giacaman et al. (2007c) notes that humiliation in the context of political conflict is usually utilized as a tactic by dominant groups over subordinate groups, or groups with equal power, but is rarely exercised by subordinate groups. A qualitative study with 3415 Palestinian youth in the West Bank found that humiliation induced by political conflict was an independent traumatic event associated with poorer psychological health outcomes (Giacaman et al. 2007c). Humiliation was defined by participants as feelings of debasement and injustice in relation to experiences to which they were exposed directly or which they witnessed being inflicted on others (Giacaman et al. 2007c). A study examining the link between a 25-year-long exposure to political violence and adult functioning, including exploring the impact of persistent humiliation, was conducted in the Gaza Strip, East Jerusalem, and the West Bank (Barber et al. 2016c). While most research aggregates exposure to political violence across time and type of exposure, this study pioneered the event history calendar which assessed exposure to five types of political violence in the oPt annually between 1987 and 2011, in a representative sample of 1788 adults with a mean age of 37. As one might expect, during the periods of elevated political conflict (and more so for the first intifada [1987–1993] than the second intifada [2000–2005]), the exposure to many types of violence was increased. These included home raids, being shot at, being verbally abused, being hit or kicked, and witnessing the humiliation of a close person. High and constant exposure to humiliation (of a close person and/or being verbally abused) over the whole 25-year period was reported by 12% of the participants. These men and women predominantly lived in areas with a large Israeli military presence. In comparison to periodic intermittent exposure to political violence, those who experience persistent humiliation report significantly worse psychological, health, political, and economic functioning. Barber et al. (2016c) concluded that constant humiliation is an overlooked form of political violence, and is best described as an acute, direct (versus structural), macro, and high-grade stressor. The authors note that the injury caused by this stressor is due to the infringement of collective and individual rights, identity, dignity, and justice. Hammad and Tribe’s (2020a) study noted that humiliation induced in the context of political conflict can take many other forms, including economic oppression and structural violence. Their study illustrated that humiliation was embedded within political systems that obstructed civilians from meeting their needs; these systems create poverty which the average person finds it difficult to escape from; this poverty creates humiliation, injury to dignity, and shame. Giacaman and Johnson’s (2013)

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study revealed that relatives must accept humiliation to be able to see prisoners. Mothers and wives of Palestinian political prisoners describe the use of humiliation during their encounters with Israeli colonial powers at the prison and checkpoints, which manifested in strip searches, insults, denial, and long bus journeys where no stops are permitted and no toilets are on board (Giacaman and Johnson 2013). Humiliation and debasement are often used as strategies during interrogation and torture (Punamäki 1988). In Meari’s (2015) study on female Palestinian political prisoners in Israeli prisons, she reports on the use of fixed orientalist/colonialist perceptions of Palestinian sexuality regarding concepts of women’s dignity and honor, which are employed as part of strategies used during interrogation. Political imprisonment and the use of torture against Palestinians in Israeli prisons is a common strategy used to endeavor to subvert resistance to colonialism and oppression (Meari 2015). However, there is a lack of research exploring the impact of political imprisonment and torture. El-Sarraj, from the Gaza Community Mental Health Programme, and colleagues found that former Palestinian political prisoners suffered with greater traumatic stress; economic difficulties, health problems during imprisonment, duration of imprisonment and harassment during arrest and after release predicted intrusive re-experiencing of trauma (El-Sarraj et al. 1996). As expected, former prisoners suffered with greater psychological distress, and worse mental and physical health compared to non-prisoners (Punamäki et al. 2008). Similarly, McNeely et al. (2015) found that men who were imprisoned during the Oslo Accords (1994–1999) reported greater trauma-related stress compared to men who have never been imprisoned. Men imprisoned since 2006 reported lower functioning in various domains including human insecurity, freedom of public expression, feeling broken or destroyed, perceived government stability, and physical limitations. The majority of the studies mentioned benefit from large sample sizes and the use of representative and random sampling. Criticisms have been made regarding the lack of qualitative mental health studies, the absence of Palestinian specific measures, and how some quantitative studies self-design questionnaires (Marie et al. 2016). Marie et al. (2016) highlight how there is a need for more qualitative studies. Further qualitative research on the impact of structural violence, economic oppression, political imprisonment, torture, and humiliation induced by conflict is needed. Emerging research indicates that humiliation is an important area worthy of further investigation due to the pervasive nature and employment of humiliation as a tactic of war (e.g. Barber et al. 2016c; Giacaman et al. 2007c; Hammad and Tribe 2020a).

Conclusion and Implications This chapter aimed to provide a contextualized account of mental health, exploring local expressions and idioms of distress, and different features of protracted political conflict that impact on Palestinian civilians in the oPt, which are often neglected in research studies, such as structural violence, economic oppression, and conflict induced humiliation. This literature review sheds light on the psychological

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experience of Palestinians’ living under Israeli military occupation and chronic warlike conditions, revealing the pervasive negative impact the military occupation, protracted conflict, and structural violence has on Palestinians’ mental health and multiple domains of their life. An apparently unique type of mental suffering connected to the oppressive economic and political conditions experienced was identified in the oPt (Barber et al. 2014, 2016a, b; Hammad and Tribe 2020a). Research indicated that humiliation induced by political conflict constitutes an independent traumatic event (Giacaman et al. 2007c) and that Palestinians who experienced persistent humiliation reported significantly worse psychological, health, political, and economic functioning, compared to those who experienced periodic exposure to political violence (Barber et al. 2016c). Unique insights regarding how continual, systemic, and structural oppression can be potentially more psychologically detrimental than specific incidents of conflict and violence were reported (e.g. Hammad and Tribe 2020a; McNeely et al. 2014). The findings discussed in this chapter reinforce the need to move beyond the utilization of the post-traumatic stress disorder (PTSD) model for Palestinians in the oPt (Giacaman et al. 2007a, 2011; Tawil 2013; Ziadni et al. 2011). Marie et al. (2016) highlights how the focus on PTSD neglects the sociopolitical cultural context by situating it as an individual problem, and does not take into account that trauma in the Palestinian culture is interpreted based on collective meaning, as opposed to individual traumas (Hammad and Tribe 2020b, c). The ongoing stress and psychological and social suffering stemming from the Israeli military occupation, the protracted conflict and colonialism calls into question the de-politicization and medicalization of Palestinian distress (Giacaman et al. 2007a, 2011; Hammad and Tribe 2020a; Tawil 2013; Ziadni et al. 2011). There is a need for mental health in the oPt to be understood contextually. This means an emphasis on the value of freedom, security, political stability, human rights, social justice, self-determination, and relief from poverty as the fundamental basis of wellbeing (Kagan et al. 2011; Martín-Baró 1994; Nelson and Prilleltensky 2010). The findings discussed in this chapter reinforce the need to utilize a mental health model embedded within a social justice human rights framework, which identifies and addresses the root causes of Palestinian distress (Giacaman et al. 2007a, 2011; Hammad and Tribe 2020a; Tawil 2013; Ziadni et al. 2011). The advancement of human rights is directly linked to the advancement of mental health (Inter-Agency Standing Committee 2007).

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Part III Special Categories

Migration and Psychosis

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Contents Introduction and Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Explanation for Increased Psychosis Risks in Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Identity and Psychosis Misdiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Vignette 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Conceptualizations of Distress and Psychosis Misdiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Vignette 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial Stressors and Psychosis Misdiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Vignette 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient–Clinician Interaction and Psychosis Misdiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Vignette 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening and Assessment of Migrants During the Migratory Trajectory . . . . . . . . . . . . . . . . . . . . . Screening and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening Tools and Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention and Treatment of Psychosis in Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tertiary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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S. O. Okpaku (*) Center for Health, Culture and Society, South Nashville, TN, USA e-mail: [email protected] A. B. Adeponle Department of Psychiatry, McGill University, Montreal, QC, Canada Culture and Mental Health Research Unit, Jewish General Hospital, Montreal, QC, Canada e-mail: [email protected] R. Kohn Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI, USA e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_12

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Patient Therapist Matching and Somatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342

Abstract

This chapter reviews the literature on migration as a risk factor for psychosis dating from the work of Ødegaard. The earlier crude hospital counts have been replaced by more sophisticated population-based incidence studies. Research has identified several major trends: I. European studies indicate that the risk of psychosis is higher in all immigrant groups than in the host population. II. Meta-analytic studies have shown a high mean weighted relative risk for developing schizophrenia for first generation immigrants. III. Some studies have shown also that the increased risk persists for second generation immigrants. Various explanations are given for the above findings. The chapter then considers issues of screening and assessment of immigrants and concludes with treatment approaches. The need for an anthropological and ethnographic approach is emphasized. The encounters between providers and migrants and their families are to be seen essentially as transcultural encounters. Keywords

Wars · Political · Unrest · Extreme poverty · Global migration

Introduction and Background In a world replete with wars, political unrest, and extreme poverty as in Afghanistan, Iraq, Syria, South Sudan, Burma, the migration of individuals and families seeking a better life and wishing to escape certain death; physical, emotional, and sexual abuse; or other forms of degradation has led to the highest levels of migration ever recorded. In 2015, the number of international migration was 244 million (IOM Global migration trends fact sheet 2015). In a recent conversation, one of us (SO) asked a researcher on migration, after she had delivered a lecture with grim data and pictures, why will a Sub-Saharan African or a Syrian mother with her children take the risky and uncertain attempt to cross the Mediterranean to Greece or Italy? She replied that these parents are driven by the hope for a better life or at least something better than the option to them in their war-stricken or deprived homelands. The full range of psychotic disorders have been reported among immigrant and refugee persons, from transient, stress-related, psychotic-like experiences to major psychotic disorders such as schizophrenia. In this chapter, we will make references

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to the different psychosis syndromes, including schizophrenia, drug-induced psychosis (e.g., khat and cannabis use), brief and atypical psychosis, posttraumatic stress disorder with psychotic-like symptoms, and psychosis found in relation to malnutrition and infections. Migration as a risk factor for developing psychosis is ranked as carrying the same risk magnitude as that associated with cannabis use, urbanicity, or perinatal complications (Tandon et al. 2008; Bourque et al. 2011). The origins of clinical and research interest in the association between migration and psychosis risk in modern times are often traced to the work of Ödegaard (1932) who is credited with making the first direct link between migration and mental illness. Using hospital admission records, Ødegaard showed that Norwegian emigrants in America had significantly higher rates (2–3 times) of insanity than did native-born Americans or the Norwegian population (Ödegaard 1932). In the 1960s and 1970s, increased rates of psychiatric illness in immigrants were reported from Australia (Krupinski et al. 1973), the UK (Hemsi 1967; Hashmi 1968; Rwegellera 1977), and other Western European countries (Sanua 1970). An important limitation of these early studies was lack of precise criteria for differentiating between native-born and foreign-born, and failure to control for confounders (Cantor-Graae and Selten 2005). A new era was ushered in the 1980s when studies began to report higher rates of psychosis in the Afro-Caribbean population in the UK compared to the native white population (Littlewood and Lipsedge 1981; Harrison et al. 1988). For the first time, elevated rates were also reported for second-generation migrants (McGovern and Cope 1987). Subsequent population-based incidence studies from the 1990s onwards used more precise estimates of the ethnicity and indicated that all ethnic minority groups in the UK had increased susceptibility to developing psychosis (King et al. 1994; Kirkbride et al. 2010; Fearon et al. 2006). For example, King et al. (1994) found a population and age-adjusted schizophrenia incidence rates of 1.2/ 10,000 for whites, 4.6/10,000 for blacks, 6.0/10,000 for Asians, and 3.9/10,000 for other ethnicity. Increased psychosis risk in immigrants has also been reported in continental Europe, including the Netherlands (Veling et al. 2011), Sweden (Gilliver et al. 2014), Italy (Lasalvia et al. 2014), and Denmark (Pedersen and Cantor-Graae 2012). The European studies report increased rates in all immigrant groups, including immigrants from European countries. In the USA, interest has centered more on explaining a disparity, that of racial differences (white vs. black) in rates of affective and nonaffective psychosis in hospital samples that disappear in population-based studies (Gara et al. 2012). More recently reports of increased psychosis risks among Asian and Latino immigrants in the USA have emerged (DeVlyder et al. 2013), although the US data suggest also that migration may actually protect against psychosis especially amongst Latinos (Oh et al. 2015). Similarly, a recent Canadian study (Anderson et al. 2015) found incidence rate of psychotic disorders was higher among immigrants from the Caribbean, whereas immigrants from Europe and East Asia were protected from increased risk of psychosis. The differential rates across ethnic subgroups, the authors concluded, suggested that psychosocial and cultural factors associated with migration may contribute to the risk of psychotic disorders (Anderson et al. 2015). Two published meta-analyses have investigated the

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association between immigration and psychosis (Cantor-Graae and Selten 2005; Bourque et al. 2011). Cantor-Graae and Selten (2005) found a mean weighted relative risk (RR) for developing schizophrenia among first generation migrants of 2.7 (95% CI = 2.3–3.2); a separate meta-analysis performed for second generation migrants found a RR of 4.5 (95% CI = 1.5–13.9). The study also found that psychosis risk was increased for migrants from developing versus developed countries (RR = 3.3, 95% CI = 2.8–3.9) and for migrants from areas where the majority population is black (RR = 4.8, 95% CI = 3.7–6.2) versus white and neither white nor black (Cantor-Graae and Selten 2005). Similar findings were reported by Bourque et al. (2011), who also found that increased risks persist into the second generation and argued for the relative greater importance of postmigration factors, rather than premigration factors, such as selective migration, in conferring increased psychosis risk.

Explanation for Increased Psychosis Risks in Immigrants Numerous explanations have been proffered for the finding of elevated psychosis rates in migrants, biological, environmental, and social. Biological and physical factors postulated as likely contributory include substance misuse, prenatal exposure to viruses, or other infectious agents, such as toxoplasma gondii, and vitamin D deficiency in dark-skinned immigrants who live in cold climates (Sharpley et al. 2001; Cantor-Graae and Selten 2005; Bourque et al. 2011). In an early review, Sharpley et al. (2001) argued that biologic or genetic factors were of less likely causal importance in the increased psychosis rates among the Afro-Caribbean in the UK given: (i) rates of schizophrenia in Caribbean countries were not elevated, (ii) the morbid risk for schizophrenia was similar for parents and siblings of both white British and first-generation British Afro-Caribbean patients with schizophrenia, and (iii) morbid risk for schizophrenia was markedly higher among siblings of secondgeneration Afro-Caribbean probands than their white British counterparts. More importantly, Sharpley et al. (2001) argued for social environmental and contextual factors including: (i) cultural variations in symptom reporting between white patients and minority patients, (ii) use of specific phenomenological constructs by psychiatrists, and (iii) social adversity and disadvantage. Sharpley et al.’s framework remains very useful still as it encompasses the two strands of enquiry dominant today: (1) the social defeat hypothesis (Cantor-Graae and Selten 2005; Selten et al. 2013) and similar theories such as acculturation stress (Rudmin 2009; DeVlyder et al. 2013) and (2) psychosis misdiagnosis (Hickling et al. 1999; Adeponle et al. 2012). An important distinction can be made; thus, social defeat is more relevant as an etiological factor in increased psychosis risk, and thus of more importance in health promotion and prevention work, whereas misdiagnosis is germane to the clinical work of disentangling phenomena that constitute artifacts of the intercultural encounter from real (actual) psychopathology. Social defeat refers to the negative experience of being excluded from the majority (dominant) group, including social, economic, and political marginality,

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held as being a common denominator for some well-established risk factors of schizophrenia such as migration, urban upbringing, childhood trauma, low IQ, and illicit drug use (Cantor-Graae and Selten 2005; Selten et al. 2013). The social defeat hypothesis holds that long-term exposure to the experience of social defeat or social exclusion may lead to sensitization (Sensitization is a process whereby exposure to a given stimulus, such as a drug or a stressor, results in an enhanced response to subsequent exposures.) of the mesolimbic dopamine system and as a result increase the risk for schizophrenia. Additional support for the social defeat thesis comes from findings of associations between psychosis risk and ethnic density, in particular, the observation that the relative incidence of psychosis among immigrants increases as they form a decreasing proportion of the population (Boydell et al. 2001; Bourque et al. 2011) and between psychosis risk and perceived discrimination by host society (Karlsen and Nazroo 2002; Veling et al. 2007). Acculturative stress refers to the tension or strain associated with adjustment and integration to a new culture that may result in ill-health (Rudmin 2009), and it has been shown to be associated with greater risk of psychosis among Asian and Latino immigrants in the USA (DeVlyder et al. 2013). Immigrant patients are at particular high risk for misdiagnosis, especially with respect to diagnosis of psychotic disorders. For example, a study conducted at a cultural consultation clinic in Montreal, Canada, found that 50% of immigrant patients diagnosed with a psychotic disorder by their psychiatrist or primary care clinician were given a diagnosis of a nonpsychotic disorder when the DSM-IV cultural formulation was used for case reassessment (Adeponle et al. 2012). Misdiagnosis includes (i) missing a diagnosis entirely (nonrecognition), (ii) mistaken diagnosis (underlying medical illness), (iii) over-diagnosis, and (iv) under-diagnosis (Westermeyer 1987). Over-diagnosis may occur, for example, when a clinician mistakes a cultural norm for psychopathology, while underdiagnosis might result when the reverse situation holds (Lin 1996). Similarly, Strakowski et al. (2003) attributes misdiagnosis in minority patients to (i) cultural differences in symptoms expression, including the mislabeling of “healthy paranoia” and (ii) clinician inadequacies or bias in clinical assessments. The issue of clinician bias reflects the view that misdiagnosis is rooted in stereotypes about minorities (e.g., as violent and more disturbed) that majority clinicians hold unconsciously (Lopez 1989; Abreu 1999). For example, Hickling et al. (1999) investigated the proposition that white British psychiatrists incorrectly diagnose schizophrenia in Afro-Caribbean patients in the UK. They had a Jamaican psychiatrist rediagnose a group of inpatients (whites and blacks) at a UK hospital using his own standard clinical assessment methods along with the Present State Examination (PSE). PSE diagnoses were subsequently computer-generated from the CATEGO program. The study found that agreement between PSE CATEGO and British psychiatrists was poor (kappa = 0.16) and poorer than agreement between PSE CATEGO and the Jamaican psychiatrist (kappa = 0.54), suggesting potential bias in assessments among the British psychiatrists. In more recent work, the roots of misdiagnosis are held as residing more in clinician’s reasoning and the prototypes they draw upon in intercultural work, as prototypes appear crucial in diagnostic decision-making and

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are important sources of both clinician expertise and bias (Neighbors et al. 2003; Adeponle et al. 2015). Misdiagnosis occurs when clinicians fail to elicit crucial diagnostic information or misinterpret it because of insufficient attention to social, cultural contextual factors that often shape symptom expression and illness behavior (Gone and Kirmayer 2010). Intercultural clinical work often requires that clinicians assess patients from backgrounds vastly differently from their own, and since no gold standard method exists for diagnosis in cross-cultural settings, intercultural assessments pose considerable challenges for both novice and experienced clinicians alike. The DSM-5 Outline for Cultural Formulation (CF) (APA 2013) and the accompanying Cultural Formulation Interview (CFI) provide a systematic approach that clinicians can use as guide to cross-cultural assessments. The different sections of the CF outline allow detailed assessment of the role culture, and social context has on illness presentation and on the diagnostic process: (i) cultural identity of the individual, (ii) cultural conceptualizations of distress, (iii) psychosocial stressors and cultural features of vulnerability and resilience, and (iv) cultural features of the relationship between the individual and the clinician. Reports from clinicians who make use of the CF indicate its utility as a tool for intercultural patient assessments (Kirmayer et al. 2014; Rosso and Bäärnhielm 2012; Dinh et al. 2012; Rohlof et al. 2009). In the succeeding sections, we shall use clinical case examples based on the CF Outline sections to help illustrate the challenges and pitfalls in clinical assessments of immigrant patients with suspected psychotic disorder.

Cultural Identity and Psychosis Misdiagnosis Cultural identity describes “the individual’s racial, ethnic, or cultural reference groups that may influence his or her relationships with others, access to resources, and developmental and current challenges, conflicts, or predicaments” (APA 2013, p. 749). Cultural identity is here viewed as being both a “marker” of status and as acquiring “meaning” (social significance) in everyday life. Other relevant aspects of cultural identity include acculturation, individual’s relative degrees of involvement with both the host culture and own culture of origin, language abilities and preferences, socioeconomic background, and religious affiliation (APA 2013). Individuals’ racial or ethnic identity may lend itself to psychosis misdiagnosis because of differences in the ways patients from different backgrounds present clinically and differences in the ways sociopolitical factors shape symptom presentation. Exposure to racism, for example, is held as resulting in a “healthy cultural paranoia” in African-Americans that may be mistaken for psychopathology by majority clinicians (Whaley 1997). Passivity experiences, such as thought broadcast and thought control, seen as highly suggestive of schizophrenia, are more prevalent in African-Americans with affective disorder (Strakowski et al. 2003). Research from European countries found a positive relationship between Asian or African migrant status and self-reported hallucinations (Vanheusden et al. 2008; Berg et al. 2011). Similar findings were reported in a US study that examined psychosis risk

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among Asian and Latino immigrants (DeVlyder et al. 2013). The study found a positive association between acculturative stress and risk for psychosis like experiences (visual and auditory hallucinations) among Asian immigrants and for hearing voices only among Latino immigrants. The pathways through which patients enter psychiatric care are also often related to ethnicity and can exert a subsequent bias on diagnosis. In the USA, UK, and Canada, for example, compared to the white majority patient, minority patients more often enter psychiatric care through the criminal justice system and the emergency room than through more conventional routes such as the family physician (Morgan et al. 2004; Jarvis et al. 2005). Racial prejudice in conjunction with stigma associated with a view of schizophrenia as a disorder associated with the dangerous and the alien may make clinicians preferentially diagnose schizophrenia in minority patients, especially when they come to clinical attention through these adversarial, coercive routes (Fernando 2003; Metzl 2009). Immigrants often are limited in their abilities to use the host society language and in their ability to express their concerns, describe symptoms, and negotiate the health care system, and research shows that the use of interpreters facilitates better communication and increases the likelihood of recognition of psychological symptoms (Kirmayer et al. 2011).

Clinical Vignette 1 Ms. O is a 30-year-old female, who lives alone. She recently emigrated from an African country. She has a history of epilepsy. She has been seizure-free and off medications for the past 3 years. She recently gave birth to a healthy male baby. Social services were threatening to take the baby from her because of concerns about her ability to care for the infant and the suspicion that she had a psychotic disorder. The question of psychosis arose because the patient had not bought many of the usual baby household items expectant mothers typically buy in anticipation of a baby’s birth. Examples of such items are a baby bed-cot, baby stroller, baby car seat, and toys. When questioned why she had not made ample preparation for her baby as she appeared to be perturbed by the situation. She seemed to have little appreciation of the gravity of the concerns the social worker had regarding her capacity to take adequate care of her baby. Psychiatric evaluation was requested to assess for presence of delusions or a psychotic disorder and if their presence could be impairing the patient’s capacity for care of self and baby. Assessment with the cultural formulation outline revealed that the patient’s behaviors were unlikely to be due to the presence of a psychotic disorder. Rather, what was discovered was that the patient held religious and traditional beliefs that viewed buying baby things prior to a baby’s birth was something one did with caution and in moderation so as not to court divine reproach. This is based on the belief that it is God who decides whether the baby is going to be born alive and in good health. Also, buying baby things ahead of time carried the risk she would be attracting “evil eye” to herself and her unborn baby. With regard to a baby-cot and baby beddings, it transpired that it was common practice in her cultural community

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of origin for mothers and their new baby to sleep in the same bed for the first year in order to facilitate ease of breastfeeding and infant-mother bonding. She did not have a car and she could not drive and had not considered it necessary to purchase a car seat. In addition, she had sought help from the women at her church (these were predominantly immigrant women living at the margins of society). The group had assisted in providing some of the baby items. It also appeared that the patient’s ill-preparedness for her baby’s arrival was related also to her tenuous status in Canada. The social services had believed she was a single mother. She was married and her spouse lived in the USA as an undocumented immigrant. Two months prior the couple had decided that the patient should proceed from West Africa for Canada to have her baby. This was because she was unsuccessful at obtaining a US visa. In Canada, the only place where she could gain access to antenatal care was at a walk in clinic. The clinic provided care to undocumented immigrant persons on cash basis. Prior to delivery this patient had no material or other support from child and family services on account of her immigration status. Use of the cultural formulation helped show that the patient’s seeming ill-preparedness for the birth of her baby could be better explained by attention to factors rooted in aspects of her cultural identities rather than due to psychotic disorder. These factors include her being an African immigrant, and religious beliefs and practices. Her behavior could be better understood as being within the range of behavior responses observable in persons from social and cultural backgrounds similar to hers. Specifically, crucial insights came from the understanding that individuals can hold notions about nesting (socialization patterns on preparing for a baby’s birth) that depart from that of mainstream cultures in North America and from the understanding that individuals’ identities, that is, their ascribed social positions because of who they are, as migrants and minorities, shapes how they experience health and social services. This dual focus on eliciting the patients’ own perceptions and cultural beliefs on the one hand, and identifying the ways patients’ identities may divert attention from social structural and economic problems on the other, highlights how individuals’ cultural identity may lend itself to increased risks of misdiagnosis.

Cultural Conceptualizations of Distress and Psychosis Misdiagnosis Cultural conceptualizations of distress describe “the cultural constructs that influence how the individual experiences, understands and communicates his or her symptoms or problems to others” (APA 2013, p. 749). They include cultural syndromes, idioms of distress, and explanatory models or perceived causes. A cultural syndrome refers to a cluster or group of concurring symptoms recognized as a specific entity or pattern within the culture. An idiom of distress is a linguistic term or cultural mode (shared with other people from the same culture, e.g., ethnicity, religion) to communicate distress. Nichter (1981), who introduced the term, defines idioms of distress as “an adaptive response or attempt to resolve a pathological situation in a culturally

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meaningful way.” Explanatory models are primarily concerned with accounts of reasons for illness, as causal attributions or perceived causes. These include names or labels linked to notions of causation, underlying mechanisms, diagnoses, prognosis, and treatment (Kirmayer and Bhugra 2009). DSM-5 exhorts that clinicians assess severity and meaning of the distressing experiences in relation to the norms of the individual’s cultural reference groups (APA 2013). Patients who present with cultural syndromes, such as amok and koro, may present as delusional or psychotic to the uninformed clinician, as can possession and trance-states and beliefs in occult and witchcraft (Lin 1996). Ataques des nervios, a cultural syndrome common among the Latino population, is another condition that may be confused for a psychotic disorder. Ataques symptoms include shaking, palpitations, verbal and physical aggression, and convulsive body movements (Guarnaccia and Farias 1988). Idioms of distress include somatic complaints and talk of witchcraft and supernatural causation such as “evil eye” and hexing. Idioms of distress constitute “symbolic” practices situated in the everyday, signifying practices that define and transform the environment in which they occur. Idioms necessitate culturally prescribed healing and resolution (Kohrt and Hruschka 2010), which make pragmatic sense. Ditto for illness explanatory models defined as “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (Kleinman 1980). Explanatory models allow a detailed understanding of individuals’ lived illness experience and include individuals’ causal attributions or illness explanations, perceived impact of illness, and help-seeking preferences. Kleinman (1980) introduced explanatory models to emphasize the importance for clinicians of attending to personal and social meanings of illness experience and not only etiological explanations, but also ways in which help-seeking and decision making are culturally shaped. The clinician has to be alert to situations where lay understandings, be they cultural syndromes, idioms of distress, or explanatory models, are explicitly or less explicitly presented by patients, so as to guard against missing a psychiatric disorder or misrecognition of a nonpsychotic disorder for a psychotic disorder.

Clinical Vignette 2 Mr. A is a 24-year-old male, single, from West Africa, college student. He is a practicing Christian, who presented to the psychiatric department because he was experiencing voices of unseen persons which he believed to be the voice of god and that of the devil trying to confuse him. His behavior was disorganized and had increased religiosity. He did not have mood symptoms. During the 3 weeks, Mr. A was in the hospital the voices diminished on antipsychotic treatment. His behavior improved. In fact, he and his church brethren who had brought him for treatment agreed that this was so. In spite of his response to antipsychotic treatment, Mr. A was unshaken in his belief that what he had was a spiritual problem and not psychiatric and was insistent his church be allowed to perform a religious deliverance service (“exorcism”) to provide permanent “cure.”

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Assessment with the cultural formulation outline revealed that Mr. A had grown up in a culture in his home country with a long tradition of pluralism and syncretism of epistemological interpretive frames and healing traditions. This is commonplace and socially acceptable in his culture. Mr. A therefore did not perceive any contradiction in marrying biomedical and religious-spiritual approaches. For him, one does not exclude the other. The root of such syncretism is the belief that blending disparate knowledge systems and healing traditions is superior to each taken individually. Mr. A’s church was a local branch of a transnational church of Nigerian origin that was of the evangelical and Pentecostal bent. His church like many evangelical African churches is rooted in liturgical traditions that blend Pentecostal Christian and traditional African religious beliefs and practices, such as religious deliverance practices. Religious deliverance ceremonies entail practices such as “cleansing” of witchcraft and spiritual attacks believed to cause mental illness, confession of one’s sins, and engendering community connection. Witchcraft is held to be the evil intentioned handiwork of one’s close intimates unhappy at one’s success in love or trade. Mr. A held an assistant pastor position in his local branch of the church and he led the deliverance services held in his church, as a result, he would be a prime target for such witchcraft attacks. Use of cultural formulation helped to demonstrate that Mr. A’s religious ideas were not delusional or psychotic, rather they were normative and had personal meaning given his religious orientation and cultural background. While psychiatric hospitalization and medication played a role in the reduction of his symptoms, the involvement of religious healing constituted ritual action targeted at rectifying ruptures in relationships with intimates that may have led to witchcraft attacks. For Mr. A, the “exorcism” with its rituals of cleansing, confession of sins, and re-connection allowed him to reestablish proper relationship with his community and a fulfilling life lived in ongoing connection with others.

Psychosocial Stressors and Psychosis Misdiagnosis Psychosocial stressors include adverse events and the absence of supports (emotional, instrumental, and informational) in individual’s social environment (APA 2013). Stress and resilience factors are important to consider in diagnostic assessment of psychosis in immigrant patients because (1) focusing on cultural identity and illness meaning may lead clinicians to emphasize cultural explanation instead of paying attention to the material condition of the patient (Corin 1997), and (2) they highlight the important role social contextual and environmental factors play in the etiology and clinical presentation of psychotic disorders.

Clinical Vignette 3 Mr. K is a 30-year-old man, single, from a Latin American country. He presented with a history of paranoid ideations, auditory hallucinations (torture noises), and

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disorganized behavior of 1 month’s duration. He has used cannabis since adolescence and daily for the past 2 years. He had a rapid response to a low dose of an antipsychotic and by the end of the second week in the hospital he was no longer hearing voices. He had arrived in Canada 2 years earlier as a refugee who was fleeing political persecution in his home country. Two months earlier the immigration authorities had written to him asking him to present documentation to support his refugee application. He, however, could not produce the requested papers because he had entered the country under an assumed identity. He claimed he was from a country where political persecutions were often reported, whereas he actually came from a neighboring country that was relatively stable. He had left his own country for the other country to escape a vendetta aimed at him by the local police in his town. In Canada, he has had to constantly monitor what he says. Even with friends and new acquaintances, he was on guard and hypervigilant and constantly worried if they could be trusted and how much he could tell them. He was not getting much sleep and often had nightmares. On account of stress, he was having dissociative episodes where he would have amnesia for parts of his day. He shared a flat with two friends, and it was the friends who called 911 and had brought him to the ER when one night he started to shout and break things in his room. In this case one can entertain a number of differential diagnoses such as cannabis induced psychosis, reactive psychosis, and PTSD with prominent dissociation and psychosis. One can make a case for each and perhaps they each contribute in some way. What is indisputable, however, is the salience of the stress of living under a false identity that shaped Mr. K’s symptoms and presentation in ways that were significant. He was trying to fanaticize a world that he made up which eventually became his nightmare.

Patient–Clinician Interaction and Psychosis Misdiagnosis Elements that are important to attend to in the patient-clinician interaction include differences in culture, language, and social status, between the individual and clinician. This may cause difficulties in communication and influence diagnosis and care (APA 2013). Patients’ experiences of societal discrimination may hinder establishing trust and safety, cause problems eliciting symptoms, and lead to misunderstanding of the cultural and clinical significance of problem behaviors and to difficulty establishing or maintaining treatment alliance (APA 2013).

Clinical Vignette 4 Ms. J is a 42-year-old female, married, living with her spouse and four children. She is a Moslem and a recent immigrant from Pakistan. She presented to her family

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physician, a white male, with complaints of headaches, crawling sensations, and other vague somatic complaints. The family physician had known Ms. J for about 8 months. She went for a visit after she cancelled three previous appointments. The family physician prescribed some analgesics for Ms. J, told her he was going to schedule a neurology consult for her, and asked her to return in a week. At follow-up, Ms. J very thankfully reported the headaches had improved on the medications and the family physician did not bother to send her for the neurology consult. A month later, the family physician got a call from Ms. J’s social worker that Ms. J had been taken to the psychiatry ER the week before by her family because she had not been sleeping well for weeks and during the previous week had been saying she was seeing and hearing the voices of “Jinns.” She was acting strangely. She would stare into space and take up postures for no discernible reason. The social worker, who had been involved with Ms. J’s family since they arrived in Canada a year ago, informed the family physician that in hospital it came out that Ms. J had two previous major episodes of psychotic illness in Pakistan for which she required hospitalization. The family physician expressed his surprise at learning Ms. J had a psychiatric history and that she did not bring up her sleep problems or psychological problems during her visit to his office a month ago. The family physician reasoned that he may have been blind-sided by Ms. J’s effusive show of gratitude after her headaches improved on the medications he prescribed. His decision to no longer send her for a neurology consultation as he had earlier told her he would was not ideal for building therapeutic alliance, especially since Ms. J had canceled three previous appointments. The social worker confirmed that Ms. J had a terrible record of poor sustained engagement with services. She would disappear from time to time, as she was distrustful of services and wary of engagement with services. Her behavior made a working relationship with her difficult as she would often came across as defiant and help-rejecting. The social worker stated that much of the information she had gathered about Ms. J have come from collateral sources, some through her husband and adult children, and some is through a member of Ms. J’s cultural community. At the end of their discussion, the family physician and social worker agreed on a follow-up appointment for Ms. J with her family physician in a month’s time by which time she would have being discharged from psychiatry inpatient care. This will enable the social worker, the patient’s spouse, and Urdu language interpreter to be present. This plan was based on the fact that the family physician did not seem to have done an adequate assessment and failed to pick the presence of a psychotic disorder. There was miscommunication in the clinical encounter that led to flawed inferences about the patient’s symptoms presentation because inattention to: (i) difference in status between patient and clinician (in this case, the deference to the authority of the physician); (ii) clinician nonfamiliarity with patient’s cultural background (e.g., that vague somatic complaints may be idioms of distress in some cultures); and (iii) linguistic barriers.

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Screening and Assessment of Migrants During the Migratory Trajectory Screening and Assessment The above clinical vignettes illustrate the complexity of the clinical presentation and diagnosis of psychosis in migrants. Migrant populations are heterogeneous on a multitude of important factors. Some of these include age, gender, educational background, economic status, physical health, language skills, past history of mental illness, family structure and composition, and social support. The reasons for the migration and the migratory process may contribute to the overall experience. In addition, the context in which the screening and/or the assessment of the individual/ family is carried out is influenced by the phase in the trajectory of the migration. Hence, it is useful to divide the migratory phases to (I) premigratory phase in the country of origin, (II) the actual migratory process from the country of origin to the host country, (III) the early settlement phase, where the individual or family has gained legal status and has found basic needs such as housing, employment, or education for children and (IV) late settlement or adaptation and acculturation phase where the migrants can participate as a full citizen or permanent resident. The screening or assessment for the migrant and his or her family may be supplemented with needs assessments of community agencies and civic organizations. For the various phases and contexts during which the screenings and assessments are carried out, different goals are emphasized. Furthermore, they may be carried out for clinical and servicedelivery objectives or for the purposes of evaluation and services research. This raises an ethical question regarding the need to balance direct services priorities with monitoring and evaluation. To illustrate the above points during the premigratory phase in the country of origin, there may be a cursory observation for mental illness during the screening and physical examination for the necessary immigration papers. During the migratory phase of a humanitarian crisis, it is useful to assess the mental and psychological state of the migrant or refugee as well as the perceived needs of community agencies, civic organizations, and community leaders. In the detention center or asylum center, initial screening issues related to legal status, substance abuse, and past criminal behavior assume greater importance. During the early settlement phase, issues such as housing, employment for the adults, and schooling for the children are major tasks for the family. They also serve as important for avenues immigrants families may come to the attention of mental health services. The problem behaviors of the children and adolescents may bring them to the attention of their teachers and school counselors who may have to refer them out if the behaviors are severe. In this period, the teachers should be on the lookout for bullying of these children by their peers. During the late settlement adaptation and acculturation phase, the services available to the average citizen are usually available to the migrant and his/her family. For the male head of the family, stress from unemployment and under-employment may be particularly pertinent. For example, it is not unusual to see individuals who have

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been physicians, engineers, and lawyers in their countries of origin struggle through board examinations and have to work for years as security men or taxi drivers. Migrants or their children in the late settlement phase may present themselves at public health clinics, primary care clinics, or receive treatment from private providers. During various points of the migratory process, the migrant is exposed to different social stressors and demands.

Screening Tools and Checklists In 2012, WHO and UNHCR published a tool kit that has various sections to screen individuals as well as to assess community readiness, resources, and needs for tackling resettlements. For individuals, a brief checklist from the tool kit may be used. It is easy to administer and can identify individuals mostly at risk for psychosis. Although useful for case identification, they carry a risk of misdiagnosis and over-diagnosis. For a more comprehensive assessment of individuals, Ali et al. (2016), after a systematic review of validated instruments, suggested the use of SCL-20 for general common mental disorder (CMD), the GHD-12 for CMDs in populations with physical illness, the HASDS-D for depressive disorder, the PHQ-9 for depressive disorders in population with good literary levels, the EPDS for perinatal depressive disorders, and HADS-A for anxiety disorders. They also suggested the need to locally validate the instruments. Rogler (1993) has suggested three ways in which culture can influence psychiatric assessment and diagnosis. The first level is that of the expression of the subjects’ symptoms, the background to these symptoms, and readiness by the subject to share them. The second level is the clustering of the symptoms into ethno psychiatric diagnosis, which may include the readily identifiable culture bound syndromes. The third level addresses the interpersonal context in which the subject is engaged by the interviewer. The belief is that the greater the distance between the patient and the psychiatrist due to language or other difficulties, the poorer the outcome. For the community readiness and perceptions of needs, appropriate sections of the tool kit can be administered to community leaders, traditional healers, and public officials. While data are important for monitoring service delivery and clinical service, there are sensitive ethical issues. Appropriate priority has to be set to balance service needs with data collection and involvement of the community leaders and service recipients. Table 1 is a summary of tools in the toolkit. The responses to the tools are helpful in planning and advocacy. These assessments require a certain level of cultural validity for the design and interpretation of the results.

Individual Assessments With the above background in mind, in the assessment for psychosis in migrant populations, a psychiatric interview should be carried out as a minimum even after a screening has been completed. The traditional psychiatric interview should

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Table 1 A quick guide to identifying tools Tool # Title For coordination and advocacy 1 Who is Where, When, doing What (4Ws) in Mental Health and Psychosocial Support (MHPSS): Summary of manual with activity codes 2 WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS) 3 Humanitarian Emergency Setting Perceived Needs Scale (HESPER)

Method

Why use this tool

Page

Interviews with agency program managers

For coordination, through mapping what mental health and psychosocial supports are available

30

Part of a community household survey (representative sample)

For advocacy, by showing the prevalence of mental health problems in the community

34

Part of a community household survey (representative sample) Or exceptionally (in acute, major emergencies) as a convenience sample For MHPSS through health services 4 Checklist for site visits at Site visits and institutions in interviews with staff humanitarian settings and patients

For informing response, through collecting data on the frequency of physical, social, and psychological perceived needs in the community

41

For protection and care for people with mental or neurological disabilities in institutions For planning a mental health response in PHC

42

5

6

Checklist for integrating mental health in primary health care (PHC) in humanitarian settings Neuropsychiatry component of the Health Information System (HIS)

Site visits and interviews with primary health care program managers Clinical epidemiology using the HIS

For advocacy and for planning and monitoring a mental health response in PHC 7 Template to assess mental Review of documents For planning of (early) health system formal and interviews with recovery and resources in humanitarian managers of services reconstruction, through settings knowing the formal resources in the regional/ national mental health system For MHPSS through different sectors, including through community support 8 Checklist on obtaining Review of available For summarizing general general (non-MHPSS documents (non-MHPSS specific) specific) information from information already sector leads known about the current humanitarian emergency (to avoid collecting data on issues that are already known)

47

53

55

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(continued)

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Table 1 (continued) Tool # 9

Title Method Template for desk review Literature review of preexisting information relevant to MHPSS in the region/country

Page 60

10

Participatory assessment: Perceptions by general community members

63

11

Participatory assessment: Perceptions by community members with in-depth knowledge of the community Participatory assessment: Interviews with Perceptions by severely severely affected affected people people (free listing with further questions)

12

Why use this tool For summarizing MHPSS information about this region/country – already known before the current humanitarian emergency (to avoid collecting data on issues that are already known) Interviews with For learning about local general community perspectives on problems members (free listing and coping to develop an with further appropriate MHPSS questions) response Interviews with key informants or groups

70

74

Note: MHPSS indicates mental health and psychosocial support

be supplemented with information or risk factors as previously identified as well as known stressors such as legal status, malnutrition, head injury, physical, and mental abuse. For the examiner, the task is a challenge to obtain an adequate examination, especially in the presence of language barriers, restricted time, and burden of work demanded by the circumstances of the migrant. In some cases, there is a need for the migrant to bundle together their emotional, physical, financial, or other psychosocial needs into their presenting complaints. The examiner may need the services of a translator. The use of family members and children is to be discouraged because of confidential issues and added burden. For the child, there is a risk of parentifying him or her. However, corroborative information from the family members is frequently useful. The psychiatric interview and assessment should be followed up by a physical examination, blood work, chest x-ray, and other investigations to help screen other causes of psychosis other than schizophrenia. Also, this helps to exclude conditions such as HIV/AIDS, tuberculosis, and syphilis. Finally the assessment should conclude with a differential diagnosis and formulation of the index case. A variety of conditions may present with psychosis during the different phases of migration. The major categories are schizophrenia, posttraumatic stress disorder, acute stress disorder, brief psychosis, paranoid states, and drug induced psychosis. These conditions may be precipitated by the stressors of

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migration. Many individuals who have been forced out of their countries because of civil wars have been exposed to considerable stressors. Individuals who have been living a marginal existence with poor nutritional and health status may be thrown into psychotic episodes such as brief psychosis. Individuals exposed to chronic cannabis and khat may manifest their distress as psychosis. Head injury and traumatic brain injuries also need to be considered in the provisional diagnosis as are nutritional and vitamin deficiency states.

Prevention and Treatment of Psychosis in Migration The treatment of migration psychosis can be heuristically divided into primary, secondary, and tertiary prevention. The word heuristic is used to emphasize a family and community approach in dealing with mental illness in migrant communities. In providing direct treatment to the index patient, we should also be aware of the needs and resources that other family members and the migrant community may need to reduce their exposure to psychosocial stressors including access to school, employment, housing, and healthcare.

Primary Prevention This requires an amalgam and coordination of a variety of agencies at the global, international, regional, and local levels. The objective of this array of agencies and their services will be geared to compliance with international policies and approaches that may reduce the risks and stressful factors of migration as well as efforts to identify actual cases. An example of global and international public policy is the adherence of the signatory states to the 1951 UNHCR Charter. This provides protection of the rights of migrants and refugees and guidelines for the signatory states. Other UN agencies, e.g., UNICEF, have a role to play under their mission for the protection of children. These agencies provide their services in coordination with national organizations, whose policies percolate to the local districts, e.g., the division of refugee resettlement in the Mayor’s Office. An array of religious organizations, NGOs, humanitarian agencies, and foundations, e.g., the Red Cross, Oxfam, Doctors without Borders, the Catholic Relief Fund, and World Vision, are engaged in reducing the psychosocial stressors that may predispose migrants to psychosis. Usually these agencies have considerable experience and are very efficient. However, we have encountered recipients of services feeling that they have been left high and dry. To reduce such complaints, these organizations should provide adequate supervision over their staff to reduce opportunities for abuse and exploitation. Other theoretical possibilities under this category of prevention include efforts to reduce political strife, ethnic and civil conflicts, climate change, and poverty. As previously indicated in 2015, over 1,300,000 migrants arrived in Europe due to fighting in Syria, Iraq, and Afghanistan and political instabilities in Kosovo and Eritrea. In the last two decades, with increasing volume of immigration in an

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attempt to provide smoother settlement experiences in high host countries like Germany, USA, UK, Canada, there has been a trend for integrated services systems. Integrated service delivery has been defined as any model of delivery programs and services wherein two or more organizations collaborate by coordinating their knowledge and skills. This is designed to improve efficacy and efficiency in service delivery to the mutual benefits of clients and front line workers (CDCD 2010). There are several models of integrated service delivery. Broadly speaking, there are two approaches to integrated service delivery. These are, namely, the Place-Based Planning approach and System-wide collaborative approach to settlement. In the place-based approach, the strategy is to build a local knowledge and skills reservoir. An example is a Mayor’s office bringing together ethnic specific organizations and local religious organizations in a “formal” and “informal” network. In System Wide Collaborative approaches to integrated settlement, there tends to be a longer vision especially as it applies to skilled workers. Here, the strategy is to engage key stakeholders, which might bring in an assortment of service providers, industries, colleges, universities, NGOs, and other organizations. Each approach has its assets and challenges.

Secondary Prevention This refers to the treatment of an identified case. It consists of the reduction of symptoms using individual, group, and family psychotherapy and counseling. When necessary, the migrant patient may require hospitalization. The support of the family in these endeavors is very important. Sometimes the family may delay in presenting the patient for treatment or hospitalization on account of stigma and also when the migrant does not have a legal status. Conventional wisdom points to the best outcome when pharmacotherapy is combined with counseling and or psychotherapy. The psychiatrist should be equipped with some basic principles of ethnopharmacology. In addition, he/she should be aware of the behaviors that may impact on the efficacy of the prescription. There are genetic influenced ethnic differences in drug metabolism and drug responses. The migrant population may have a different profile of enzymes as the host population. For example, 50% of Chinese and Japanese (Kalow 1982; Lin et al. 1992) are deficient in the active form of aldehydrase dehydrogenase. These individuals are therefore poor metabolizers of acetaldehyde, a breakdown product of alcohol. This is the pharmacological explanation for flushing experienced by some Asians after ingesting alcohol. There are also other ethnic/racial differences in enzyme complements with potential consequences for plasma levels, therapeutic effects, and side effects. Examples include the relative ratio of the cytochrome P450 enzyme (CYP2D6) and (CYP2C19) in different ethnic groups (Eichelbaum and Gross 1990). CYP2C19 plays a pivotal role in the metabolism of many psychotropic drugs. One

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of us (Okpaku et al. 1980) reported that red blood cells of blacks concentrate Li+ in a ratio of 2:1 as white red blood cells. This may have consequences for response and side effects in the use of Lithium for treating different racial/ethnic groups. Nongenetic influences on the outcomes of prescribing include compliance, trust in the medication and in the prescriber, cost of the medication, family attitudes, the concurrent use of native herbs, and the route of administration. Some patients view injections as being potentially more effective than medications administered orally. The prescriber should not spare any effort in explaining to the migrant or his family his treatment plan, the reason for the prescription, and potential side effects. It is generally recommended that treatment starts with small doses of medication. As previously stated and not requiring any further emphasis is the requisite to be culturally sensitive and informed as much as possible. Migrant patients very often tend to be polite and respectful. This attitude should be reciprocated. Family roles, interactions, and rituals should be closely observed and when healthy should be acknowledged. If there is significant language barriers, a professional interpreter should be used. An essential service for the migrant/family is the ability to communicate accurately with the service providers. This is essential not only in day to day communication with the individuals in the host country, but it is very important in health care, court appearances in asylum courts, and immigration hearings. An attempt to fill this gap is usually provided by interpreters who are in short supply. The preference is to use a trained interpreter (Lee 1997). There are several models of interpretation. Five models have been identified in mental health service delivery. These are I: Approximate interpreting model II: Tele-active model III: The bilingual worker/interpreter model IV: Volunteer interpreter pool model V: Staff interpreter model The approximate interpreter model refers to the practice of recruiting the nearest person who is available to assist. This could be a bilingual nurse, any hospital employee, or anyone who is available. The “tele-active” describes a practice in which the migrant selects responses to telephone prompts. There is no direct human contact. In the “bilingual worker/interpreter model,” the interpreter sees the migrant/family and summarizes his or her session with the provider. The “volunteer interpreter pool model” has a pool of volunteers to assist upon request. Some religious organizations or disability groups, e.g., learning impaired organizations, usually provide such services. In the “staff interpreter model,” the departments or institution have paid bilingual and multilingual individuals who fulfill that role. Each model has its strength and liabilities with regards to cost, ethics, and efficacy. It is generally believed that for good interpretations, the interpreter should be trained. In addition, there are some practical guidelines for setting up the session and

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the execution of the session and debriefing after the session (The Royal Children’s Hospital Melbourne 2016). Caimcross (1989) has suggested some criteria for achieving competency in interpretations. Among these are technical, cultural, interpersonal, and ethical considerations. Needless to say that caution should be exercised when using family members and children as interpreters and when the client is a female. In the USA, considerable effort is made to have professional interpreters either at site or long distance by telephone. When the interpreter is good, the experience is very satisfactory; otherwise, it can be frustrating especially when the professional can sense a lack of fidelity on the part of the interpreter. The presence of comprehensive psychosocial welfare services to link the individual and their families for treatment and benefit programs is essential. In providing treatment, an accurate diagnosis of the psychotic illness is useful. The differential diagnosis should include forms of psychosis other than schizophrenia, infections-related psychosis as in HIV/AIDS, febrile malaria, postconcussional syndromes due to head injuries, substance abuse related psychosis, e.g., khat and cannabis use, and esoteric syndromes such as brain fag and other culture bound syndromes. As previously indicated, Kleinman (1997) recommended that local assessments require a certain level of cultural validity for the interpretation of the results. He suggested an ethnographic and anthropological approach in working in cross cultural encounters. Okpaku (1998) recommends a transcultural approach in these encounters. He sees transcultural psychiatry as being essentially an entity with a dynamic core in which an attempt is made by the therapist to show empathy and respect for cultural differences. In such a relationship, the therapist remains open and willing to be informed by the patient. “The clinical conflicts are defined within the patient’s cultural context, and the goals of therapy are predicted on a dynamic and bilateral relationship between therapist and patient” (Okpaku 1998). Also when appropriate, consultation can be sought from local ethnic specific clinics or departments with cultural and global psychiatry.

Tertiary Prevention This refers to efforts to provide rehabilitation services and reduce disability. Here compliance with treatment is crucial. The support of the family and availability of transportation to take the patient and his family is crucial. When indicated home services may be beneficial. Although the family is helpful in improving compliance with medications and other treatments, the family can sometimes be obstructive and unhelpful. In tertiary prevention, various organizational and client centered approaches can help reduce barriers to adequate resettlement of immigrants and their families. Local educational and civic activities to reduce discrimination can be helpful. We previously referred to the WHO-UNHCR tool-kit and its advocacy and planning potential. The results can help highlight areas that require attention. An integrated service that brings various agencies together to tackle training, education,

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and housing for migrants and their families is likely to be helpful. The WHO/UNHCR toolkit gives information on the available health services that are useful in case of crisis, a brief survey of the epidemiology of services, symptoms of distress, and perceptions of target groups including traditional leaders.

Patient Therapist Matching and Somatization This section will be incomplete without mentioning two other relevant issues. The first has to do with matching of patients to the therapist. In general, this is very useful in ethnic specific clinics serving largely individuals with a common language or culture. For a newly arrived migrant/family, there perhaps is no better welcome than that provided by a provider with the same racial or ethnic background. A meta-analytical study of racial/ethnic matching of clients to therapist examined three aspects of the issue. These were the clients’ perception of the therapist, the client’s preferences in therapist selection, and the outcomes of the treatment. The average effect sizes (Cohen D) were, respectively, 0.63, 0.32, and 0.09, for preference for one’s own racial/ethnic therapist, for preference for one’s own racially/ethnic matched therapist, and for the therapeutic outcome. When there was a match between the client and therapist racially/ethnically, the results were interpreted as showing a moderately strong preference. A somewhat more positive perception and no difference in outcome between racially matched versus no racially/ethnically matched client therapist arrangements. However, the benefits of ethnic matching cannot always be assumed. One of us (SO) can vividly recall four cases of matching with Africans which were negative. One was a woman who had lost her husband. She did not perceive my intense attention to listen to her as sufficiently empathetic. As she was relating her story, she challenged me with “you don’t even say you are sorry.” Another was a student who was not forthright in giving me the necessary clinical and background information. He probably felt I might know members of his family. The third was an individual who I was unable to socialize as to the primacy of keeping her appointments. The fourth was an African woman, very educated, burdened by having several children; additional burden was placed on her by her husband who wanted more children. She had psychotic episodes and was prescribed antipsychotics. However, she felt she benefitted more from the services of an itinerant Imam who visited her city and read her from the Koran. These examples are however exceptions, but they direct us to inquire from the patient their wishes, even with a simple question “Do you think I am the type of person who can help you?” The second issue has to do with somatization and other psychosis like symptoms as occur in Post-Traumatic Stress Disorder and other anxiety disorders in persons from non-Western countries. The matter is dealt with exquisitely by Van Moffaert based on her research on Mediterranean migrants in Belgium (Van Moffaert 1995). She observed that for that population, matters of mind and body tend to be holistic

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and rather inseparable and that somatization represents a direct message of distress. Similar findings have been made by other workers. The mental health worker has to distinguish between the presence of spirits and a true pathological preoccupation with the body. In some cultures, the spirit world almost coexists with the terrestrial world. Therefore, rituals and behaviors that reflect this may not be misinterpreted.

Summary and Conclusion In this chapter, we presented data on the complex and yet unsettled issue of the association of migration and psychosis. Various explanations were given for the association of migration and increased risk of psychosis. We suggested a protocol for the assessment of migrants and their families. An ethnographic and anthropologic approach that takes into account the world view and explanatory models of the migrant is emphasized. The use of screening instruments may be helpful in the detection of vulnerable individuals and cases. These instruments should be culture sensitive. Treatment should be appropriate and humane. The limit of matching clients with providers is mentioned. The chapter concludes with the need to properly understand the role of somatization in the presentation of psychosis in individuals from non-Western societies.

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Migration History and Psychopathology

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Mauro Braca, Domenico Berardi, Giuseppe D’Andrea, and Ilaria Tarricone

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migrants’ Vulnerability: An Anthropological Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration and Corporality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Micro- and Macro-social Factors of Psychopathological Vulnerability in Migrants . . . . . . . . . . Epidemiological Perspectives: Migration History and Psychopathology . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Migration is an ever-painful event which may expose personal vulnerabilities: individuals may experience the loss of the symbolic, cultural, and social reference framework, the arrest of the ongoing processes of identity formation and reproduction, and the paralysis of temporalization. The scientific research on mental disorders in the migratory and transcultural context mainly focuses on the identification of the pre-, intra- and post-migratory M. Braca · I. Tarricone (*) Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy e-mail: [email protected]; [email protected] D. Berardi · G. D’Andrea Department of Mental Health and Pathological Addiction, Local Health Authority, Bologna, Italy Bologna Transcultural Psychosomatic Team, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_26

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risk factors, with particular attention to the latter phase which is more associated with the onset and structuring of psychic disease in the migrant population. It is therefore necessary to further implement the research on the relationship between psychopathology and migration history in order to better understand the psychic vulnerability in the migration context. Keywords

Migration · Psychopathology · Culture · Identity

Introduction Migration is an ever-painful event. To abandon one’s birth land and loved ones, the cultural codes of one’s own country and one’s own language, and to find oneself outside the usual semantic and affective networks that give meaning to experiences and provide support in the phases of social and individual change can upset balances, certainties and values achieved in the course of a lifetime: even more so when this occurs in conjunction with the discovery of a new world, “where everything is difference” (Beneduce 1998), and in which the individual is required to adapt, if not bend, to the logic of the host country. Constantly suspended between two worlds, migrants find themselves experiencing feelings of nostalgia for their homeland and, at the same time, structural uncertainty about their position and their role in the host society (Sayad 2002). For a historical and epidemiological background of migration, see ▶ Chap. 2, “Migration, Globalization, and Mental Health”

Migrants’ Vulnerability: An Anthropological Perspective The first factor of vulnerability for migrants is the loss of cultural and social context. Migration produces in fact a progressive contraction of relevance and power of one’s symbolic systems which, albeit fragmentarily and slightly out of context, usually continue to operate and hold together bonds, metaphors, and memories of individuals for long before resulting in peculiar forms of intrapsychic conflict even many years after the actual migratory event. The traumatism of the loss of the internal cultural framework, which triggers the process of decoding the external reality, would therefore be the essence of migratory trauma (Nathan 1987; Moro 2002), in which the deep core of identity can be disorganized, become disharmonious once unstuck from its outer shell, eventually declining in different psychopathological forms. Another element of vulnerability connected to migration is identity crisis: more specifically, the crisis of the constant process of identity reproduction. Identity, the outcome of self- and hetero-perceptions, is an extremely composite material in whose formation different variables concur (gender, social status, age, linguistic

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style, education, religious affiliation, etc.). It is a dynamic construction continually renewed in the dialogic relationship with the other: in fact, in order to build one’s identity, it is necessary to constantly recognize that of the other. Therefore, the very concept of identity implies the notion of alterity: the other is established and perceived as another myself, and not assumed as radically or absolutely other in a perspective of ontological rupture. According to Francesco Remotti (1996), in fact, identity is not built only by reducing, by cutting off the multiplicity of possibilities, by marginalizing alterity, but rather identity also means resorting to, using, introducing, and incorporating alterity in the developmental and metabolic processes of identity. Alterity has a formative and not simply additional or oppositional role in the constant process of identity negotiation. In light of this conception of identity construct, the difficulty of the continuous reproduction of identity in the existential situation of migrants could be defined as self-evident, because here the other is often a very distant subject from a cultural, linguistic, and social point of view, if not sometimes frankly hostile. Moreover, in the migratory situation, the dialogic relationship is often invalidated by political speculations and social conflicts which can push the migrant towards absolutistic identity positions such as entrenchment or overadaptation (Mazzetti 2003). In order to better understand the vicissitudes of identity through migration, however, it is necessary to consider a crucial aspect of the temporalization of migrants’ lives, namely the temporal fracture connected to the migratory process. Migration inevitably infringes the threads of one’s own existence, causing “a discontinuity starting from which the before and the after will take on a new value” (Beneduce 1998), an interruption in the psychological becoming which is both evolution and history, and whose function is that to integrate the past into the present in a unity without conflict (Foucault 1997). However, this process can be pathogenic “to the extent that the link between the present and the past is not constructed in the manner of progressive integration” (Foucault 1997). It is precisely on this link that migration can have its most destructuring effects: by complicating the attribution of meaning to everyday experiences lived in a different world, by raising doubts and anxieties about a reality that appears less and less tangible, or by reactivating conflicts and confrontations. The “victim” of this process turns out to be the identity of the migrant, or rather the concatenation of his dis-identities, wanting to consider with this latter term that constant process of transformation that leads individuals to never be identical to themselves, to be “disidentical [. . .] in different conditions of space and time,” and at the same time be “a story that unites all these dis-identities” (Mazzetti 2003). Therefore, the immigrant and the emigrant are not the same person but rather are the two space-time extremes that enclose the migratory and emotional history of the migrant. Precisely this “thread” linking the various dis-identities can be torn apart in a migratory context, complicating the natural process of transformation and remodeling of the self of every human being. Such risk exists especially when this “call to the transformation of the individual and his relationship with the world,” when this “hybridization” takes place “without the

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time for a conscious and intentional integration” (Coppo 2003) between the individual and the external reality, between past and present; in this case, “the hybridization is transformed into deculturalization, in the loss of old references, not replaced by others” (Coppo 2003), “leaving individuals without the fundamental mechanisms of protection and [. . .] of reproduction of their own identity” (Beneduce 1999). The uprooting from the cultural and symbolic framework and the insertion into a new social fabric, full of different and often contradictory meanings, can therefore provoke a laceration in the existential continuity of the migrant.

Migration and Corporality Often it is the body that becomes the scene of the social and affective life of the individual, a true “embodied metaphor” of psychic distress represented “according to the collectively significant codes” (Vacchiano 1999), “an appropriate idiom to describe the malaise” (Beneduce 1996). The migrant often bears a responsibility that goes far beyond the purely individual dimension: they become, in fact, the custodians of a collective mandate that sees them involved with their reference group as a “form of investment” for all those who remain in the country of origin. At the time of migration, a “dynamics of investment” germinates, entailing unavoidable consequences: the more intensely one invests in a project, the less bearable the failure is. The breadth of the original scope often makes it difficult to tolerate failure, for those who live it and for those who have invested in it. “The emigrant has the obligation of success, which is expressed in relation to himself and in relation to the expectations of his family and his social group, whether the departure is in accordance with a mandate from the relatives, or whether it happens as a break from them” (Taliani and Vacchiano 2006). In cases of failure, “it then becomes necessary to elaborate a set of cognitive strategies that have the double outcome of reducing the scope of the initial investment or of concealing its consequences [. . .]. The sense of incapacity and inadequacy emerges through forms of discomfort and malaise that often find in the local codes of the body and of the disease important ways of signification” (Taliani and Vacchiano 2006). Conforming to the biomedical reality of the host countries, migrants find in somatization an important communicative language (often the only possible language) through which to convey one’s suffering and see one’s inner pain legitimized; in the words of Zempleni (1999), “psychosomatic disorders are conceivable [. . .] as the unconscious waste of the biomedical model, in which the production of an attestable organic alteration is the main criterion of social validation of the disease.” These disorders often reflect “the desire to unconsciously withdraw from unsustainable rhythms and demands,” as well as “the profound and insistent demand for one’s own individuality” (Beneduce 1998), often unrecognized except at the time of illness: questions and desires, these, expressed through modalities learned in the process of transculturation.

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Micro- and Macro-social Factors of Psychopathological Vulnerability in Migrants In addition to the existential challenges of migration and the failure of the migration project previously mentioned, other factors can determine mental suffering once migrants have entered the new social fabric. In his study on the relationship between mental health and migration in Quebec, Morton Beiser (1988) has identified several fragilization factors deemed to cause or favor the onset of mental disorders in migrants: • • • • • •

A bad socioeconomic situation The inability to speak the language of the host country Separation from the family Negative attitudes on the part of the native population The scarce possibilities of finding support in the community of origin A stress or trauma prior to migration and resulting from the social or political situation in the country of origin • Age at migration (migrating during adolescence or old age increases the risk of mental disorders) Beiser’s conclusion is that migration itself does not increase the risk of developing mental disorders; it is rather circumstances and living conditions that create a context susceptible to favoring the onset of such disorders, which therefore must always be considered within macrosocial variables (Beiser 1988). More recently, several studies have shown the relevance of social disadvantages (such as unemployment, poor living condition, absence of an affective relationship, low education, etc.) and of their cumulative effect on increasing risk of psychosis among migrants (Stilo et al. 2017). So, it is only through a systematic analysis of the context that it is possible to understand the meaning of mental distress in migrants and operate appropriately within the social and symbolic networks in which these personal experiences and collective phenomena are situated (Beneduce 1998). Indeed, it is within such networks that there are also some of the effective resources for reestablishing uncertain connections and broken links.

Epidemiological Perspectives: Migration History and Psychopathology In the last two decades, the relationship between mental health and migration has been the subject of various investigations by the international scientific community. Studies were mainly prompted by the finding of a higher prevalence of mental disorders among migrants or ethnic minorities compared to natives or fellow countrymen without migratory experiences (Bhugra 2003; Cantor-Graae and Selten 2005; de Wit et al. 2008; Fearon et al. 2006; Hutchinson and Haasen 2004). In

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particular, there has been a progressive increase in studies that did not limit themselves to considering migration as a mere risk factor – or as a proxy for other factors – and so have tried to push further its analysis by exploring the characteristics inherent to the very migratory experience. Most of the studies currently available, conducted mainly in north European and Anglo-Saxon environmental contexts, focus specifically on psychotic disorders, tracing different etiological hypotheses in relation to the characteristics of the migration history. The latter was broken up and analyzed in three main phases (pre-migration, migration process, post-migration), each of which includes specific risk factors for the onset of mental disorders (Bhugra and Jones 2001): the most significant of these lie in the post-migration phase and, in particular, in the difficulties of integration in the host society (Kirkbride et al. 2007; van Os et al. 2001), in a greater level of perceived discrimination (Berg et al. 2011; Cooper et al. 2008), in the relative poverty of one’s social capital (Allardyce et al. 2005; Kirkbride and Jones 2011), in the mismatch between their own pre-migration expectations and their actual realization (Reininghaus et al. 2008), and in a worse quality of general health in the post-migration context (Tarricone et al. 2009a). These findings mirror those highlighted by van Os (2008), for whom social exclusion, discrepancy between expectations and realization, lack of confidants/emotional relationships and loneliness are important factors along the etiopathogenetic cascade that leads to psychotic onset. Such unfavorable life experiences would figure among the socioenvironmental stressors whose accumulation, according to the sociodevelopmental model of Craig Morgan et al. (2010), would interact with a specific genetic predisposition and impact on brain development (in particular on the dopaminergic system), as well as on personal sensitivity to stress, inducing a state of persistent vulnerability to psychosis, consisting of social bias, psychoticlike experiences, and affective disorders. In other words, social experiences and the socio-environmental context are factors that determine which vulnerable individuals will develop psychosis. Risk factors for the development of psychosis are not only at the individual level but also in the living and social area of the individual. The risk of developing psychosis is higher in urban areas (Krabbendam et al. 2005; Lewis et al. 1992; Mortensen et al. 1999); however, the reason remains unclear; it is assumed that one reason could be social isolation, which can occur in large urban areas (van Os et al. 2001). Indeed, the quality and the resources of the social structure in which a person lives (social capital) may significantly affect their risk of developing psychosis (Kirkbride and Jones 2011). Some studies have shed light on how urban areas with the presence of strong socioeconomic disparities show a higher incidence of psychosis (Mueser and McGurk 2004). Migration is a life experience that puts the individual at an increased risk of dealing with the events and factors listed above (Bhugra and Jones 2001; Morgan et al. 2010). These factors may represent the key to understanding the higher rate of psychosis in migrants described by Morgan and Hutchinson (2009) as “a public health tragedy.”

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In recent years, Chou (2009) and Ryan et al. (2006) have pointed out the role played by a poorly prepared migration project in the genesis of depressive disorders, while Tarricone et al. (2009b) have shown how certain migration projects can be associated with the development of specific mental disorders when implemented in unfavorable environmental contexts (higher incidence of depressive disorders in women passively migrated in the context of family reunification; more frequent finding of psychotic disorders in migrants who had undertaken the migratory experience in search of a job placement and found themselves unemployed and living in socially disadvantaged environments; higher incidence of anxiety and posttraumatic disorders in young refugees or asylum seekers with recent migration and difficulty in entering the host country’s social fabric). Another study from the same research group conducted on a nonclinical population has found that variables correlated to the migration experience (passive or recent migration, post-migration housing status) were associated to a higher incidence of psychotic symptoms, even in the absence of a diagnosis of a frank psychotic disorder (Tarricone et al. 2009a). A study by Braca et al. (2014) has shown that migrants can present peculiar and polymorphic phenomenal expressiveness of mental disorders from which they are affected, denoting a limited validity of the usual diagnostic and nosographic categories in the circumscription and identification of mental suffering – and of the modalities to experience it – of this population. In those patients diagnosed with a psychotic disorder, the main psychopathological dimension extracted through the factor analysis was the somatic syndrome. Somatic symptoms are an important way of experiencing mental distress: they represent “cultural idioms of distress” (Kirmayer and Young 1998), “culturally prescribed modes of understanding and narrating health problems and broader personal and social concerns” (Kirmayer and Sartorius 2007), ways of signifying one’s own experiences through embedded fragmentary metaphors. Preliminary results of the PEP-ITA study, which was conducted on migrants presenting a first-episode psychosis in Italy and analyzed the psychopathological dimensions underlying clinical diagnoses (Tarricone et al. 2014), the somatic syndrome scores were significantly associated to events related to migration history (passive migration, perceived discrimination in the host country). Furthermore, the most pronounced psychotic syndromes (paranoid-hallucinatory syndrome and manic syndrome) were mainly associated with recent life events correlated above all to migration: poorly planned migration and lack of feeling of belonging to the territory of residence for manic syndrome, mediocre economic remuneration for paranoid-hallucinatory syndrome. Finally, poorly prepared migration was significantly associated with greater severity of the overall symptomatology at the onset of psychosis (Braca et al., submitted). Migration history – and the narration of the experiences that have contributed to writing it – needs privileged listening when dealing with a clinical population of migrants, frequently made up of individuals with extremely heterogeneous roots and life histories. The in-depth study of the migratory history of migrant women and men with mental disorders was recently included in the European research project EU-GEI

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(European Community’s Seventh Framework Program No. HEALTH-F2-2010241909: Project EU-GEI – European Network of National Schizophrenia Networks studying Gene-Environment Interactions). It involved study centers located in 11 European countries (the United Kingdom, Holland, France, Spain, Turkey, Germany, Italy, Austria, Belgium, Ireland, and Switzerland) and in 2 non-European countries (Hong Kong/China and Australia), and it aimed to extensively investigate the genetic, clinical, and environmental risk factors associated with the onset, severity, and outcomes of schizophrenia. In this project, the analysis of migration history has been carried out by using the Bologna Migration History Questionnaire and Social Integration Interview (BoMHQ): this instrument has been developed by the Bologna Transcultural Psychosomatic Team (BoTPT) research group from the University of Bologna in the light of the results obtained from the studies conducted by the group itself over the years (Tarricone et al. 2009a, b). This tool evaluates the conditions and the life satisfaction in the pre-migration, migration, and post-migration phase, as well as the factors related to the planning of the migration process and its implementation, the satisfaction of pre-migration expectations, the degree of social support received in Italy, and the existential planning deriving from the migratory experience.

Conclusions Migration is an ever-painful process, potentially responsible for a halt in the historical evolution of the individual and of the identity, which can evolve into several psychopathological disorders. It is therefore necessary today to further implement the research on the relationship between the identity transformations during the migratory history and the psychopathology.

Cross-References ▶ Migration, Globalization, and Mental Health

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hukou and the Marginalized Life of Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . Prevalence of Mental Health Problems Among Chinese Rural-to-Urban Migrant Workers . . . Time-Trend in the Prevalence of Mental Health Problems Among Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Service Utilization of Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . Factors Associated with Mental Health Problems Among Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Nonfatal Suicidal Behaviors Among Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Factors Associated with Nonfatal Suicidal Behaviors Among Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pattern of Mental Health Morbidity Among Chinese Rural-to-Urban Migrant Workers: Summary and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A High Level of Unmet Mental Healthcare Need Among Chinese Rural-to-Urban Migrant Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health of Chinese Rural-to-Urban Migrant Workers: The Future . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

In many countries, internal migration has been increasing dramatically over the past five decades or so. The reasons for internal migration are many. Internal migration contributes to urbanization. The speed of migration from rural to urban

B.-L. Zhong Department of Social Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong Province, China H. F.-K. Chiu (*) Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, SAR, China e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_28

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areas along with the sheer numbers in China has contributed to economic development in China and also consequent social development. Not surprisingly males are much more likely to migrate sometimes leaving families behind who subsequently may or may not follow them to the cities. Significantly higher scores of psychopathology have been found among migrant workers. They also have higher levels of unmet needs regarding healthcare. There are specific challenges related to mental health and well-being of older adults. In view of the ongoing pandemic, public mental health interventions are needed. Keywords

Internal migration · Migrant workers · Public mental health · Urbanization · Rural-urban migration · Migrant mental health

Introduction Population migration, including internal and international migration, is the main driver of urbanization and globalization. In China, since the “Reform and Open” policy and market-oriented economic reform in 1978, there has been a dramatic growth in the number of people who move from poor rural areas to prosperous urban areas, a population named “rural-to-urban migrant workers” (“Nongmingong” in Chinese) (Fig. 1). China has the world’s largest number of rural-to-urban migrant workers, and, in 2019, the total number of migrant workers was 290.77 million, representing 20.8% of the total Chinese population (National Bureau of Statistics of China 2020b). The massive rural-to-urban migration has substantially contributed to China’s rapid socioeconomic development, rural poverty reduction, and transformation from a traditional peasant society to an industrial one during the past four decades (Chan and Zhang 1999). Nevertheless, due to China’s unique household registration system (“hukou”) and dual social urban-rural structure, migrant workers are confronted with a variety of challenges in their urban living, including less job opportunities, difficulties in socially integrating into the urban societies, limited access to social welfare and public services, social discriminations, low medical care insurance coverage, infectious diseases, and mental health problems (Mou et al. 2013; Tian et al. 2019; Wong et al. 2007).

Hukou and the Marginalized Life of Chinese Rural-to-Urban Migrant Workers Unlike household registration systems of most countries in the world, which are adopted for the purpose of population statistics and identifying personal information, China’s hukou system is additionally used for dichotomizing citizens at birth into rural and urban groups, preventing the free flow of rural labors, and determining a

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300 280 260 240

Number (million)

220 200 180 160 140 120 100 80 60 40 20 0

Year Fig. 1 Total number of rural-to-urban migrant worker in China, 1978–2019. (Data from National Bureau of Statistics of China [http://www.stats.gov.cn/] and National Health Commission of China [http://www.chinaldrk.org.cn/wjw/#/home]. Figures before 2001 are unavailable due to no nationwide surveillance system of migrant workers, which was established until 2008)

citizen’s accessibility to social services and welfare benefits (Lei and Liu 2012). Because of the shortage of labor force in cities and increasing number of surplus labor forces in the rural areas since the economic reform, the hukou system was no longer used for controlling rural-to-urban migration. However, its essential operational mechanism, determining one’s access to social services according to the hukou category, is still kept and continues (Bai 2012). Because of this, people with rural hukou are given less opportunities of employment, housing subsidies, free education and health care, and old age pension (Chan and Zhang 1999). In recent years, although the Chinese government has gradually softened criteria for hukou conversion from rural to urban in small- and middle-sized cities, the allocation of public service resources in cities still largely depends on the hukou status (Lu et al. 2019). Even for farmers who have obtained the urban hukou, the social benefits such as education they enjoy are still limited by their previous rural hukou status (Jie 2019). Until today, migrant workers are still the underclass of city societies and remain segregated from urban residents in China. According to China’s population statistics in 2018, compared to the general population, migrant workers are characterized by overrepresentation of males (65.2% vs. 51.1%), younger age (% of 16–40 years: 52.1% vs. 34.9%), higher percentage of an educational attainment of junior middle school (55.8% vs. 31.3%), and higher percentage of being employed in labor-intensive industries (49.1% vs. 27.6%) (National Bureau of Statistics of China 2019, 2020a). Empirical

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evidence also shows that Chinese migrant workers are more likely to be separated from families, have insufficient job skills, work overtime, exposure to workplace hazardous factors, and take up “3-D” jobs that urban residents are unwilling to do (dirty, dangerous, and demanding) (Fitzgerald et al. 2013; Lau et al. 2012). Therefore, migrant workers have been acknowledged as a socially and economically vulnerable group for a long time in urban China. In 2010, a cluster suicide of 14 migrant workers shocked the general public around the world, which occurred in the Foxconn factory in Shenzhen, China (Cheng et al. 2011). Since then, this tragedy has aroused great public concern and much research interest about the mental health morbidity among millions of migrant workers; however, explanations on this phenomenon vary considerably. In the following section, we systematically summarize available epidemiological studies on mental health problems and nonfatal suicidal behaviors in Chinese migrant workers, in an attempt to inform the public mental health policymaking and the development of mental health services for this special population.

Prevalence of Mental Health Problems Among Chinese Rural-toUrban Migrant Workers Most existing studies focused on the psychological symptoms of Chinese migrant workers and a variety of symptom self-rating scales were used with the Symptom Checklist-90-Revised (SCL-90-R) being the most common (Mucci et al. 2020; Shen et al. 1998; Yang et al. 2016). While there are a few inconsistent findings, the majority of studies using SCL-90-R reported significantly higher scores in migrant workers than the general population on all the nine subscales of SCL-90-R when Chinese SCL-90-R norms were used as reference (Zhang et al. 2012). Two large-scale surveys used the Center for Epidemiologic Studies Depression Scale to assess depressive symptoms of migrant workers in Chengdu and Shenzhen, China, respectively, and revealed that over one-fifth migrant workers (21.4–23.7%) had clinically significant depressive symptoms (Mou et al. 2011; Qiu et al. 2011). Another large-scale survey administered the Beck Depression Inventory to assembly-line migrant workers in Shenzhen, China, and reported that as high as 31.7% migrant workers had clinically significant depressive symptoms (Ren et al. 2019). Zhong and colleagues employed the General Health Questionnaire to assess the presence of psychological distress in a sample of 3031 factory migrant workers and found that 34.4% migrant workers were psychologically distressed (Zhong et al. 2018). When comparing with nonmigrant urban counterparts, migrant workers presented significantly more psychological symptoms (Li et al. 2009; Shen and Fan 1997), depressive symptoms (Lam and Johnston 2015; Li et al. 2019), and emotional health problems (Yi et al. 2019). However, studies comparing the mental health of migrant workers with rural nonmigrant counterparts presented mixed results: one found similar prevalence of emotional health problems (Yi et al. 2019), one reported more depressive symptoms in migrant workers (Li et al. 2009), and one revealed less depressive symptoms in migrant workers (Dai et al. 2015). Because Chinese

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rural residents per se have more psychological symptoms than urban residents and the severity of psychological symptoms may differ across rural populations (Zhang et al. 2008), the above mixed comparative results are expected. To address inconsistent findings on the mental health of Chinese migrant workers, a meta-analysis that included 48 studies with a total of 42,813 migrant workers was conducted (Zhong et al. 2013). Findings from this pooled analysis confirmed the significantly higher prevalence of psychological symptoms in migrant workers than the general population, and more psychological symptoms in migrant workers than urban residents, but found no significant prevalence differences between migrant workers and rural residents in terms of most psychological symptoms. High prevalence rates of both psychological symptoms and common mental disorders have been reported in many studies with samples of international migrants (de Wit et al. 2008; González-Castro and Ubillos 2011; Lindert et al. 2009). However, unlike international migrants, Chinese migrant workers did not exhibit higher prevalence of common mental disorders. For example, two clinical interviewbased surveys found that 1.4% of the factory and 2.5% of the service industry migrant workers suffered from major depression during the past month and the two prevalence estimates fall into the normal range of prevalence of major depression in the Chinese general population (1.3–4.3%) (Xu et al. 2016; Zhong et al. 2015). A further supporting evidence is the comparable prevalence of mood and anxiety disorders between migrant workers and the general population in a largescale interview-based study (Zhong 2014). An interesting finding that deserves to be emphasized from this study is the much higher prevalence of adjustment disorders (1.9%) in migrant workers compared to the general population (0.02–0.13%).

Time-Trend in the Prevalence of Mental Health Problems Among Chinese Rural-to-Urban Migrant Workers Although the hukou system still remains, the social welfare for migrant workers has been gradually improved in recent years (Li and Zuo 2018). Correspondingly, in a cross-temporal meta-analysis, researchers have observed the declining time-trend of the prevalence of psychological symptoms among migrant workers in recent years, which was more substantial among migrant workers of eastern China, female gender, and manufacturing industry (Huang et al. 2015). However, this study also revealed an increasing time-trend in the prevalence of psychological symptoms among young and male migrant workers.

Mental Health Service Utilization of Chinese Rural-to-Urban Migrant Workers Worldwide, the underutilization of mental health services is very common among migrant populations (Lindert et al. 2008), and Chinese migrant workers are no exception. For example, in a study on mental health services utilization, compared to urban dwellers, migrant workers had higher rate of reporting a need for mental

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health services when they were anxious or depressed (61% vs. 50%), but had significantly lower rate of the actual help-seeking from someone (39% vs. 67%) (Li et al. 2007). Moreover, the rate of mental health service utilization in migrant workers with mental disorders was extremely low: two interview-based studies found that only 4.9% migrant workers with lifetime mental disorders and 3.3% migrant workers with lifetime major depression had ever sought help from mental health professionals (Wei et al. 2013; Zhong et al. 2015).

Factors Associated with Mental Health Problems Among Chinese Rural-to-Urban Migrant Workers Like correlates of mental health problems in the general population, indicators of a low socioeconomic status and poor social support are the two most common types of factors associated with mental health problems in migrant workers: a low level of education, family financial problems, no medical insurance, low monthly income, bad living conditions, “no relatives in the city,” and “no friends in the city” (Li et al. 2007; Liu et al. 2010; Qiu et al. 2011; Zhong et al. 2015). Other important correlates of mental health problems in this population can be divided into two groups: pre- and post-migration. In the literature, the former includes migrating before adulthood, reluctance to migrate, and originating from south China (versus north China) (Yang et al. 2012; Zhong et al. 2015), while the latter includes high migratory stress, bad adaptation to city life, uncertainty about personal future, short duration of city residence, separation from family members, homesickness, infrequently calling family members, long working hours, poor Mandarin proficiency, perceived social stigma, and discriminatory experiences (Mou et al. 2011; Qiu et al. 2011; Shen et al. 1998; Wang et al. 2010; Wong et al. 2008).

Prevalence of Nonfatal Suicidal Behaviors Among Chinese Ruralto-Urban Migrant Workers In China, no population-based data is available regarding the suicide rate in migrant workers. Five large-scale studies reported a low prevalence of nonfatal suicide behaviors among migrant workers during their lifetime: ideation: 0.64– 12.8%, plan: 0.4–8.1%, and attempt: 0.15–4.6% (Chen et al. 2019; Li et al. 2007; Sun et al. 2008; Zhong et al. 2019; Zhou et al. 2016). Four large-scale studies found that prevalence rates of one-year suicidal ideation, plan, and attempt among migrant workers were 1.3–9.6%, 1.2–1.7%, and 0.5–3.6%, respectively (Dai et al. 2015; Yan et al. 2009; Yu et al. 2018; Zhou et al. 2020). Although these rates vary widely, on the whole, these lifetime and one-year prevalence estimates are still within the prevalence range of the Chinese general population (Cao et al. 2015; Zhong et al. 2019). Accordingly, Ding and colleagues assessed the suicide risk of 1845 migrant workers with the Mini International Neuopsychiatric Interview (MINI) and found only 2.2% at risk for suicide (1.6% low and 0.6%

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moderate-to-high) (Ding et al. 2013). In another study the risk of suicide was as high as 13.8% in the rural population in China, as defined by the MINI (13.0% low and 0.8% moderate-to-high) (Xu et al. 2017).

Factors Associated with Nonfatal Suicidal Behaviors Among Chinese Rural-to-Urban Migrant Workers Factors associated with nonfatal suicidal behaviors among migrant workers are similar to those among the general population. The most commonly reported factor is indicators of poor mental health, including depression, anxiety, and loneliness (Ding et al. 2013; Zhong et al. 2019; Zhou et al. 2016). Other reported factors include lack of social support, poor working conditions, history of abuse in childhood, alcohol drinking, and low self-esteem (Chen et al. 2019; Sun et al. 2008; Yan et al. 2009; Yu et al. 2018; Zhou et al. 2020). Few studies have examined the relationships between nonfatal suicidal behaviors and post-migration factors in this population such as discrimination, city adaptation, and working hours. A study assessed the attitude towards suicide (ATS) of migrant workers and found significant and independent associations between negative ATS (attitudes against suicide) and low rates of nonfatal suicidal behaviors (Zhong et al. 2019). Importantly, the majority migrant workers hold a negative ATS, which may explain the relatively low risk of suicide in this population.

Pattern of Mental Health Morbidity Among Chinese Rural-toUrban Migrant Workers: Summary and Explanations Undoubtedly, migration has negative effects on the mental health of migrants, because its process is associated with loss and changes and with substantial psychosocial stress. So a high risk of common mental health problems and death by suicide is frequently noted in international migrants (Close et al. 2016; Forte et al. 2018). For Chinese migrant workers, their mental health is additionally challenged by the social inequity caused by the hukou system and workplace psychosocial stressors. As a result, currently available evidence reviewed above shows a high prevalence of psychological symptoms and distress among migrant workers. However, what is counterintuitive is no convincing evidence supporting the elevated risk of common mental disorders and nonfatal suicidal behaviors among this population. We speculate that there are several possible reasons for these observations. First of all, although both psychological symptoms and mental disorders belong to the mental health continuum, they are different mental health constructs. So the mental health morbidity pattern, higher prevalence of psychological symptoms and comparable prevalence of common mental disorders and nonfatal suicidal behaviors in migrant workers relative to the general population, is not surprising. Second, as evident by a qualitative study, due to significant cultural differences between rural and urban societies in China, migrant workers have to experience substantial

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rural-to-urban acculturative stress including difficulties in adapting to the city environment, work-related stress, family-related stress, financial hardship, and lack of sense of belonging to cities (Zhong et al. 2016). Because of stress-related reactions, psychological symptoms and distress are more likely to occur among migrant workers. This feature is also consistent with the aforementioned higher prevalence of adjustment disorders in this population. Third, in Chinese culture, enduring hardships and being hardworking are common traits of migrant workers (Wu 2004), implying that these people may be more resilient to migration-related difficulties. This attribute may prevent the development of mental disorders from psychological symptoms. Fourth, one of the main goals of migration of migrant workers is to earn money and support their rural families. Therefore, despite the presence of psychological symptoms and distress, migrant workers’ inherent sense of family responsibility, as well as the abovementioned negative ATS, might reduce their risk of non-fatal suicidal behaviors. Fifth, migrating to cities for work has benefits for migrant workers such as improving economic conditions and enriching social experiences. These benefits may increase mental well-being and offset the negative effects of rural-to-urban migration, thereby lowering the risk of mental disorders and nonfatal suicidal behaviors in migrant workers. For example, a high level of perceived benefits of migration was found to be associated with a low risk of mood disorders and nonfatal suicidal behaviors in migrant workers (Zhong 2014). Sixth, unlike international migrants, migrant workers move within a relatively homogeneous society without race and color discrimination and with less religious, cultural, and language barriers. Therefore, common mental disorders are less prevalent in migrant workers than international migrants. Finally, the comparable prevalence of developing common mental disorders in migrant workers and the general population might be the result of selection bias in study samples of migrant workers, because those with severe mental health problems are more likely to have returned to their home villages and hence are not included as study subjects. For example, a comparative study found significantly poorer emotional health in migrant workers who had returned to home villages than migrant workers who stayed at cities (Yi et al. 2019).

A High Level of Unmet Mental Healthcare Need Among Chinese Rural-to-Urban Migrant Workers The findings on the mental health service utilization of migrant workers reviewed earlier in this chapter are disturbing because over 95.0% of the migrant workers with mental disorders never sought help from mental health professionals in their lifetime, suggesting a high level of unmet mental healthcare need of this population. Given the high level of perceived need for mental health services (61.0%), poor mental health literacy may not be the main reason for this issue. Possible reasons for the very low rate of mental health service utilization may include the lack of a nationwide health services scheme, the low medical insurance coverage for migrant

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workers, perceived stigma associated with psychiatric disorders, and inadequate mental health resources provided in workplaces (Mou et al. 2013; Wei et al. 2010).

Mental Health of Chinese Rural-to-Urban Migrant Workers: The Future Currently, China’s ongoing hukou system reform is aiming at creating a more people-centered system (Li and Zuo 2018); however, the existing hukou system cannot be abolished or changed radically in the short run. So the largest vulnerable group of Chinese society, migrant workers, and its mental health morbidity, will still exist for some years. Given the very large size of this population and its very low rate of use of mental health services, public mental health interventions targeted at migrant workers should be an effective way to reduce the burden of mental disorders in China. The health authorities and policy-makers may need to reform the existing mental health services system to ensure that the services are easily accessible and available to migrant workers in need, for example, transforming the mental health services model from hospital-based to community- and factory-based and increasing medical insurance coverage. The second issue of migrant workers that deserves special attention is the mental health of “elderly migrant workers” (>50 years), which is an emerging but rapidly growing subpopulation of migrant workers due to population aging in China. For example, from 2009 to 2019, the total number of elderly migrant workers had sharply increased from 6.1 to 71.5 million (National Bureau of Statistics of China 2020b). Due to poor physical health, lack of vocational skills training, being employed in low-end industries, and no old-age pension after retirement, they have been a particularly vulnerable group of contemporary China. An empirical study has shown the significantly poorer mental health in elderly than young and middle-aged migrant workers (Wu et al. 2016). The mental health services for elderly migrant workers are urgently needed. Third, the ongoing COVID-19 pandemic is very likely to have profound effects on the mental health of migrant workers, because it remains unknown how long it will last and many factories have been shut down or closed in China. The mental health of unemployed migrant workers in cities and returned migrant workers in rural villages should be of great public health concern.

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Help Seeking Views Relating to Depression Among Older Black Caribbean Adults Living in the UK

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Contents Migration from the Caribbean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Depression and Older People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Black and Asian Minority Ethnic (BAME) Older Adults’ Accessing Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Help Seeking Attitudes Among the UK’s Black Caribbean Older Adults . . . . . . . . . . . . . . . . . . . . . Aims and Scope of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overview of Master Theme One: “If You Don’t Know, You Don’t Seek Help” . . . . . . . . . . Participants’ Experiences of Migration in Relation to Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Just Get on with It” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Participants’ Significant Relationships Experiences in Relation to Depression . . . . . . . . . . . . . . . Participants’ Experiences of Health Professionals and Listening Skills . . . . . . . . . . . . . . . . . . . . . . . Overview of Master Theme Two: “. . .I was Depressed. . .I Knew I was Depressed” . . . . . Grief in Later Life and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Matter of “Inconvenience” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Natalie Bailey would like to dedicate this chapter to her beloved parents Vilna Louise Cruickshank and Uriah Bailey, who both sadly passed away during her training on the professional doctorate program in Counselling Psychology. “I will forever remain grateful for their love, encouragement, and belief in me. We did it!” N. V. Bailey School of Psychology, University of East London, London, UK e-mail: [email protected] R. Tribe (*) School of Psychology, University of East London and Centre for Psychiatry, within the Wolfson Institute for Preventive Medicine, Queen Mary University of London, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_36

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Abstract

The need for community engagement within mental health services is being increasingly recognized nationally and internationally to improve services and ensure they meet the needs of all members of our communities. In the UK, rates of mental ill-health are thought to be higher in the Black Asian and Minority Ethnic (BAME) community when compared to the white population. For these reasons, further detailed research is required. In this chapter, eight Black Caribbean older adults (aged 65 years and over), who migrated to the UK as young adults, discuss and reflect upon a variety of personal experiences relating to depression and help seeking in their lives now, as well as looking back over their earlier experiences when they first migrated to the UK. Keywords

Help seeking · Depression · Older · Black-Caribbean.

First Author’s Personal Reflections

The experience of conducting research on help seeking views relating to depression among older Black Caribbean adults living in the UK was a thought provoking and fascinating experience for me. What particularly felt touching and remained strongly with me was learning about the participant’s experiences of arriving to the UK for the first time (as migrants) and how this influenced their thoughts and feelings of depression. With further reflection, I realized just how much of my personal history I was not aware of (being of Black Caribbean decent) and felt a profound appreciation for the evident effort my parents made to protect me from experiencing what they had experienced when first arriving to the UK. As I analyzed participants’ accounts, I recognized similarities in attitudes and values held within my own family and upbringing. For example, my parents (now both sadly passed away in recent years) had experiences similar to those of the participants in my research, they were given the “opportunity” to come to the UK to “better themselves,” and in turn improve the lives of their children. I recognized that they achieved this and subsequently I remain forever grateful. Reflexivity is a distinct feature of qualitative research (Banister et al. 1994; Barrett et al. 2020); in that the researcher acknowledges the impact of their own personal background (which might include but is not limited to culture, ethnicity, race, gender, age, sexuality, religion or other factors including migratory history), beliefs, and behavior on the research process (Finlay and Gough 2003). Therefore, in reflexivity not only are the participants included in the construction of the research and knowledge process but so is the researcher (Fade 2004). Furthermore, reflection is crucial to comprehending how (continued)

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meanings are described and interpreted within the research methodology of Interpretative Phenomenological Analysis (IPA) which is used in this study. Being a reflective practitioner involves a process whereby clinicians can explore their own beliefs, frames of reference, the language that is used (that carries its own meaning), and how this informs their own research or clinical work (Tribe and Morrissey 2020). Given this process, I understand that being a doctoral trainee Psychologist of Black Caribbean descent may sway what participants will share with me – meaning how their experiences are talked about, the knowledge formed, and the explanations made. Furthermore, I am aware that these aspects may influence my interpretation of the narratives explored. As a result, I maintained regular supervision and kept a reflective journal to try and remain mindful of these influences throughout the process. Willig and Stainton-Rogers (2008) note how the researcher’s own identity, values, and interests inevitably impacts in some way on the research process. For this reason, the interpretation of the analysis (in this study), to some extent, will almost certainly be colored by my own experiences. Nevertheless, a voice was given to a population, who are underrepresented in research; and as a result, this study may contribute further to knowledge on older Black Caribbean adults’ experiences and views that underlie help seeking behavior in relation to depression. It is hoped that this study could also contribute to assisting in the delivery of effective, culturally appropriate, and accessible mental health services for Older Black Caribbean people. It felt important to me to honor participants by ensuring their experiences were heard and understood. I am grateful to be part of the journey in achieving this.

Migration from the Caribbean The area known as the Caribbean is a group of over 7000 islands which comprises of 13 sovereign states and two dependent territories and is located by the Caribbean Sea (Caribbean islands 2020). The Caribbean covers approximately one million square miles. Many Caribbean islands had slaves forcibly brought from Africa to work on the plantations and in other jobs as part of the Transatlantic Slave Trade. A number of the Caribbean islands had been colonized by the British and other Caribbean islands by the governments of the Netherlands, France, Spain, and the USA. Independence was obtained for all the islands with links to Britain between 1962 and 1983. So the Caribbean has a long history of migration (both forced and voluntary) as well as colonization, discrimination, and human rights abuses stretching over a number of generations. Each island has a unique and individual identity and the islands vary in size, population, and economic wealth. The terms Caribbean and West Indies are often used interchangeably, but in fact the West Indies includes the area known as the Caribbean plus the Bahamas and the Turks and Caicos islands.

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Approximately 20,600 people from the West Indies volunteered to fight with the British in World War I (1914–1918) and 16,000 people in World War II (1939–1945) (MG Trust 2020). Many of these volunteers suffered racism, prejudice, and systemic inequalities during this time (Imperial War Museum 2020). Some of the people who had fought in WWII chose to remain in Britain. At the end of WWII, Britain required additional workers to assist in rebuilding the country and they turned to British Commonwealth countries (these are countries which had historical links through colonialism to Britain). The British Nationality Act of 1948 was developed to encourage immigration to Britain and gave all commonwealth citizens automatic entry into the UK. One of the boats bringing people from the West Indies was the SS Empire Windrush which came from the Caribbean island of Jamaica in June 1948. Many people migrated with high hopes of the “mother country” and were shocked by the blatant racism, structural disparities, and lack of welcome they received from some people and institutions in the UK (BBC 2020). By 1961 approximately 161,000 people (90,000 men and 71,100 women) had migrated from the Caribbean (British Library 2020). The enormous contribution they made to Britain after the war and subsequently future generations in all aspects of British life has only recently been openly recognized and celebrated. In 2018 a government backed national Windrush day is to be celebrated annually in recognition of these contributions. The latter appears to have partly been a response to the Windrush scandal (2018), this related to people from what has been labeled within the UK as the “Windrush generation.” These are people who migrated to the UK between 1948 and 1971 from the Caribbean and had never chosen to obtain British passports or other documentation, although they would have been entitled to these. Many of these people had worked most of their adult life in Britain and their descendants had been born in Britain. Some found themselves denied their legal rights and approximately 164 people were either detained or deported back to the Caribbean; since 2002, many were unable to receive medical treatment which they needed and numerous problems were caused (The Windrush Lessons Learned Review 2018, updated 2020). Following the Windrush review attempts at reparation were made, the psychological legacy of these events cannot be measured. The contribution that the Windrush and Caribbean community has made and continues to make in the fields of politics, health, the arts, and across the continuum is substantial. The term Windrush resilience has been used to describe the resilience exhibited by many people who migrated from the Caribbean.

Depression and Older People As the world’s population is living longer a variety of new services or adaptions to current services may be necessary to ensure their needs are met (Huq et al. 2020). In addition, this growth requires health professionals to develop better strategies of engagement with this population and among and between services. Many older adults are isolated, and this can particularly affect people with migratory histories as family members can be living in different countries. A number of older adults

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report feelings of isolation, loneliness, and marginalization (WHO 2016). In the UK, in excess of one million older adults have not talked to relatives, neighbors, or friends for at least a month (Age UK Buckinghamshire 2016). However, these numbers may be higher, as some older adults may not feel at ease with disclosing their circumstance to others (Tribe 2017). Isolation has been found to be a risk factor for depression (NHS England 2017). The National Health Service (NHS) England (2017) published “A primer for colleagues in primary care, in particular GPs, which highlights symptoms often attributed to ‘old age’ but where a mental health diagnosis and follow-up is more appropriate” (p.1). Half of all adults aged over 55 reported that they had experienced depression (Age UK 2017). NHS England (2017) noted that the symptoms exhibited by older adults may be markedly different to those shown by young adults and are frequently missed by health professionals. In addition, culture can influence presentation of distress, as well as help-seeking behavior (Fernando 2014). NHS England lists the risk factors for depression as including physical health problems, loneliness, life events (particularly bereavement), and loss of independence. They also list being female as a risk factor, although research shows that men are less likely to talk about their psychological distress (Mental Health Foundation 2016) or visit their GP (GP patient survey 2019) so this finding may partly reflect this. They reported that in addition to the symptoms found in younger adults, older adults might just present the following or these might be in addition to the traditional symptoms associated with depression. *Reporting physical rather than emotional symptoms (somatisation). Typical symptoms are: faintness or dizziness, pain, weakness all over, heavy limbs, lump in throat, constipation. • • • • •

Health anxieties (hypochondriasis), especially if unusual for the person. Prominent anxiety. Unusual behaviour. Hysteria does not exist in older people. Slowing down of emotional reactions or agitation. Psychotic features (delusions of guilt, poverty or physical illness, or having no clothes which fit. Auditory hallucinations with derogatory or obscene content, provoking guilt and paranoia) (NHS England 2017).

They also list an indicator for the diagnosis of depression as lacking interest in something which the person previously enjoyed and cite visits from grandchildren as a key indicator. Attention is also drawn to the possibility of Cotard’s syndrome (where a person feels that their insides are dead) and assuming a self-blaming causality. Although depression may be commonly experienced later on in life, many older adults report having good mental health and living meaningful, rich lives (WHO 2016). Furthermore, numerous older adults, having lived through and experienced difficult times, have successfully navigated through life, and in turn, demonstrate immense resilience (Centre for Policy on Ageing 2014). Importantly, resilience does not decrease with age; as a result, older adults are just as resilient as younger people (Gooding et al. 2012). As mentioned earlier, the term Windrush resilience has been used to describe the resilience exhibited by many people who migrated from the Caribbean.

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Nevertheless, many studies have found that the older adult population is more vulnerable to mental health concerns. The reason being that older adults are more often than not exposed to significant life events such as partner bereavement, retirement, the onset of a long-term health condition, social isolation, reduced functional ability and loneliness; as well as experiencing potential anxieties about poor health or death (Lane and Tribe 2017). Similarly, Kamiya et al. (2013) suggest depression is prominent later on in life due to the impact of disadvantaged health in childhood, socioeconomic challenges and pressurizing life events. Therefore, given the evident concerns surrounding this population, mental health providers may need to consider strategies to help older people to maintain wellbeing (preventative measures); and (when required) help older adult service users to access mental health services easily. Kamiya et al. (2013) argue that for some older adults the reason these factors are prominent later on in life links to the accumulative effect of a lifetime of difficulty showing itself through a number of health and economic discrepancies, often called the underlying social determinants of health which may play a role. In addition, depression experienced later on in life can be attributed to the intersection of several factors throughout the life span – that is psychosocial, genetic and psychological influences (Kamiya et al. 2013). In summary, older adults are susceptible to depression (Conner et al. 2010), and it is the primary reason of suicide among older adults (Mackenzie et al. 2006). Depression if left untreated can escalate the cost of health care, add to disability from other illnesses and shorten a person’s life span (Baldwin 2014).

Black and Asian Minority Ethnic (BAME) Older Adults’ Accessing Mental Health Services In the UK, there are few studies on the Black, Asian and ethnic minority mental health use (Mental Health Foundation 2016). What is more, in primary care, older adults from BAME groups have been found to have the highest risk of mental disorders not being detected (Borowsky et al. 2000). Evident concerns surrounding mental health service use from BAME older adults highlight the need for mental health professionals to further understand the decisions and experiences (of service users) that influence help seeking behavior. In doing so, mental health providers may be able to deliver more effective, culturally appropriate, and accessible services. Reasons for the lack of service use among BAME older adults may include lack of familiarity with services, stigma, cultural views about aging, ageism, racism, intersectionality, different idioms of distress, and help seeking (Tribe 2017). Carr (2014) found that people from BAME communities were reluctant to engage due to fear that services would be discriminatory, as well as issues relating to trust being viewed as a primary and complex concern. Bowes and Wilkinson (2003) also noted previous poor experience of services as a main factor. Furthermore, Cinnirella and Lowenthal (1999) argue the negative perception of psychological distress among

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BAME communities may result in the distress being hidden, only to be sought when problems become chronic or difficult for families to deal with. It has also been argued that the low uptake of mental health services by older adults may be due to people not ever having to access services previously. As a result, older adults with migratory histories may not know the role of the GP as a source of information and support for mental or emotional problems (Bhui and Bhugra 2002). In a study of Indian women living in the UK, Jacob et al. (1998) noted that they found it difficult to understand the services available and how to access them. The term “mental literacy” has been used to understand why some people may not know how to access help for mental health concerns (The Sainsbury Centre for Mental Health (SCMH) 2002). This term generally speaks of the absence of information surrounding mental illness rather than of services in mental health (SCMH 2002). People with migratory histories may be less likely to be informed about the mental health systems and resources available in a second country. In the UK, BAME groups with mental health issues appear to have different patterns of service utilization (Bhugra et al. 2004; Lawrence et al. 2006). Bhugra et al. (2004) argued that the diverse pathways taken by some ethnic minority groups may be due to previous experiences with services (including mental health) and health beliefs. What is more, the diverse pathways may reflect help seeking attitudes toward services, which includes how culturally appropriate, appealing, and accessible they are. Bhugra et al. (2004) further claimed once points of access are identified within this population, the weak points in pathways can be strengthened, therefore improving service provision and enabling access to services. Overall, the reported barriers to accessing services among the BAME population are said to be many; with available services being viewed as culturally insensitive, inadequate, inaccessible, and inappropriate (Fernando 2014). In addition, MIND (2013) argued that the National Institute for Health and Clinical Excellence (NICE) guiding principles may not always account explicitly or effectively for matters surrounding ethnicity or age. Lawrence et al. (2006) suggest the influencing factors of help seeking behavior are not often explored within older adult BAME groups. While numerous studies have examined barriers to treatment among older people, there is a scarcity of qualitative studies that examine the lived experiences of Black Caribbean older adults and their perceptions when seeking help from well-being and mental health services. Furthermore, there are few studies examining how and what coping strategies are utilized by this populace (Conner et al. 2010). On the whole, the low uptake of these services by BAME older adults could potentially lead to their needs being unnoticed or underestimated by service commissioners (Bhugra and Gupta 2011). As a result, mental health professionals need to evaluate the pattern of service usage (among this group) to enable appropriate services being developed (Tribe 2017). Furthermore, BAME older adults’ service users need to be involved in this evaluation (Morgan et al. 2009), if not it could prove detrimental to the improvement of future mental health services for this population. It is crucial for action to be taken at every influencing level to ensure services are appropriate and accessible; as well as in line with anti-discriminatory practice (Tribe 2017). Enabling a common/shared language between both service user and provider

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improves service engagement by encouraging both to have an open dialogue, which could be understood by both. Mental health professionals need to remain mindful of social contexts and discrimination in their work, as well as practice in ways that empower instead of control. By exploring the lived experience of Black Caribbean older adults’ mental health service use and relevant professionals are in a position to better identify any barriers impacting upon service use for our increasingly diverse population. Moreover, identification of these points may influence delivery and promotion of mental health services for this population.

Help Seeking Attitudes Among the UK’s Black Caribbean Older Adults People of Black Caribbean origin in the UK form one of the longest established and biggest ethnic minority communities (Williams et al. 2015). For some their migratory histories will be complex and may have included significant hardship and adaption. As the majority of migration from the Caribbean occurred between the late 1940s and the 1960s, the first generation of migrants in the UK are now approaching or have reached retirement age. As this population have had particular experiences of migration, further research is required into their mental health and the associated issues (McIntosh and Huq 2017; Williams et al. 2015). Research on help seeking among people of Black Caribbean origin is limited (Woodward et al. 2013). While numerous studies have identified barriers to treatment among older people, there is a scarcity of qualitative studies that examine the experiences of Black Caribbean older adults and their views of barriers faced when looking for help from well-being and mental health services.

Aims and Scope of Study The importance of listening to communities and community organizations is being increasingly recognized as part of a process that can reduce health inequalities (WHO 2020) enhance the quality of services (NICE 2016) and contribute to enhancing accessibility and appropriateness (British Psychological Society 2018). This chapter reviews a qualitative study which explored and contextualized the UK’s older Black Caribbean adults’ experiences of coping with depression (self-defined) and help seeking views. Mental health providers need to comprehend the decisions and experiences of service users or potential service users to understand and plan appropriate service provision and to deliver effective, culturally appropriate, and accessible services. The importance of service users’ perspectives has been increasingly recognized (Trivedi 2020). This has particular resonance when groups that have been defined as hard to reach are considered (Tribe and Bell 2018). Specifically, this study will explore the personal experiences, meanings, and contexts that underlie help seeking in relation to self-defined depression among the

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UK’s older Black Caribbean adults, both now and when younger. Most of the participants migrated to the UK as young adults. In addition, the study aims to explore some of the barriers experienced by participants, if any when considering seeking help from mental health services. In line with these objectives, the research questions developed are: 1. How do older Black Caribbean adults make sense of coping with (self-defined) depression? 2. How can we better understand the decisions that older Black Caribbean adults make surrounding help seeking and accessing mental health services in relation to depression? Table 1 describes the participants. Table 2 presents a summary of the master and subordinate themes. This chapter will look at themes one and two Theme 3 has been discussed in Bailey and Tribe (2020). Table 1 Ethnic origin: All participants identified as Black Caribbean Pseudonym Earl Mary Freddie Shirley Vincent Beverley Leroy Margaret

Gender Male Female Male Female Male Female Male Female

Age 73 69 65 69 79 69 74 73

Aged arrived to the UK 19 17 20 15 19 17 18 19

Marital status Single Widowed Married Married Divorced Married Married Married

Table 2 Presents a summary of the master themes and subordinate themes Master themes 1. “If you don’t know, you don’t seek help”

2.“. . .I was depressed. . .I knew I was depressed” 3. “You have to decide”: Attitudes to help seeking and mental health service use

Subordinate themes Participants’ experiences of migration in relation to depression “Just get on with it” Participants’ significant relationships experiences in relation to depression Participants’ experiences of health professionals and listening skills Grief in later life and depression A matter of “inconvenience” “. . .Recognise and start . . .” “Why should I go tell somebody my business?”: Challenges and cultural beliefs “Just get on with it” part 2 “No guarantee”: Professional services

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Overview of Master Theme One: “If You Don’t Know, You Don’t Seek Help” Master theme one sets the scene for the following themes. This theme reveals how in earlier life participants made sense of coping with their self-defined depression and what influence this experience had on their help seeking views. Four subordinate themes emerged, they are: • • • •

Participants’ experiences of migration in relation to depression “Just get on with it” Participants’ significant relationships experiences in relation to depression Participants’ experiences of health professionals and listening skills.

Participants’ Experiences of Migration in Relation to Depression Participants described a process of discovery, which involved learning to adapt to a new country, whereby the lack of knowledge about depression and services presented a challenge to help seeking at the time. In this excerpt, Mary depicts her selfdefined depression. When I first came in this country. . . I was depressed (gasped) but I didn’t know it because in those days we didn’t hear the word depression. . . didn’t know what it was, didn’t hear the word stress or depression so I didn’t know I was depressed. . . but of course I had left home, I’d left sunny, sunny climes, all my friends, my comfort zone as it were. . . and I came to this country.. and in those days there was a lot of smog. . . everywhere was grey. . .I was picked up at the airport and everywhere looked like a factory. . . I was told they were houses, where smoke was coming out of every chimney because it was in the month of September. . . . . . it was grey . . . I came but I was used to my own room and suddenly I was sharing a room with my mother in a back room, where you couldn’t see the light of day. . ..my mother was a very strict lady and I was used to my freedom.. . . I remember just crying, every letter I wrote to friends. . . were blotted with tears. . . I was just a very sad person but I didn’t know I was depressed at the time because it wasn’t a word that was used. . .

Mary further elaborates: . . . the thing is . . . not knowing that I was depressed . . .. if you don’t know you don’t seek help. . ... I just know that I was very unhappy. . .. I couldn’t ask for help because there wasn’t labelling in those days. . .. it’s in later life . . . long after I had my children. . .when it really registered that there was a problem. . .I went into higher education and I had to study psychology, then I realised that, it was a problem. . . that it was depression.. . . ..

Shirley echoes some of Mary’s experience: Well I would say that when I . . .came to England . . . I never thought of it as that but I would think that that was. . .a very depressing time. . .. and why was it depressing. . .. I cried for 3 months. . .it was a crying session with me to go back home and I couldn’t go back home because I was here with my parents. . .so it was always crying. . . I left a happy life, my friends, my familiarity, and everything that I knew of, to come to a very. . . at that time I felt it

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a very depressing country you know. . . cause it was very dark, very dull, very dismal and I remember crying until December. . .. but I sort of woke up .. you know so maybe enrolling in college gave me that hope that OK this is not bad after all. . . but that was my first as far as I can think back . . . because I don’t think that I was ever depressed before, I didn’t even realise I was depressed then to be quite honest with you so I would say my first experience was coming to England in 1962.

Being able to “label” as exemplified by Mary or name their self-defined depression seems key to seeking help at the time. Below, Shirley further shows how her experience of migrating, lack of knowledge about depression and services influenced her help seeking views and seemingly the attitudes of others within the Black Caribbean community. I wouldn’t have known because I mean in those days in the 60’s everybody come here and they come here to work . . . or come to study and that’s everybody’s mindset. . .you work or your studying to come back home. . . so you weren’t looking . . .I don’t know if there was help available but you weren’t looking for any help because you were just looking between you and your local environment. . . my uncle knew I was not happy but what could he do but say girl just behave yourself. . .stop your nonsense type of thing. . .

She further elaborates: . . . there was no time to pamper you with your problems . . .because .. far as they’re concerned. . . you should be lucky that at least you are somewhere where there’s opportunity. . .and the opportunity they’re talking about is finding yourself a job, you know that you couldn’t find back home or educating yourself. . .. so even if there was somewhere to go for help . . .we didn’t know about it because we just kept in our little community.

Finally Shirley states: . . .the English people were not friendly and they were not accommodating. . . so you’re not going to go to them for help. . ..

To conclude, these excerpts illustrate how at that time the “opportunity” to come to the UK to better one’s self was viewed as crucial within the Black Caribbean community. This focus appeared to override desires to seek help as Shirley hints “no time to pamper you with your problems.” People were learning to adapt to a new way of life in the UK, people were “not looking for help” outside this focus, regardless of the impact on their mental health following their migration. Also social exclusion and racism are alluded to and the difficulty of being seen as part of the wider community.

“Just Get on with It” This subordinate theme demonstrates the influence a self-sufficient outlook had on participants’ help seeking views when experiencing their self-defined depression. Participants’ accounts gave a sense of “just get on with it” as if there was no

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other choice but to deal with ones experiences on their own. Margaret’s excerpt illustrates this: . . .I was unhappy; I was disappointed – many, many times disappointment comes into my life in different ways. . . But, you know, I just thought, well, I had to get on with life. . . and that’s what I did. . . . . .I know people say they go and they get counselling but I didn’t. . . well, I think the reason why I was depressed, I didn’t think that I needed to go and talk to anyone about it. I just felt like I could cope with it as I said.

Interestingly, to “just get on with it” is a mindset also highlighted within the participants’ experience of migration theme accounts, indicating perhaps this is an embedded cultural norm of the time. Participants also seemed to be motivated by a sense of being “depended on” by their family, suggesting strong influences of cultural or family values on help seeking attitudes at the time. Beverley depicts this in her excerpt below: . . .., as a mum, I had to do it. even though I couldn’t cope. So I didn’t tell much people that and I didn’t care if they wanna come and see the house dirty; that’s their business. . .

Margaret echoes: . . . as far as I’m concerned, those five people depended on me and I was determined to be there for them come what may.

Vincent concludes: I think . . . what really helped me along is this working. . . steady working because my idea is this. . .my wife and my children, it’s up to me to go out there and work for them. . .

The need to provide or care for one’s family independently seemed to be key to managing participants’ self-defined depression, this seems to override desires to seek help for their self-defined depression. Other participants’ accounts gave a sense of personal development, distraction, strength and resilience as a way of coping with their self-defined depression at the time: Freddie illustrates this: . . .you asked how I got out of that (self-defined depression) so I suppose you start to spend more time identifying with those things that strengthens you rather than those things that actually weakens you. . ..so my mind was always on what I loved at that time. . ., so I could escape and read a book I was trying desperately not to damage anybody so the getting out of the environment for that period was more or less beneficial for me now that I look back at it.

Leroy depicts a similar experience. If there was any help it was the fact that you can escape and when you had to go to a certain place to do a certain duty. . . you might hang about longer in that area than you probably should. . .

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Freddie and Leroy highlight a need to psychologically escape, to source help from within instead of sourcing external help. Below, Shirley also speaks of another form of escapism through music: . . .I’ve learnt that music really lifts depression. . .lifts you when you’re feeling low. . . and then when becoming a Christian I realised even when David was down he used worship music to lift his soul. . . so for me I realised that music really keeps me when I’m in that frame of mind. . . back then whenever I felt down I’d make sure I’ll be where the nearest party was. . .

Below, Margaret depicts an experience where she was prescribed medication; however, she describes her decision to not take them. . . .I must have said something to the GP, because . . ., at one point, he gave me some tablets. . . and I was working as an auxiliary nurse at the time and I wanted to know what they were. They were Valium and I thought, ‘I don’t want these’. . .and so I decided I wasn’t gonna take them. I used to work under certain wards and when patients get rowdy and start, they will bring these things, give it to them and they will sort of calm down and sleep and I thought, ‘No, I don’t want these’ (laughs). . . I wasn’t going to indulge in these things. . . I thought, ‘Oh, these things are tranquilizers; I don’t want them. . .. . ., I thought, these things, these are for crazy people, and I’m not crazy. I decided I wasn’t gonna go down that road, I wasn’t gonna take them. . .Those things, they don’t help; drugs don’t help. Just keep you like a zombie; . . .and that’s what I didn’t want for myself, that’s why I wasn’t gonna take anything. . .

Margaret’s accounts illustrate how her understanding of the effects of medication and its observed impact on others strongly influenced her decision to cope with her depressive thoughts on her own, and seemingly evade further follow-up with her GP on the matter. To conclude, several aspects expressed by participants within this theme suggests a strong influence that a self-sufficient outlook had on participants’ help seeking views in relation to depression, as well as on preferred coping strategies with their depression at the time.

Participants’ Significant Relationships Experiences in Relation to Depression This subordinate theme encapsulates the importance of participants’ relational experiences with significant others when coping with their self-defined depression and how this impacted on their help seeking views. Furthermore, the influences of cultural norms and family values on participants help seeking views are also echoed in this theme. In the excerpt below Margaret describes a need for her depressive thoughts to be noticed or heard by her family; however, this did not occur. When asked what help was available to her at the time? Margaret replies:

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. . .None I don’t even know if they were and I don’t even think that did cross my parents’ and siblings’ minds that I had those thoughts. . .no one stopped to ask me, well, how do you feel about being this way, you know.

Margaret further elaborates: I don’t know if they ever think that way; being, you know, the society. . . I don’t think it will cross their minds. The way we were brought up, I don’t think they thought of your feelings. All they could see is that, you’ve let them down, you know. They never stop to think that; you’re thinking, ‘Oh, my God! What am I gonna do now?. . .

In this account Margaret gives a sense that an individual’s feelings were not valued in comparison to the importance of “family reputation.” It appears if Margaret was given this space she may have been willing to share her thoughts and feelings. She hints at how doing this might have conflicted with familial or cultural requirements at the time. Margaret depicts further on other experiences of significant relationships while coping with her self-defined depression: Well, no one ever sat down and talked to me; well, I think I was too embarrassed to tell people how I’m feeling anyway. So I never said to anybody. Once I went to my elder sister and I was telling her about certain things that I wasn’t happy with and all she said to me, ‘well, you don’t have to upset yourself’. . . and I thought, ‘Well, you’re no help so what’s the point of talking to you’. So, I used to bottle things up a lot. I think maybe I was ashamed to talk about certain things. . .

And: . . .Then this uncle, I think it was a great uncle, tell him things and before you know it; it’s all over the place. I remember, I said something to him once, then I met another relative on the street and she said, ‘oh, but I heard so, so and so’; and I was so shocked, I thought, ‘No’. . .and that was when I decided, you know something, keep it. But I never thought of going for professional help . . .

In Margaret’s excerpts it seems a key influence on her help seeking views was not being noticed or heard within her significant relationships while it also appeared important for Margaret to experience trust and not feel judged in her relationships. Moreover, as Margaret describes an attempt to open-up to a significant relation, it appeared she felt shut down, and this appears to suggest the importance of empathetic listening within relationships to aid help seeking positively. Beverley’s account below depicts her experience of being noticed by a family member and how important this seems to be to her at the time. . . . my husband’s niece came to visit and realised that I wasn’t too well and she used to come and help. . .. . . .She was young but she was clever enough . . .. . ... I’ll never forget her, yeah. . . My sisters them were there but I think it was too close. They were too close to me to see what was going on. Not until I told them what the doctor tell me . . .

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Beverley further illustrates this with another family member: . . .. . ..I was so pleased that he spoke to my doctor, my husband, in the presence of me . . .and by then, my husband start taking notice . . .and then he cut down work. . . he cut down the time at work to do more in the house and he helped, yeah. And eventually, I got out of it because they will help, yes, yes. . ..

Beverley’s excerpts highlight the value of being noticed or heard by significant relations; however, she also emphasizes that at times some significant relations may be “too close” to notice. Nonetheless, whether positive or negative both Beverley and Margaret expressed how much an influence significant relationships had on their help seeking views when coping with their self-defined depression.

Participants’ Experiences of Health Professionals and Listening Skills This subordinate theme reflects the influences being listened to by health professionals had on participants’ self-defined experience of depression and what impact this experience had on their subsequent help seeking views. In the excerpt below, Beverley shares her experience. . . ..the best thing is for somebody to listen to you when you tell them how you’re feeling, listen to how you’re feeling and open up to them. . . .at first I didn’t open up. I think, the trigger of the doctor saying to my husband about the medication that I’m taking helped me to tell my husband how I’m feeling more and he kind of noticed, yeah. . ..

Beverley further explains: . . . my doctor is saying the things that I’m feeling. . .you see, he’s telling him, she’s probably gone through this. . . And we are saying the same thing in different ways and he understood.. so, you know. . . it was good that somebody took over the voice . . .you know, so he was my voice. He was good, yeah,. . .

Beverley’s accounts highlight the importance of being listened to by a health professional and the normalizing effect this had on her coping, as well as enabled her to discuss this with her husband. Shirley also shares a similar normalizing aspect of being listened to by a health professional: . . .. I recognised it because the mid wife mentioned it. . . because I just burst into tears. . . I was getting ready to get out of hospital and she said ..are we having a little bout of depression. . .so I said. . . what! do I look like any depressed person to you (laughs) . . .she says to me well its common . . . I said is it!. . .so she said oh yeah it’s quite common after a baby you have a little bout. . . . . . so I said I don’t really entertain depression so you know it’s not common for me!. . .

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Shirley further elaborates: . . .so she said anyway and she sat on the bed and we talk. . .and it was after talking with her she said never mind but you know you can join a group . . . you know find a group. . .look inside the community hall where you live . . .there’s lots of groups where mothers meet. . .you know post-natal depression. . . so I said I’m not depressed . . .I don’t have no depression I don’t have no depression (laughs) so at least that time I was aware of what was available. . .

In this account, Shirley reflects on her self-defined depression experience following the birth of her second child. It seems having a health professional notice, then normalize her feelings, enabled Shirley to “talk” further about her experience, which in turn gave way to her hearing options about help available. This experience emphasizes the important aspects of being listened to by health professionals; furthermore, despite Shirley being reluctant to accept the term depression “I don’t have depression,” Shirley acknowledges her new awareness of existing help “so at least that time I was aware of what was available.” Interestingly, Shirley’s attitude seems to echo aspects within the subordinate theme “just get on with it/person’s choice.” This subordinate theme illustrates the strong influences being listened to by health professionals seemed to have on participants’ help seeking views and selfdefined experience of depression.

Overview of Master Theme Two: “. . .I was Depressed. . .I Knew I was Depressed” The second master theme seeks to explore how participants made sense of coping with their self-defined experience of depression now aged 65 years and older. In addition, the theme examines the influences of these experiences on participants’ help seeking views; however, the context in which each participant’s depression occurred varied. Participants also highlighted some issues that had influence on decision making on whether to seek help or not from mental health services. In the next theme participants’ experiences with depression are summarized in two subordinate themes: Grief in later life and depression, and a matter of “inconvenience.”

Grief in Later Life and Depression This subordinate theme reflects the influences grief had on two participants’ selfdefined experience of depression. Participants now older and reflecting on their earlier life experiences of depression described their actions to cope with their self-defined depression. In the excerpt below, Mary’s account describes her self-defined experience of depression aged over 65 years, following the death of her husband four years previously.

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Well yes. . . after the death of my husband . . .it did not impact in me immediately until a year later. . . one year to the day . . .and I woke up.. I was away from home, I was on a retreat and I woke up and the head stone was laid. . . and a WhatsApp of it was sent to me and . . .I just lost it . . . I left the hall of the retreat and went to my room on site, and I remember. . . just curled up in the foetal position on the bed and I just cried and cried and cried. . . I had friends that came to my room and I could not be consoled . . . prayers were sent up or offered. . . and. . .. yeah . . .that was my grieving time and it was a dark corner . . . really a dark place. . .

Mary further elaborates: I knew I was depressed. . .. and friends that came to the room said that they were very concerned about me because I got a friend whose husband has bi polar . . .and she came and said she was really concerned about me . . . yeah. . .My faith. . . yeah I thought to myself. . . I have a little understanding of what God went through for his son, to have lost his only son . . . and I thought Jesus came through it and I will. . . yeah. . . and I did.

As Mary reflects, she declares twice “I knew I was depressed” and her awareness seemed to be reinforced by the observations and experience of friends. When asked what helped her to cope at the time, Mary reflected on how her Christian faith helped her through. Like Mary, Beverley connects her self-defined depression experience following the death of her mother three years previously. However, Beverley’s account highlights her integral view of being listened to, particularly outside significant relationships, when coping with her self-defined depression experience at the time. Well, maybe grieving is part of depression . . .. You’re grieving; you know why you’re feeling like that. . .. you’ve lost someone; she’s no more there . . .and your family them, remember all of you are grieving, you know, every one of you is grieving in different ways. . . but when you feel that you need somewhere else, you need somebody else to listen to you, Samaritans is the best. . . for me I felt that well, they listen to me and they’re not telling anything different from what you know but they help you to understand what you’re going through; they help you to make sense of what you’re going through and that help. . .yes. . .,so outside help is very important.

Beverley further explains: Sometimes, your family, they can’t see what you’re seeing. . .remember, they’re there, going through the same thing in different ways, so it’s nice to get somebody’s point of view outside of the family; yeah, yeah. . .

It is noticeable that Beverley presents part of her account in the second person as if somewhat emotionally distant to her experience. Nonetheless she clearly articulates what she found helpful when coping with her self-defined depression at the time. Although Mary’s and Beverley’s experience with grief and depression differed, it seems given their earlier life experiences with their self-defined depression, both Mary and Beverley were able to seek help be-it “self-sufficiently” or to source external help. What is more, it also appears that both Mary and Beverley gained the knowledge and/or skills to cope with their self-defined depression due to their

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earlier life experiences with depression. As a result, this seemed to help remove possible barriers to help seeking now they were aged 65 years and over.

A Matter of “Inconvenience” This subordinate theme demonstrates the influence not wanting to “inconvenience” a health professional had on a participant’s help seeking attitude when experiencing their self-defined depression. Vincent’s’ account below further illustrates this: 7 years ago, I was really really really down and I went to see my GP. . .. me and my doctor always get along well. . ..and we sit down and we talking and talking. . . and what I really went to see him about, I end up not discussing it. . .. but I didn’t want to walk away and leave the surgery and he may think, say, ‘that’s madness. . .So what you do? instead of you continuing with what you were going to say. . ..your mind shifts away from that because you don’t want no body to feel you’re inconveniencing them. . .

Above, Vincent describes feeling really low in mood “down.” He appears self-aware enough to seek help from his GP, yet when in his GP’s presence seems to find it hard to discuss his low mood due to a concern of “inconveniencing them.” Vincent continues: I wanted consciously to express my feelings but nothing made me do it. I don’t know why it didn’t come out because I have so much confidence in my GP right, that I could tell him anything and he was a dark man like myself so everything was perfect there but that didn’t come out. . ... I think in the long run now, why that didn’t come out. . .I think if I did go down the road of expressing it to my GP, probably he might have put me on some kind of tablets but it might only numb the feelings. . ..we are always going to our doctors to get something . . .but those things can’t take away, they only suppress it for a little while, after that, it come back. . ..

Vincent’s account illustrates his awareness of the change in his mood and his willingness to seek help; yet he was reluctant to follow through in receiving help. Initially it appeared Vincent was concerned about inconveniencing his GP but when further explored, he revealed his concern with prescribed medication. The issue of stigma around suffering from depression may also have played a role. Vincent describes an open and positive relationship with his GP, yet the strength of their relationship did not seem enough for him to share his concerns. It may also be possible that Vincent held some views on masculinity and on his cultural identity that influenced his decision to not tell his GP about his self-defined depression. In conclusion, the participants in this study, members of the older adult Black Caribbean community in the UK, shared a variety of experiences relating to migration, depression, and help-seeking from the vantage point of now being senior citizens (over 65 years of age). Some issues relating to migration and the cultural prerequisites prevalent at the time and in their current situations were discussed. The importance of considering issues relating to both migration and culture within mental health services worldwide requires consideration throughout service

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planning and delivery. The importance of community engagement when considering service provision relating to mental health is being recognized internationally, nationally, and by professional organizations training mental health workers. This should help to ensure that the requirements and needs of all members of our communities including those with migratory histories are met, and they have much to teach us.

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Tribe R, Morrissey J (eds) (2020) The handbook of professional, ethical and research practice for psychologists, psychotherapists, counsellors, psychiatrists and social workers, 3rd edn. Brunner- Routledge, London Trivedi P (2020) Service user involvement, ethics and power in therapy services. In: Tribe R, Morrissey J (eds) The handbook of professional, ethical and research practice for psychologists, psychotherapists, counsellors, psychiatrists and social workers, 3rd edn. Brunner- Routledge, London Williams ED, Tillin T, Richards M, Tuson C, Chaturvedi N, Hughes AD, Stewart R (2015) Depressive symptoms are doubled in older British south Asian and black Caribbean people compared with Europeans: associations with excess comorbidity and socioeconomic disadvantage. Psychol Med 45(9):1861–1871 Willig C, Stainton-Rogers W (eds) (2008) The Sage handbook of qualitative research in psychology. Sage, London Windrush Lessons Learned Review (2018) https://www.gov.uk/government/publications/ windrush-lessons-learned-review Woodward AT, Taylor RJ, Abelson JM, Matusko N (2013) Major depressive disorder among older African Americans, Caribbean blacks, and non Hispanic whites: secondary analysis of the national survey of American life. Depress Anxiety 30(6):589–597 World Health Organisation (WHO) (2016) Mental health and older adults fact sheet. www.whp.int/ medicawntre/factsheets World Health Organisation (WHO) (2020) Community engagement for quality, integrated, peoplecentred and resilient health services. www.who.int/servicedeliverysafety/areas/qhc/communityeengagement/en/

Part IV Services

Designing Mental Health Services for Vulnerable Migrants and Refugees

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O. Ananyeva, N. Gionakis, N. K. Movsisyan, Adil Qureshi, Meryam Schouler-Ocak, and N. Serre-Delcor

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Systemic Flaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient’s Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overcoming Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mapping and Managing Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understaffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Competence and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychoeducation for Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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O. Ananyeva (*) Tilburg University, Tilburg, The Netherlands e-mail: [email protected] N. Gionakis Babel Day Centre, Athens, Greece N. K. Movsisyan International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic A. Qureshi Servei de Psiquiatria, University Hospital Vall d’Hebron, Barcelona, Spain M. Schouler-Ocak Psychiatry and Psychotherapy, University Psychiatric Clinic of Charité at St. Hedwig’s Hospital, Berlin, Germany N. Serre-Delcor Tropical Medicine and International Health Unit Vall d’Hebron-Drassanes, PROSICS, Catalan Health Institute, Barcelona, Spain © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_21

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Abstract

Migration has become a ubiquitous phenomenon worldwide. Stress experienced by migrants in home countries, during migratory process and in receiving countries might have detrimental consequences for their health and stipulates an increased need in utilization of health and mental health care services by migrant populations, which, in turn, determines the need to reconsider services provided to vulnerable migrants and refugees (VMR). In this chapter we discuss challenges for service setup in mental health care for VMR arising both on service and patients’ side and propose possible ways to respond to these challenges. We ground our discussion on the results of VMR’s needs analysis and barriers to health care project conducted by MyHealth consortium in four European sites and review some examples of good practice in mental health care for migrants adopted in different countries that face similar problems. Keywords

Vulnerable migrants and refugees · Mental health care · Service setup

Introduction In recent years global displacement and migration flows of refugees and asylum seekers have increased significantly and continue to grow annually (UNHCR 2016, 2017, 2018). In 2017, the number of people forcibly displaced by conflict reached 68.5 million globally, 25.4 million of whom are refugees and 3.1 million are asylum seekers (UNHCR 2018). Such flows impose an additional load on the capacities of health care systems in receiving countries and require reconsideration of services provided to vulnerable populations examining whether such services are able to respond to challenges arising from global migration. In this chapter we aim to map essential components of service provision for the specific population of vulnerable migrants and refugees (VMR). To do that we discuss challenges that emerge with the migrant crisis on the service side as well as on the side of patients themselves; we also sort barriers to health care for vulnerable populations based on the analysis of needs of VMR conducted by MyHealth consortium in four sites (Barcelona, Spain; Berlin, Germany; Brno, Czech Republic, and Athens, Greece) and discuss implications for practice. The structure of the chapter is as follows: first, we provide the results of aforementioned needs analysis and discuss it in the light of challenges for service setup; second, we propose ways to overcome deficiencies and analyze good practices adopted in different countries to ensure effective utilization of health care services by different population groups and, finally, we discuss implications for future work. Needs Analysis project “Models to engage Vulnerable Migrants and Refugees in their health, through Community Empowerment and Learning Alliance” (MyHealth Consortium 2018; Babel Day Centre/Syn-eirmos 2018) is a research project by

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z z

Life conditions z z z z z z z z z z z

Housing and satisfaction of basic needs Management of daily routines Meaningful activities Information (infrastructure, transport, community) Employment and training Language skills training Legal assistance with resolution of refugee status Reducing discrimination and racism Safety Community participation and support Long-term planning

z

z z z

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z z z z z z z z

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Health care (general) Informational provision Access to health care by all groups of migrants with varying legal status More staff (doctors and interpreters) Shorter waiting lines Medication and vaccination for children Cultural competence and professionalism of staff Accompaniment (by social workers) Support vs. autonomy: provision of conditions for autonomous use Coordination of departments and services, reducing complexity Equal distribution of aid and reducing discrimination

Mental health care Cultural training for immigrants (cultural differences, definition of mental health, need for therapy, issue of psychosomatics) Cultural training for doctors (different perceptions of mental health, stigma) Continuous and regular treatments Sensitivity concerning professionalism of interpreters (lack of established rules of organization of communication) Flexibility Comprehensive assessments

Fig. 1 MyHealth project results: Needs of vulnerable migrants and refugees

MyHealth consortium that is aimed at defining health- and mental health-related needs of VMRs and barriers to health care in four European sites in Spain, Germany, Czech Republic and Greece. The project uses a mixed-method approach and gains insights from both migrant participants (VMRs) and health care professionals. The main project results are represented in Fig. 1: The main results are structured into three categories of needs related to life conditions, health care in general, and needs related to mental health and mental health care. Further, we focus only on the latter two categories.

Challenges in Treatment Systemic Flaws Challenges for effective utilization of health care services arise both from service side and from the side of patients themselves. Current status quo of most European health care systems is that they are not capable of responding to challenges associated with the migrant crisis. Systemic flaws deal with financial, legal, cultural, and structural issues that create barriers which are often insurmountable for migrant

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patients. Setting up services for VMR must concur with adjustment of federal policies targeted at vulnerable populations as well as with structural changes in health organizations at local levels.

Lack of Funding and Proper Allocation of Resources The most common reason behind patients’ complaints and professionals’ concerns deals with insufficient funding of health care systems. It is manifested in understaffing and, as a consequence, enormous waiting lines, lack of medication options, inaccessibility of specific medical specialties or female representatives, and services of medical interpretation. The lack of funding often makes specific services inaccessible both in terms of physical (i.e., geographical) accessibility and timely access to it upon request. On the other hand, professionals note that it is not always lack of funding itself, but, instead, improper utilization of funds allocated for VMRs, lack of mental health service promotion, and imbalances in health care systems. Discriminating Policies Sufficient funding and resources including human are necessary, but is not a sufficient condition for setting up effective services. Legal issues and, often, underdetermined formal game rules lead to uneven access to services by different migrant groups. Distribution of humanitarian aid is often unequal depending on nationality and legal status. Such discriminating practices impose additional stress and could result in deterioration of personal health justifying increasing need in health services. Complexity and Capacity of Healthcare Systems Lack of system coordination and overall complexity create extra barriers for service utilization. Often a patient has to apply to one clinic for initial consultation and to other hospitals to get medical tests and to have results. The lack of organizational coordinating support assisting with it and complexity of bureaucratic procedures present an additional issue that complicates the use of health care services in many European countries. In addition, in cases where more actors (NGOs, state agencies, etc.) are involved in service provision to VMRs, there is a huge gap in a collaboration/coordination culture as well as intense competitive spirit. The challenge here refers to developing well-coordinated professional networks of state health organizations, professionals, volunteers and NGOs, and acquiring a culture of working in complex realities. Another issue is a lack of capacity of the healthcare systems in Eastern European countries, including the Czech Republic, which reflects the past influence of the totalitarian ideology on psychiatry making its development lag behind western trends in mental health care. However, modern mental health care services have been slowly developing in these countries (Winkler et al. 2017). Lack of Informational Provision System complexities determine an increased need in extended informational provision. Most migrants lack information concerning health care system structure and the

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range of available services. At best, it is provided by nongovernmental organizations (NGOs) assisting migrants and refugees; however, it often deals with general information and if an immigrant patient needs a highly specific treatment, the general information provided by NGOs might not be enough. Informational provision must be supplied in different languages and by different delivery methods such that all migrant groups have access to it regardless of language and digital skills. Another important issue that needs informational elucidation is cultural differences between a health care system in a host country and those of countries of origin. Attitudes to time, treatment, and health in general are varying across cultures, and divergent views on it might be time consuming at best and undermining the effectiveness of treatment at worst.

Lack of Cultural Competence on the Part of Doctors and Medical Interpreters Sufficient staffing is a crucial element of service provision, it is nevertheless not sufficient for effective service utilization. Setting up services for VMRs should consider not only quantitative parameters of staff “equipment,” but qualitative characteristics therewith. Such qualitative characteristics include cultural competence and comprehensive professional training as well as establishment of the rules of conduct in different cultural patient groups in various settings. Although some medical organizations provide interpretation services, its percentage is extremely low; in most cases, due to lack of funding and understaffing, doctors have recourse to untrained staff speaking a patient’s language. It often results in medical malpractice (Arredondo 2010; Quan and Lynch 2010) which runs risks both for patient’s health and organizational outcomes. Provision of language services of interpretation does not necessarily rule out the problem. A fair number of interviewed VMRs had concerns about professionalism of interpreters signaling the need in additional professional training for interpreters and establishment of the rules of communication between a doctor, a patient, and an interpreter (MyHealth Consortium 2018; Babel Day Centre/Syn-eirmos 2018). Professional training should be tailored not only to cultural competence, but additionally focus on work with specific populations such as refugees, victims of sex trafficking, and unaccompanied minors.

Patient’s Side Internalization and Psychosomatics For most refugees and asylum seekers, stress experienced in host countries during migration routes and in receiving countries have detrimental impact on health. Prevalence of somatization among VMRs vary from 5% to 85% (Rohlof et al. 2014; Bas-Sarmiento et al. 2017; Ferrari et al. 2015) and stipulates the need in continuous and regular mental health care. Interviewed VMRs and health professionals also highlight tendencies of internalization of VMR’s image as weak and dependent which could result in self-harming behaviors and further deterioration of health. Unfortunately, most VMRs are unaware of the differences between somatic

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and physical symptoms and are inclined to seek medication options or help of physiotherapists who often are powerless to help since they face nonclinical problems that demand hospitalization.

Different Perception One of the main impediments retaining patients from seeking help of mental health professionals is a perception of mental health and disease. Most VMRs carry attitudes toward mental health differing from those being conventional in western societies. For some of the VMRs the recourse to a psychotherapist might be associated with shame and stigma refraining them from seeing a psychologist or psychotherapist. Health professionals and social workers explain that most VMRs generally seek someone “just to talk,” and seeking the consultation with a psychotherapist might signal serious problems for them. Stigma and shame are the factors that have both intrinsic and extrinsic influence; feeling oneself as a patient needing psychological treatment might be self-perceived as “being ill or diseased” and impede seeking help, but another deterrent effect is the threat of social perception of “being ill or diseased.” Some people might refuse to see a professional consultant due to the fear of being a black sheep or shame for a family or a local community. Perceived prejudice from doctors, nurses, interpreters, or people around also disrupt the motivation to seek help. Support vs Autonomy Another concern expressed both by professionals and VMRs was the balance between need for support and accompaniment and need in provision of conditions for autonomous use of services without escort. The need for accompaniment arose from language barriers and insufficient skills to orient at hospitals and other organizations that determine some sort of dependency on social workers assisting VMRs. Along with that, interviewed VMRs mention the need for autonomy in using health services such that they are no longer dependent on an accompaniment. The balance is challenging since most of the interviewed VMRs although agreeing with the fact that provision of orientation signs and informational navigation in different languages makes orientation easier to understand and to use independently, it severely undermines the motivation to learn the local language. Family Obligations Family responsibilities, managing daily needs, waiting for legal status resolution and job search are often mentioned as factors that make VMRs postpone visits to psychotherapists. These obligations are often considered as more significant in comparison with the need of treatment. The problem is further aggravated by the lack of psychoeducation and unawareness of the importance of self-care.

Overcoming Deficiencies Designing effectively working services for vulnerable populations are well served by a need-based approach. It should, if not overcome shortcomings, then at least find the ways wherein existing deficiencies are covered enough to allow such services to

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respond to challenges arising from increased global migration flows. In a perfect world most of the problems could be potentially solved by the massive increase in funding and the increase in number of professional organizations providing tailored and extensive services for VMRs. In reality, lacking sufficient resources drives us to act thriftily and consider good practices adopted in different countries that face similar challenges. Priebe et al. (2011, 2016) identified seven components of good practice in health care for migrants in order to overcome problems of access to it. The components are the following: (1) organizational flexibility with sufficient time and resources; (2) good interpreting services; (3) working with families and social services; (4) cultural awareness of staff and specific training on working with vulnerable populations; (5) educational programs and information material for migrants; (6) building of positive and stable relationships between staff and migrant patient audience; (7) clear guidelines on the care entitlements of different migrant groups (Priebe et al. 2011, 2016). Researchers analyzing good practices in refugee youth mental health in addition to all above also include resilience- and strengths-focused approaches, creative and complementary approaches and interventions, and mobile connections and online counseling (Marshall et al. 2016), and school-based interventions (Chiumento et al. 2011; Murray et al. 2010). As for the population of immigrant women and victims of sex trafficking, complementary components of good practice include gender-, trauma-informed care, and facilitation of social integration and support (Aubrey et al. 2017; Bengs et al. 2017; Guruge et al. 2015).

Mapping and Managing Needs The analysis of needs is crucial in setting up services for VMRs. It allows gathering relevant data for interventions and receives up-to-date insights concerning current trends and new emerging needs. Optimally, it should focus not only on VMR’s viewpoint, but also those of professionals working with VMRs in different fields. Furthermore, needs analysis should include varying migrant populations and have systematic and regular data collection aimed at analyzing the dynamics of needs and measuring effects of potential interventions. Additionally, it is reasonable to gather information in different regions and at different institutional organizations (e.g., not only at hospitals, but at NGOs, shelters as well as online) in order to monitor imbalances and reach diverse audience. The objective of managing needs should take a holistic approach that does not victimize people in need, but focuses also on strengths, skills, resources, and backgrounds of VMRs in order to build empowering and sustainable services and seek further ways to promote resilience of these populations. A variety of institutions collaborate in research projects aimed at improving access to health care by vulnerable populations. There is IMPACT Research Program consortium of several institutions in Canada and Australia conducting research to co-create models of care to enhance access for vulnerable populations (IMPACT Research Program 2018). The IMPACT program aims to develop professional networks of partnerships between policymakers, researchers, health professionals,

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and representatives of vulnerable communities to design interventions in healthcare, to facilitate innovations that improve access to health care services, and to evaluate efficiency of these interventions. The IMPACT program is supported by Canadian Collaboration for Immigrant and Refugee Health, an interdisciplinary collaboration of researchers, health professionals, policymakers, and immigrant community leaders who aim at knowledge translation in order to improve health access for migrant populations (Canadian Collaboration for Immigrant and Refugee Health 2018). The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) develops comprehensive guidelines for working with these populations, provides “checklists” and e-learning for health practitioners, and recently has created a tool for policy improvement, Health Equity Impact Assessment (HEIA). Immigrant supplement (HEIA) ensure that needs of immigrant populations are included in evidence-based policy development.

Understaffing The lack of funding of most European healthcare systems primarily results in understaffing making most services for VMRs unavailable. On the one hand, increase in funding is necessary to meet arising demands; on the other hand, it is not always possible. One possible attempt to cover deficiency may involve collaboration of healthcare and educational and social institutions to attract young professionals to work for free in exchange for nonfinancial rewards. One such good practice exists in Canada and presents the student-run clinic IMAGINE providing interprofessional services and health education for marginalized and underserved population groups (IMAGINE Clinic 2018). It is understandable that professional therapeutic work with vulnerable migrant populations requires professional expertise, training, and experience, and qualification of students might be insufficient. But it might be advisable to develop collaboration of health care and educational institutions and attract students in order to delegate some tasks (i.e., information provision, basic psychoeducation, stigma fighting campaigns) in exchange for educational credits and professional experience. Another practice exists in rural Nepal and deals with mental health service delivery in low-resource settings (Acharya et al. 2017). Possible Health project is built on an integrated healthcare model implying interdisciplinary approach that includes mental health perspective in primary physical care (Possible Health Project 2018). Since there are approximately 50 psychiatrists who work in Nepal, primarily in major cities, whereas the large proportion of population lives in rural area (Acharya et al. 2017), mental health coverage is severely insufficient; professional network of Possible project suggests training and supervision for generalist health workers by off-site psychiatrists. Adoption of such practice might be beneficial to raise awareness of general practitioners on migration-related issues (e.g., psychosomatics, cross-cultural adaptation) and enhance interdisciplinary approaches in health care. It might be especially beneficial in rural/low-resource areas where government funding has been cut (Cimas et al. 2016; Vázquez et al. 2016).

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Accessibility Difficulties with physical access are often mentioned as common barrier to health services, especially in settings wherein consultations, medical tests, and getting the results occur at different locations. A good practice addressing this issue is adopted in Canada and presents a mobile clinic The Alex Community Health Bus (The Alex Community Health Bus 2018), which stops at a number of city locations including housing and community food centers, provides health care and education services, and facilitates referrals to a wide range of primary health care and community organizations.

Access to Information Most of the interviewed VMRs highlight the strong need in provision of information concerning health care. Literacy, educational background, language proficiency, and digital skills of migrants impose certain challenges for service providers. The participants of MyHealth project recommended to both disseminate information through flyers, banners, and posters in transport and public spaces and use mobile apps and websites for information provision. A good practice of mobile mental health app is examined by East and Havard (2015). They argue that well-designed mobile mental health apps could be very useful in dissemination of information concerning local health providers and services available and for learning and enhancement of mental health. Such kind of apps could also be helpful for mental health self-checks and developing strategies for self-care. For those population groups whose digital skills or access to technologies are limited, delivery channels should be adjusted. The research names several other channels that could be used: social networks of immigrants, formal sources (i.e., health organizations, public libraries, community and religious centers), ethnic media (Caidi et al. 2010; Khoir et al. 2015), and educational centers (Qayyum et al. 2014).

Cultural Competence and Training Cultural competence (CC) is considered a three-dimensional concept including affective (beliefs and attitudes), cognitive (knowledge and understanding), and behavioral dimensions (interaction and intervention skills) (Burchum 2002; Sue 2001). Sue (2001) proposes a multidimensional model for developing CC wherein aforementioned components of CC interact with culture-specific attributes on individual, professional, organizational, and societal levels (see Fig. 2): The proposed model stipulates the importance of provision of training on different foci. European Psychiatric Association guidance on cultural competence training provides further detailed recommendations for policy makers, service providers, and

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s te bu tri t EUROPEAN AMERICAN 1 cA e on fi nc si eci te NATIVE AMERICAN en -Sp pe m m Di ture Co l al LATINO AMERICAN Cu ltur nd u -A f C ASIAN AMERICAN e O c

Dimension 3 Foci of Cultural Competence

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AFRICAN AMERICAN

SOCIETAL

AWARENESS KNOWLEDGE OF ATTITUDE/ BELIEFS

SKILLS

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Dimension 2 Components Of Cultural Competence

Fig. 2 Multidimensional model for developing CC by Sue 2001, p. 792)

psychiatrists (Bhugra et al. 2014; Schouler-Ocak et al. 2015). Other professional organizations such as the American Psychological Association especially highlight the role of psychologists in promoting positive change in racial equity by raising social awareness on relevant topics and encouraging social discourse (American Psychological Association 2003, 2013). British Psychological Society underlines the crucial role of professionally trained interpreters in work with VMRs (British Psychological Society 2018). Developing cultural competence on societal level, besides policy development, might also include anti-stigma campaigns and work dedicated to reducing discrimination and prejudice. Organizational and professional foci must include, besides organizational changes, ensuring that training in CC becomes a ubiquitous social and professional norm, provision of services of intercultural mediation or culturally competent interpreters, development of professional networks and alliances aimed at improving quality of health care accessible to VMRs.

Psychoeducation for Migrants Challenges arising on the side of migrant patients themselves determine the strong need in provision of basic psychoeducation for VMRs. Psychoeducation must

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enlighten different migrant populations concerning stress factors and its influence on health, issue of psychosomatics, and importance of psychological counseling; it should include some analog of cultural competence training for VMRs themselves which clarifies differences in definitions of mental health and disease in different cultures, fight with stigma, and provide education on methods of selfcare. Such educational activities could further promote creation of safe spaces where different people could receive social support and experience meaningful social inclusion.

Conclusions The current migrant crisis imposes an additional load on health care systems in receiving countries stipulating the need in reconsideration of services accessible to different migrant populations in terms of realization whether these services are capable of responding to emerging challenges associated with global displacement and developing services ensuring quality and accessibility of health care for all immigrant groups. Service setup should begin with an analysis of needs of vulnerable migrant populations and barriers to efficient service utilization. Such analysis optimally has to monitor dynamics of trends in the field and ground in both migrant experience and professional expertise. Gained insights on barriers and deficiencies illuminate relevant challenges and show direction for improvement on professional, organizational, and federal levels. Unfortunately, not all deficiencies are easily covered and solutions are affordable. Taking the aim to find cost-effective ways to design services for VMRs, we often are encouraged to learn from relevant good practices adopted in countries that face similar problems. Insisting on the need of legal and organizational changes concerning migrant-oriented service setup in European region, we nevertheless have to endeavor to facilitate positive change on a smaller scale at organizational and personal levels. There are plenty of good practices adopted in the USA, Canada, Australia, and the UK, our further steps are to run pilot projects of good practice adjusted to European environments to further develop professional interdisciplinary networks and to include the issue of migrant-oriented service setup into educational curricula. Responding to current challenges also determines the need to include professionals with migrant backgrounds into the discourse and embolden culturally competent and diverse leadership. Public education and social enlightenment are vital likewise.

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Marshall E, Butler K, Roche T, Cumming J, Taknint J (2016) Refugee youth: a review of mental health counselling issues and practices. Can Psychol 57(4):308–319 Murray K, Davidson G, Schweitzer R (2010) Review of refugee mental health interventions following resettlement: best practices and recommendations. Am J Orthopsychiatry 80(4): 576–585 MyHealth Consortium (2018) Models to engage vulnerable migrants and refugees in their health, through community empowerment and learning alliance. Health, migrants, refugees and healthcare professionals, a preliminary report on current needs: needs assessment report. MyHealth Consortium, Athens Possible Health Project (2018) Cited 20 Dec 2018 [Internet]. Available from: https://possiblehealth. org/ Priebe S, Sandhu S, Dias S, Gaddini A, Greacen T, Ioannidis E et al (2011) Good practice in health care for migrants: views and experiences of care professionals in 16 European countries. BMC Public Health 11(1):187 Priebe S, Giacco D, El-Nagib R (2016) Public health aspects of mental health among migrants and refugees: a review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European region [internet]. WHO Regional Office for Europe, Copenhagen. Health Evidence Network synthesis report, no. 47. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK391040/. Accessed 20 Dec 2018 Qayyum MA, Thompson KM, Kennan MA, Lloyd A (2014) The provision and sharing of information between service providers and settling refugees. Inf Res 19(2):19–12 Quan K, Lynch J (2010) The high costs of language barriers in medical malpractice. National Health Law Program, University of California, Berkeley Rohlof H, Knipscheer J, Kleber R (2014) Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol 49(11):1793–1804 Schouler-Ocak M, Graef-Calliess I, Tarricone I, Qureshi A, Kastrup M, Bhugra D (2015) EPA guidance on cultural competence training. Eur Psychiatry 30(3):431–440 Sue D (2001) Multidimensional facets of cultural competence. Couns Psychol 29(6):790–821 The Alex Community Health Bus (2018) Cited 20 Dec 2018 [Internet]. Available from: https:// www.thealex.ca/ UNHCR (2016) Global trends. Forced displacement in 2015 [Internet]. Available from: https:// www.unhcr.org/statistics/unhcrstats/576408cd7/unhcr-global-trends-2015.html UNHCR (2017) Global trends: forced displacement in 2016 [Internet]. United Nations High Commissioner for Refugees. Available from: https://www.unhcr.org/statistics/unhcrstats/ 5943e8a34/global-trends-forced-displacement-2016.html UNHCR (2018) Global trends. Forced displacement in 2017 [Internet]. United Nations High Commissioner for Refugees. Available from: https://www.unhcr.org/statistics/unhcrstats/ 5b27be547/unhcr-global-trends-2017.html Vázquez M, Vargas I, Jaramillo D, Porthé V, López-Fernández L, Vargas H et al (2016) Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia. Health Policy 120(4):396–405 Winkler P, Krupchanka D, Roberts T, Kondratova L, Machů V, Höschl C et al (2017) A blind spot on the global mental health map: a scoping review of 25 years’ development of mental health care for people with severe mental illnesses in central and eastern Europe. Lancet Psychiatry 4(8):634–642

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Main Concerns About Providing Health Care to Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barriers to Health Care for Undocumented Immigrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legal Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barriers on the Health System Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barriers on the Individual Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Providing the Standard of Health Care to Undocumented Immigrants . . . . . . . . . . . . . . . . . . . . . . . . Ethics and the Need for Research in the Refugee Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Migration is a very contentious topic in politics today and access to health care by immigrants is a puzzle that different stakeholders usually view through political lenses. In this chapter, we set the foundations by explaining the key concepts about health care and migration, and then we address some of the most pressing concerns about providing health care to migrants, with an emphasis on undocumented immigrants. Lastly, we present a summary of the evidence-based guidelines for physicians on how to screen for clinical and mental illnesses in migrants. Keywords

Migration · Migrants · Refugees · Access to healthcare · Ethics

J. Torales (*) · I. Gonzalez-Urbieta Psychiatry, National University of Asunción, School of Medical Sciences, San Lorenzo, Paraguay e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_19

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Introduction How we define migrants define the way we interact with them and guide the policies that are directed towards them. Broad definitions, such as the one from the International Organization for Migration, better capture the complexity of the phenomenon, they define a migrant as “any person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of the person’s legal status; whether the movement is voluntary or involuntary; what the causes for the movement are; or what the length of the stay is” (International Organization for Migration 2018). Under this definition, migrants can be classified using several criteria depending on the needs and the motives for said classification. Some of the more frequently used categories are described in Table 1, but there are other ways of classifying migrants: the reasons for migration (voluntary vs. involuntary), the socioeconomic status of the migrant, and the intended duration of the location (short term vs. long term) (Bhugra and Becker 2005). All these aspects affect the experience of the migrants once they arrive at the destination site. Access to health care by immigrants continuously proves to be a contentious topic among policymakers and the general population (Alexandroupolis and Koviljaca 2012; Cody 2012; Conover 2018; DW 2012; Stevis 2012).

Main Concerns About Providing Health Care to Immigrants Gray and Van Ginneken outline five of the most common issues or concerns regarding the provision of health care to undocumented immigrants (Grit et al. 2012). – Humanitarian and ethical issues: Access to health care is a human right and should be available to everyone without discrimination, according to the International Covenant on Economic, Social, and Cultural Rights (UN General Assembly 1966). The World Health Organization (WHO) Constitution of 1948 Table 1 Frequently used categories of migrants, adapted (Brander et al. 2012) Temporary Highly skilled Irregular Forced Family members and closed associates

Usually laborers or guest workers These are professionals who are usually sought out by corporations in the destination site Migrants who enter the destination site without the necessary documents or permits Asylum seekers, refugees and other people forced to migrate due to political persecution, armed conflicts, or environmental disasters Also known as “chain migration,” defined as “movement in which prospective migrants learn of opportunities, are provided with transportation, and have initial accommodation and employment arranged by means of primary social relationships with previous migrants” (MacDonald and MacDonald 1964)

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establishes de right of any person to enjoy the highest attainable standard of physical and mental health (World Health Organisation (WHO) 1946), and it declares that the right to health is tied to the key principle of nondiscrimination, for locals, refugees, and migrants alike. The WHO emphasizes the obligation of national health systems to address the migrants’ right, regardless of their legal or migratory status, while noting that this will require active collaboration of governments and nonstate actors (World Health Organization (WHO) 2017). Public health issues: Providing services such as vaccination and other preventive services to immigrants can benefit not only the recipients of those services but the society as a whole, by preventing the spread of communicable diseases. Public health policies directed toward providing access to preventive services by immigrants regardless of their legal status can be beneficial towards this purpose (European Centre for Disease Prevention and Control and ECDC 2014; Kentikelenis et al. 2014; Legido-Quigley et al. 2013). Concerns about attracting more migrants: Some groups object that providing more health benefits to undocumented migrants could attract more migrations, although the evidence does not support this claim. This objection is not limited to health care, but it extends to education and other services. Concerns about fairness: The argument is that since migrants have not contributed with their taxes to the funds supporting the health care system, they should not be allowed to access those services. This argument goes against the concept of health as a human right, and the costs of treating patients who end up in emergency services due to the neglect of health care may be higher than providing early access to detection and prevention (Bozorgmehr and Razum 2015). In their systematic review about the medical expenditures by migrants in the USA, Flavin et al. found that immigrants almost certainly paid more toward medical expenses than they withdrew, and advocate for providing more access to health care to immigrants, not less (Flavin et al. 2018). Concerns about the health system: There are concerns that national health care systems may not be prepared to receive an influx of new patients and that this could lower the access and the quality of services received by nationals. Research must be done to shed light on the costs of different immigrant health policies to determine their true monetary cost.

Barriers to Health Care for Undocumented Immigrants In their review of the literature, Hacker et al. categorize and summarize the different barriers to healthcare faced by immigrants (Hacker et al. 2015).

Legal Barriers Due to the increased influx of migrants due to conflicts in different areas of the world, many countries are designing policies to limit the number of migrants coming into their territory and to limit their access to public services once they have arrived

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(Grit et al. 2012). Despite these efforts, there has been a rapid increase in the number of international migrants around the globe, going from 173 million in 2000, to 220 million in 2010, and 258 million in 2017. The global refugee population is the highest on record. According to the data displayed on their website, there are 65.6 million forcibly displaced people worldwide, 22.5 of these people are refugees (The UN Refugee Agency 2017). This is a great challenge for the health care systems of the countries of destination of migrants, and policymakers in different countries widely vary in their approach to the issue. Some of these policies can be detrimental to the provision of access to health care by migrants. Undocumented migrants frequently cite legal barriers as one of the most important deterrents for timely access to health care services. They include bans from insurance and ID requirements to get health care services. Insurance bans can effectively bar migrants from access to care since insurance is usually required for affordable care or to receive services at all (Martinez et al. 2015). ID requirements can have the same effects and they can cause parents to avoid taking their authorized children to the doctor because they cannot produce the required documents for themselves. Immigration laws and policies frequently determine the level of access to care of undocumented immigrants; they can go from explicitly excluding all undocumented immigrants from receiving any type of health care service, including emergency care, to granting minimum care (usually emergency care) or, in few cases, more than minimum care. Some jurisdictions have, at some point, even required physicians (among other professionals) to denounce undocumented immigrants if they came in contact with them (Toomey et al. 2014). Even in jurisdictions where immigration policies allow undocumented immigrants to access some level of care, there are frequently bureaucratic steps involved that can discourage immigrants from utilizing health care services (Chauvin et al. 2009).

Barriers on the Health System Level On the health system level, the first barrier many immigrants face is lack of physical access to a point of care due to lack of transportation. Transportation barriers can lead to missed appointments, and patients may postpone critical care unless they deem it urgent, which can complicate management and worsen prognosis, especially in chronic illnesses (Syed et al. 2013). Some health systems discriminate the service they provide to patients based on their legal status; this is usually related to the policies lined up by the correspondent jurisdiction. Most health systems are required to provide emergency services to all people regardless of their legal status, but few of them are required to offer anything more (Karl-Trummer et al. 2010). Bureaucracy and paperwork can be a difficult barrier for undocumented immigrants and providers alike. Many reviews highlight the fact that extensive paperwork

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can deter immigrants from accessing health care services, even when they are accessible to them.

Barriers on the Individual Level Fear of deportation was one of the most frequently cited factors cited by undocumented immigrants for not seeking healthcare (Goossens and Depoorter 2011; Vargas Bustamante et al. 2012); this can also change with the political climate, and immigration-averse administrations can have a great impact on how safe undocumented immigrants feel to attend a healthcare facility (Hoffman 2017). Language barriers can hinder immigrant’s access to health care; these barriers not only exist in the physician-patient encounter but are pervasive to the entire system. Migrants cite communication troubles when trying to make an appointment and when trying to fill applications (Morris et al. 2009). Other frequently cited barriers on the individual level include language difficulties, lack of financial resources, shame and stigma, and lack of knowledge about the health care system.

Providing the Standard of Health Care to Undocumented Immigrants Immigrants at arrival are usually healthier than the native population, but the so-called “healthy immigrant effect” tends to wane after settlement (McDonald and Kennedy 2004). Some groups, such as refugees, have a greater burden of infectious diseases and mental disorders than the native population. The undocumented immigrant population is at risk for many health-related issues. A meta-analysis examined the association between predisplacement and postdisplacement conditions and the consequent mental health status of the refugees. The associations with postdisplacement conditions were predictable: Materially secure conditions, measured by economic opportunities and permanent accommodation, were associated with better mental health, and these results indicated that psychiatric disorders such as PTSD and depression are not inexorable results of the trauma of their situation, but that other factors may influence the development of these disorders. On the other hand, the association between predisplacement conditions and mental health run somewhat against the predicted outcomes: Higher level of education and socioeconomic status were thought to be protective factors against mental disorders, instead refugees with these characteristics had worse outcomes in the meta-analysis, and one possible interpretation is that refugees with these predisplacement conditions suffer a larger loss, hence becoming more predisposed to mental health issues (Porter and Haslam 2005). Studies show that discriminatory practices in many regions discourage ethnic minorities from using health care services. They are also less likely to receive the standard of care once they obtain access to the healthcare system (Burnes Bolton

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et al. 2004). Immigrants in general show lower rates of utilization of mental health care services, likely due to cultural and linguistic barriers to care (Kirmayer et al. 2007). When immigrants face mental health issues, they usually turn first to family, friends, or religious groups (Derr 2016). A qualitative study in Montreal tried to explain why migrants are unwilling to use mental health services; they found that perceived excessive proneness of doctors to install pharmacotherapies, a dismissive attitude from physicians, and a strong belief in nonmedical interventions were the main factors leading migrants away from mental health services (Whitley et al. 2006). Establishing a meaningful relationship with refugee patients requires making an effort to understand the history of the trauma that they have suffered and its symptoms (Crosby 2013). Despite recommendations that physicians take a complete history of the trauma paying special attention to the psychosocial aspect, loss of friends and family members, and traumatic disability (Mollica 2001), physicians often remain unaware of the refugee’s trauma histories (Eisenman et al. 2000) and are therefore unable to detect the mental health issues that may be associated to them. Some of them may be reluctant to start conversations with their healthcare providers due to a perception that cultural norms expect them to be submissive to their physicians or due to a lack of knowledge about the possible repercussions of the trauma in their mental health (Shannon et al. 2012). Posttraumatic stress disorder (PTSD) is usually considered to be the main mental health outcome of the trauma associated with being forcibly displaced from one’s country, but an umbrella review of 13 meta-analyses found that major depression and anxiety could be just as prevalent in this population, affecting up to one third of the refugees and asylum seekers in certain regions (Turrini et al. 2017). The total number of trauma and exposure to torture are good predictors of both PTSD and major depression (Priebe et al. 2016). An often overlooked fact is that psychotic disorders, including schizophrenia, may be more frequent in refugees compared to other immigrants and the general population (Dapunt et al. 2017; Hollander et al. 2016). The Center for Disease Control in the United States (CDC), the World Health Organization (WHO), and many other national institutions encourage health screening during the domestic medical examination for newly arrived refugees and immigrants, since this is their first interaction with the host’s healthcare system (Pottie et al. 2011; Priebe et al. 2016; U.S. Department of Health and Human Services (HHS) 2012). Refugees are systematically screened for health care issues at detention centers before settling in their country of destination. The CDC has issued a checklist for screening refugees and immigrants at arrival (U.S. Department of Health and Human Services (HHS) 2012), and the Canadian Collaboration for Immigrant and Refugee Health has also published evidence-based guidelines for the care of refugees and immigrants in general (Pottie et al. 2011). The guidelines include checking for a general health screening that evaluates the medical history of the patient and a review of the vaccination and pregnancy status. They also encourage mental health screening, if available and feasible. Also included are recommendations for disease-specific laboratory testing. The following components of the mental health screening for refugees are suggested by the CDC:

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1. Review of records from overseas: This may not be technically feasible, but a reasonable attempt should be made to obtain them. 2. History and physical examination related to mental health: Paying special attention to signs of abuse and unexplained somatic symptoms that could be related to psychological distress. 3. Mental status examination: In the form of a semi-structured interview, physicians should look for signs of psychotic disorders assess suicidality. 4. Screening for depression and PTSD: Although they encourage the use of standardized instruments such as the PRIME-MD PHQ-9 for depression, and the PCL-C-17 or the Harvard Trauma Questionnaire checklist for PTSD, they also emphasize that diagnoses should not be made on the sole criteria of these instruments and that individuals whose scores suggest the presence of a psychiatric disorder should be referred to a professional healthcare provider for a more thorough evaluation. 5. Referral for refugees considered at significant risk: Physicians should reassure them by clearly explaining what they can expect in their visit to the specialist (U.S. Department of Health and Human Services, and Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases 2015). In following these recommendations, healthcare providers must not overlook the importance of discussing the issues that motivated the migration, since they can help the physician understand the stresses that the refugee faced in the country of origin and in the route to the host country. Many refugees suffered the loss of family members, personal health, and financial security. A great number of them have experienced famine, torture, and rape. When a clinical or mental disorder is diagnosed in these patients, the standard of care should be provided. While some clinical studies show differences in the doses needed or the adverse effect profiles in individuals from different ethnicities (Lin et al. 1989; Marcos and Cancro 1982; Strickland et al. 1995), in clinical practice, the pharmacologic approach does not differ greatly from what is used in the general population (Silove et al. 2017). In order to achieve adherence to treatment in this population, physicians must assess the expectations of the patients about the drugs and their attitude towards them, ask about use of alternative or herbal medicines in a nonjudgmental way, evaluate use of substances such as tobacco and alcohol with consideration of their cultural norms, and explain the side effects of the medications in advance while monitoring them throughout the duration of the treatment (Bhugra et al. 2011).

Ethics and the Need for Research in the Refugee Population As physicians, we are constantly looking for evidence-based solutions to the problems we face. Refugees can certainly benefit from evidence resulting in better pharmacologic treatments, more directed and available psychotherapies for mental

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disorders, better targeted social approaches, and policies supported by strong evidence and not based merely on political arguments. In order find these solutions, researchers face a “dual imperative” to balance their concerns about reducing suffering and their professional duty to produce research with the highest scientific standards (Jacobsen and Landau 2003). Ethical considerations should guide the research process without compromising on research design, in order to produce studies that will be actually useful for the affected groups (Birman 2005). The European Commission provides a guidance note listing the general principles to follow when research involves refuges, including treating them with care and sensitivity, being objective and transparent, avoiding ethnocentricity, safeguarding their autonomy, dignity, well-being, and security, respecting their values and their right to consent, and giving special protections to participants with diminished autonomy, such as unaccompanied minors. They raise the issue that traditional informed consent forms can be harmful to the refugees because they can discourage participants, jeopardize their anonymity, and be difficult to translate to their language in a comprehensible style. They suggest using less formalized procedures for providing information and obtaining consent. This can be achieved by including cultural insiders in the process, working with reputable NGOs, and using oral consent with the knowledge and approval of a competent Research Ethics Committee (European Commission 2016).

Conclusion Access to the standard of healthcare is one of the most important human rights to secure for refugees since it is essential to allow them to enjoy other human rights (Torales et al. 2014). Refugees and immigrants in general should be screened for clinical and mental health disorders as soon as they reach the host countries, and physicians must make adjustments in their style of questioning and their treatment approaches to accommodate to this special population. Researchers should be encouraged to study this population in order to find the best strategies to provide care for immigrants. At the same time, they should be held to a high standard not only in their research design but in their respect for the autonomy and the dignity of this vulnerable group.

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assistance among Mexican-origin adolescent mothers and their mother figures. Am J Public Health, 104 Suppl 1(Suppl 1):S28–S34. https://doi.org/10.2105/AJPH.2013.301655 Torales J, Villalba-Arias J, Ruiz-Díaz C, Chávez E, Riego V (2014) The right to health in Paraguay. Int Rev Psychiatry 26(4):524–529. https://doi.org/10.3109/09540261.2014.926866 Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G, Barbui C (2017) Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. Int J Ment Heal Syst 11:51. https://doi.org/10.1186/s13033-017-0156-0 U.S. Department of Health and Human Services, & Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, D. of G. M. and Q (2015) Guidelines for mental health screening during the domestic medical examination for newly arrived refugees (Vol 1) U.S. Department of Health and Human Services (HHS) (2012) Summary checklist for the domestic medical examination For newly arriving refugees. U.S. Department of Health and Human Services, 7 UN General Assembly (1966) International covenant on economic, social and cultural rights. United Nations, Treaty Series 999(14531):3 Vargas Bustamante A, Fang H, Garza J, Carter-Pokras O, Wallace SP, Rizzo JA, Ortega AN (2012) Variations in healthcare access and utilization among Mexican immigrants: the role of documentation status. J Immigr Minor Health. https://doi.org/10.1007/s10903-010-9406-9 Whitley R, Kirmayer LJ, Groleau D (2006) Understanding immigrants’ reluctance to use mental health services: a qualitative study from Montreal. Can J Psychiatry 51(4):205–209. https://doi.org/10.1177/070674370605100401 World Health Organisation (WHO) (1946) Constitution of the World Health Organization. Basic Doc. https://doi.org/10.2105/AJPH.36.11.1315 World Health Organization (WHO) (2017) The right to health. Retrieved 1 Oct 2018, from http://www.who.int/migrants/about/right-to-health/en/

Resilience, Mental Health, and Migrations

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Boris Cyrulnik

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health and Migrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intercultural Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Migration, Social and Cultural Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intercultural Transactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Paradox of the Future Generations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Only One Question to Conclude With . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

What is called mental health depends on the scale of values. In migration, it is possible to assess the rate of medical and psychiatric consultations, and antisocial behavior. Intercultural meetings depend on the host culture intertwining with the arriving group. Intercultural transactions describe four schemes: the worst is camps. Coexistence is a weak link. Assimilation is brutal. The best solution, the most agreed, is bicultural integration. Keywords

Intercultural transactions · Future generations paradox · Neuronal resilience · Gap of acculturation

B. Cyrulnik (*) Education, University of Toulon, Toulon, France e-mail: [email protected]; [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_14

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Introduction In order to understand the interaction between mental health and migration, it is helpful to look at some basic definitions. How can we best define mental health? Is it of a statistical, normative, or axiologic nature? • The biological standard is statistical: a normal blood-sugar level is defined between 90 and 110 mg/l. This norm is not directly related to one’s health. Some persons experience hypoglycemia with 70 mg/l; others do not have any medical problems with 40 mg/l. The latter are considered as abnormal although they are perfectly healthy. • The normative standard is psychosocial: the norm is often sexual or behavioral. Those who do not submit to this are considered marginalized, deviant, or antisocial. Culture dictates which behaviors are acceptable and which are deviant. As an extreme example, dictators, who are often elected and worshipped, set these standards through which they are able to control the populations they rule. • The axiological norm is psychological: the main reference is the value which the subject assigns to an event. When the ethos, the scale of values of a subject, matches with the culture, the person is said to be balanced. When there is discrepancy, each individual considers that the other is deviant. The word “culture” is not clearly defined as there are at least 100 different definitions that range from “plowing one’s field” to “developing one’s intellectual capacities.” However, it is helpful to understand what is resilience and what is its relationship to health. The definition of resilience appears to be clear: resumption of a new development after a traumatic psychic agony. According to scientific criteria, every step of this process can be analyzed, assessed, and refuted. The neuronal resilience, as photographed in neuroimaging and measured in neurobiology, shows how new brain circuits start working when an injured person is surrounded with emotional support and verbal exchange. Emotional resilience is identified through changes in the behavior of the preverbal child. At that stage, when a child speaks, he/she can be assessed through statistically validated surveys on attachment. The psychological resilience can be analyzed through the Rorschach or any other psychological classical test. It is also important to understand collective resilience which is measurable by sociological surveys. A clear understanding of both individual and collective resilience is important for public mental health but also for developing and delivering services to migrants. All these criteria require interdisciplinary collaboration, even though it might be difficult to do. The main reluctance comes from the opposition, classical since Darwin, between those who work with evolutionary theories and those who prefer the “fixist” ones. Any development, whether normal/healthy or abnormal with resilience, can only be analyzed from an evolutionary perspective. A subject changes in a changing world and “fixism” cannot address such situation. It is possible to hypothesize a living being from a calcaneus bone or a tooth, such as archaeologists do, but, from an evolutionary perspective, the biological individual is the result of crossroads of environmental pressures, whereas a speaking subject is at crossroads of narratives.

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Mental Health and Migrations It turns out that the migration phenomenon that started with Sapiens, when he left Southern and Eastern Africa, raised both the question of trauma and the resumption of a new existence in a new ecological and cultural context. In the twenty-first century, population displacement is already considerable and is likely to continue to increase due to natural and man-made disasters such as wars, poverty, and meteorological extremes. In these groups of migrants, mental distress and illness can be diagnosed: • Medical and psychiatric consultations: rates of depression and other common mental disorders, suicides, and schizophrenia are three to four times more prevalent as compared to other groups of migrants and to the indigenous population. • Antisocial behavior, delinquency, poor attachment patterns and abuse in welfare homes, low levels of education, high levels of violence toward self and others, and failures in socialization are commonplace in certain groups of migrants that accumulate a large number of markers of malaise. When these social markers improve, they provide evidence of resilience. In groups that are well integrated, after the inevitable stress of acculturation, two factors of resilience can be identified: • A natural tranquility which is based on the familiarity of contacts: same language, mutual aid organizations, and known faces that make it possible to feel confident in one’s group at a glance • A cultural tranquility which is based on sharing social rituals, such as cooking, music, or transcendent rituals, such as religion and cultural ceremonies When markers are positive in a closed group and negative outside, it can be observed that the group evolves into a clan that is called today “communitarism.” On the other hand, when the group of migrants has no access to the sensory tranquilizers (same language, same clothes) nor to ritual tranquilizers (secular or religious meetings), they may perceive any social contact as an alert. Such a group then constitutes an aggregate of individuals who may feel constantly under pressure and under constant assault. Their integration will be difficult with a rather antisocial trend: “I hate this country.” It needs to be explored further whether such attitudes can contribute to further alienation and radicalization.

Intercultural Meetings For the host country, the arrival of a group of migrants very often generates a strong emotion. If the welcoming group feels strong, stable, and confident, it will take interest in the newcomers, in their culture, and help them integrate. It is possible that the host group may take advantage of the migrant group by exploiting them

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economically to do poorly paid and unwanted jobs that the local individuals may not be keen to carry out. For example, Canada in the 1980s was a country impoverished due its aging population. Since then, the country is flourishing again thanks to immigration. It has just joined the top ten of the wealthiest countries in the world. But its culture has been modified by the arrival of Haitian and North African cultures. When the host country has difficulties, whether economic or political, it perceives the arrival of migrants as an invasion: “They will take our jobs, they will have a delinquent behaviour, they will lower our standard of living, their religion is based on war.” This difficulty is not really or necessarily economic since Canada, Germany, Israel, and other industrialized countries took advantage of immigrating groups. Instead the feeling of danger depends on the psychosocial culture of the host country. When the country is organized as a clan, the arriving group is perceived as another clan that might be aggressive. This feeling legitimizes what is considered to be self-defense, becoming aggressive against migrants, as it has been seen recently in Germany or Corsica. There is no doubt that the vast majority of Muslim migrants are well-behaved. They simply want to work, respect the law, and be integrated in the host society, like eight millions of them in France, for example. But among them, there are also fanatic and radicalized fundamentalists, 15–20,000 Salafis, who constitute an army opposed to the host country. This minority considers that the other Muslims who integrate are traitors to Islam; they call them “collabos,” referring to the French who collaborated with the Nazis during the Second World War. For them, killing a “collabo” Muslim is a moral duty, a defense of the true faith. It is therefore important to try to reason in terms of percentage of the population to avoid abusive and stereotypical generalizations. Non-Muslims are not competent to designate those who practice the true faith. Migrant groups, like all other groups, are heterogeneous, and their reasons and process of migration vary tremendously. They often experience very different conditions of migration. It is inevitable that such experiences will help form their attitudes to the host country. The chosen reasons for migration (studies, economic reasons, professional expatriation, political reasons) do not prevent the stress of acculturation to happen, but it may not necessarily be of traumatic nature. While the forced migration is a profound wound as it is linked to famine, war, persecution, attacks encountered on the journey, and difficult reception in the host country where the migrant does not know the language, laws, and procedures, the response of the host country and support systems can help mitigate some of these stressors.

Migration, Social and Cultural Changes In the twenty-first century, technology has led to rapid globalization of information and the movement of goods and people that make the migration a global priority (United Nations 2008). The rapid pace of industrialization and resulting explosion of urbanization create particular migratory conditions and issues. When an Italian

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became a baker in Grenoble, when a Pole went down a mine in Alsace, and when a Tunisian worked on a production line at Renault factory near Paris, human relations did set up, and eventually, the natural tranquilizer of the bond ended up being woven. The foreigner became gradually familiar. This is not the case in the megacities where the newcomers, who live in suburbs, organize themselves into clans, disconnected from the hosting culture. The cultural loss of their own culture and lack of integration may explain why language, laws, and rituals may become hard to learn, paving the way for high rates of crime, psychological disturbances, as well as harm to others and self as seen in increased rates of suicide. In such a context, the clan becomes a toxic defense mechanism. This unprecedented situation requires a new cultural policy that is yet to be invented. Would a bicultural integration be a potential solution? (Berry 2005). The markers of well-being of migrants have been assessed in various cultures. These assessments give very different results in the West (Australia, Canada, the USA), in the Middle East, or in Asian cultures (Hunt et al. 2004). Westerners who emigrate to Asia also tend to live among themselves, because of the language barriers. However, they do not constitute a clan because they are still seeking contact with the Asian markets and cultures. In the Middle East, the pan-Arabism of Nasser was a tragic illusion because the countless tribes and religious factions hindered the homogenization of a “nation” that would encompass many Arab countries. In Western Europe, immigrants from Central Europe and Maghreb were invited in order to do jobs which the locals did not want to do and were therefore exploited. Nevertheless, a large number of them eventually became integrated and are now happy to be French or British or Dutch. In China, market technology fundamentally changed the way people live together. Emancipated women participate actively in the economic adventure, but, deep inside, they are somewhat nostalgic of the village where everyone knew each other and where family structures secured them. A family in a village is an emotional, reassuring, and stifling constraint. It is entirely likely that loneliness in a Shanghai tower, and being bullied by an authoritarian boss every day, can cause psychic suffering and relational difficulties; social support may not exist to provide any help, thereby contributing further to isolation and stress. Suicide rate of women in China was one of the highest in the world during the last decade. On the contrary, the markers of well-being, good education, high salaries, and independence, are excellent for health and mental health. However, these women suffer in silence, because there are also unconscious sources of psychological discomfort.

Intercultural Transactions The incoming and host cultures are interrelated. Depending on cultural strategies, they can freeze, destroy themselves (as with the end of civilizations), or evolve into a new form of culture, which may be called “resilient.” Acculturation needs to be studied at a group level which was the level at which the concepts had been developed.

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Four reception schemes can be described: • Camps such as the Calais “Jungle” or the Palestinian camps in Arab countries. No interpenetration, with rapid emergence of the archaic process of socialization through the law of the strongest. • Coexistence as it is the case in Perpignan, Béziers, or Corsica, where migrants and indigenous populations coexist while ignoring each other, until a tiny problem sparks a fire. • Bicultural integration is typified by the view: “I have to learn the language and the laws of the host country but my identity is strengthened by the pride of my origins.” • Assimilation is brutal when it is required from the first generation: “Become French or leave.” Nevertheless, it can lead to a more successful outcome when the process of integration is allowed to evolve gradually over a couple of generations. It is therefore necessary to distinguish between what makes it possible for newcomers and the host country to cope. Indeed, there may be some confrontation depending upon a number of factors such as numbers of migrants, pace of migration, actual purpose of migration, and willingness to be integrated. How the new group manages the process of acculturation will inevitably influence the interaction between two cultures. Later on, an interactive process takes place that allows a positive evolution together in a new culture: this is resilience of cultures, in the diachrony (Castro and Murray 2010). It is possible to evaluate factors of migratory resilience by analyzing the experiences a migrant may have gone through as well as his/her support systems including family, neighborhood, cultural values, and behaviors. It is possible that if such an individual had poor attachment patterns in childhood, he may well have acquired a level of neuro-emotional vulnerability, which is likely to go on to influence his affective and social relationships (Davidson et al. 2008). Prevention of mental health disorders can be achieved by improving the emotional security of the parental home, by promoting education, and by offering cultural activities. Many politicians do not give enough importance to these elements. They do not want to see that an unhappy childhood might become an exorbitant cost for society. They may also feel that the impact of such interventions may well take a generation or two to show an impact while they are interested only in the short term, till the reelection. Therefore, mental health workers need to work with policymakers to ensure that long-term interventions are part of the public mental health programs.

The Paradox of the Future Generations The children of migrants may well acculturate more easily than their parents. This can contribute to conflicts within the family based on cultural values. A child who quickly acquires a second language, who obtains good results at school, and who

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hopes to socialize in the host culture can be a source of pride for his parents. However, older family members may hold more traditional views, and this tension between modern and more traditional views may negatively affect family dynamics. The family may see this integration as an act of treason or even as a humiliation: “You are ashamed because of us.” The young person is then faced with a painful choice: “If I succeed socially, I will drive a wedge between my family and myself. Whereas preventing myself from becoming integrated will allow me to maintain a close link with my family.” This is a “gap of acculturation” (Elder et al. 2005) where the young person who is integrated gives his parents a condescending impression, without meaning to do so. As for the marginalized children, they feel neither the pride of their origins nor the pride of their success. These young people wandering around are prey for the sects who abuse them and establish a psychological hold on them. This cultural conflict may create tensions which must be explored while planning any clinical, psychological, or social interventions. An important factor of family cohesion is currently developing: religion, which permits continuity between the generations. From the moment that one shares the same belief that organizes social rituals and rites and prioritizes moral values, the acculturation gap will fade away. Anxiety decreases, self-esteem increases in both generations, and the markers of well-being improve significantly (Farner et al. 2002). When personal adventure overrides the family group, religion is experienced as a constraint. But, in a group which socializes with difficulty, religion may become a factor of appeasement, of cohesion, that facilitates solidarity and attributes moral values to events. When the family structure is maintained by a shared view of the world, the mental health of parents and children is comparable to that of the “founding families.” When the emigration is desired by the parents as an intellectual or social adventure, the project for such a vision of life facilitates positive mental health. When emigration is forced, consequently unhappy, it is religion that assumes a protection factor, improves markers of well-being, and proves the resilience of the arriving group (Castro et al. 2007). The danger of this protective factor is to make the group evolve toward a clan structure: “We only feel good among us; those who do not share our beliefs are disbelievers.” The more and the more diverse the encounters, the less prejudice there is. Yet, isolation which protects the individual rapidly evolves toward a closed world, where any other approach is felt as an aggression caused by disbelievers. It is with the feeling of legitimate self-defense or self-protection that these clan migrants become aggressive toward the host culture. A curious phenomenon is beginning to show: the return of religious order in the children of the third generation. The first generation suffers and keeps silent, sacrificing itself for its family, even when exploited by the host country. This integration strategy explains the paradox of the second generation. Parental sacrifices are not reassuring for their children who feel depressed, commit suicide, and are sometimes hostile to the host country. And it is the third generation totally acculturated which increases its markers of well-being by returning to its origins. Young French learn Spanish, the language of their grandparent (that their parents no longer spoke). Young

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Jews discover the religion of grandparents that they have not known and teach it to their own parents who are often “Jews without God.” Black organizations are being created to defend their interests and to discover the history of their ancestors, thus constituting black groups, while their own parents were ashamed of their color and became activists for the disappearance of this distinction, which they considered racist (Phinney 1993). These children find the identifying, securing, and solidarizing effect of the religion of their ancestors. They join where their parents withdrew. Belonging to a group, becoming proud to be black or Jew in spite of the discriminations of the cultural context, becomes a factor of protection. At the same time, this is a proof that culture is no longer able to integrate all the individuals who live there. This psychocultural adaptation relieves individuals but prepares clans and religious extremism for war. Democratic debate is not conceivable when everybody believes that his God is the only God and that the other faiths are evil that should morally be fought.

Only One Question to Conclude With Cultures are constantly bubbling because it is the human condition. Migration triggered by ecological or political events contributes to cultural evolution. This process can enrich us, as much as destroy us. Shall we be able to choose?

References Berry JW (2005) Acculturation: living successfully in two cultures. Int J Intercult Relat 29:697–712 Castro FG, Murray KE (2010) Cultural adaptation and resilience. In: Reich JW, Zautra AJ, Hall JS (eds) Handbook of adult resilience. Guilford, New York, p 382 Castro FG, Garfinkel J, Naranjo D, Rollins M, Brook JS, Brook DW (2007) Cultural traditions as “protective factors”, among Latino children of illicit drug users. Subst Use Misuse 42:621–642 Davidson GR, Murray KE, Schweitzer R (2008) Review of refugee mental health and wellbeing: Australian perspectives. Aust Psychol 43:160–174 Elder JP, Broyles S, Brennan JJ, Zuniga de Nuncio ML, Nader PR (2005) Acculturation, parent-child acculturation differential and chronic disease risk factors in a Mexican American population. J Immigr Health 7:1–9 Farner JA, Narang SK, Bhadha BR (2002) East meet west: ethnic identity acculturation and conflict in Asian Indian families. J Fam Psychol 16:338–350 Hunt LM, Schneider S, Comer P (2004) Should “acculturation” be a variable in health research? A critical review of research on US Hispanics. Soc Sci Med 59:973–986 Phinney JS (1993) A three-stage model of ethnic identity development in adolescence. In: Bernal ME, Knight GP (eds) Ethnic identity: formation and transmission on among Hispanics and other minorities. State University of New York Press, Albany, pp 61–79 United Nations (2008) World urbanization to hit high by year’s end. World Urbanization Project, New York

Therapy and Therapeutic Considerations with Refugees and Asylum Seekers

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Farkhondeh Farsimadan

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Refugee Journey and the Impact on Mental Health Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Considerations with Refugees and Asylum Seekers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Development of UEL Refugee Mental Health & Wellbeing Online Portal . . . . . . . . . . . . . . . . . . . . Portal Background and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Process of Developing Portal’s Resource Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resource Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

A combination of pre-migration, migration, and post-migration stressors that refugees and asylum seekers are exposed to may predispose them to developing mental health problems. The refugee populations are heterogeneous groups with different cultural backgrounds, experiences, expectations, belief systems, and conceptualization of mental illness and help-seeking behaviors making it more challenging for mental health services and professionals to meet the needs of their refugee clients from a traditional culture. This chapter focuses on some of these challenges and offers detailed therapeutic considerations to mental health practitioners while working with their refugee and asylum-seeking clients. An overview of the University of East London Refugee Mental Health & Wellbeing Portal, an online hub for refugees and asylum seekers and mental health and social care professionals working with them is also presented.

F. Farsimadan (*) UEL Refugee Mental Health and Wellbeing Portal, London, UK © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_22

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Keywords

Refugees and asylum seekers · Migration stressors · Mental health · Therapeutic considerations · UEL Refugee Mental Health & Wellbeing Portal

Introduction On their journey to safety, refugees and asylum seekers may be exposed to stressors at various stages including pre-migration, during migration, and post-migration, which may predispose them to developing mental health problems. The refugee populations are heterogeneous groups with different cultural backgrounds, experiences, expectations, belief systems, and conceptualization of mental illness and helpseeking behaviors making it more challenging for mental health services and practitioners to generalize their service provision to meet the needs of their refugee clients from a traditional culture. This chapter highlights some of these challenges as well as offers detailed therapeutic considerations to mental health practitioners while working with their refugee and asylum-seeking clients. This chapter also presents an overview of the University of London Refugee Mental Health & Wellbeing Portal, an online hub for refugees and asylum seekers and mental health and social care professionals working with them developed by a team of colleagues at the University of East London. There are different terms for refugee depending on their status during the process of assessment and being legally identified as refugees, those who are seeking protection and safety are referred to as asylum seekers and those granted protection are referred to as refugees. (The 1951 United Nations Convention relating to the Status of Refugees describes a refugee as someone who: “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.” (UNHCR 1951: Article 1A (2)).) However, throughout this chapter the term refugee is used to refer to those seeking asylum and those granted full refugee status.

The Refugee Journey and the Impact on Mental Health Well-Being What primarily distinguishes between an immigrant and a refugee is that the former usually has made a planned choice to improve their life by embarking on living in another country whereas the former is forced to flee their homeland for fear of their life, usually at short notice or none at all. Refugees may be exposed to a number of stress factors that could adversely impact their mental health well-being. These are known as pre-migration, migration, and post-migration stressors (Laban et al. 2004; Bhugra and Becker 2005; Walsh 2007; Bogic et al. 2012; Slobodin and De Jong 2015; Bogic et al. 2015).

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Pre-migration stressors can include events that had led to refugee’s decision to flee including political instability and war, fear of violence and persecution on grounds of religion, ethnicity, political ideology and affiliation, ethnicity, etc. For majority of refugees the migration journey is fraught with dangers and risks exposing them to further violence, trauma, loss, and human rights abuses. This, together with post– migration-related stressors (internal & external) as listed in Box 1 may be viewed as possible predictors for psychological and mental health problems among resettled refugees and asylum seekers in the host country. It has been suggested that once a mental disorder manifest itself in a refugee at pre-migration or during migration, post-migration factors are critical in determining whether the disorder (in particular depressive disorders) will develop into a chronic condition (Lindert et al. 2009; Bogic et al. 2012, 2015). Therefore, it is crucial that mental health and social care services and practitioners attend to the complex needs of refugees and asylum seekers once they resettle in the host country and the onus is on them to prepare themselves for the challenges they may face while providing care to their refugee clients. The range and complexity of these challenges depends on a number of factors including refugees’ cultural backgrounds, expectations, and experiences and require care providers’ special considerations, some of which are offered below.

Therapeutic Considerations with Refugees and Asylum Seekers A number of therapeutic considerations that may be beneficial to psychologists/ mental health professionals working with refugees are outlined in Box 2. The list is by no means an exhaustive one but a guide and a reflection of author’s lived experience as well as her professional and clinical experiences working with refugees in different capacities such as an interpreter, a psychologist working in the NHS in a variety of secondary and tertiary services including in-patient services, and a researcher in the field. There was a tendency among professionals working with refugees during the 1990s to perceive refugees as “victims” in need of help to cope with managing their daily lives (Yesilyurt 2007). The phrase “refugee” has increasingly become synonymous with “needy, weak, passive,” labels and assumptions which could potentially encourage prejudices, biases, and stereotypes. Yesilyurt asserts that he resented being seen as a “refugee” and dumped into a category and his knowledge about the world, his skills, and experiences discounted, a notion that the author identified with. Prior to embarking on this journey, refugees have been working professionals, e.g., teachers, doctors, nurses, workers from all aspects of life and their decision to take control of their lives and their future, shielding their family from imminent harm, leaving everything behind, and starting a journey laden with risks and dangers is only indicative of bravery, courage, strength, resourcefulness, and resilience but weakness. Nevertheless, there are victims among refugees who upon arrival to the host country may present with acute psychological/mental health problems due to

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stressors mentioned above. In addition, the accumulative pressure of post-migration stressors (see Box 1) following resettlement likely exacerbated by poor quality health care in the host country together with somewhat negative and hostile sociopolitical climate in particular media concerning refugees, all in all may further prolong their ordeal. Giacco and Priebe (2015) argue that there are specific challenges in providing mental health care to refugees including language barriers, belief systems, cultural expectations, and establishing trust and offering their recommendations for good practice including setting up outreach programs for larger and difficult to engage refugee groups; developing a generalized and multidisciplinary approach taking into account refugees’ complex health needs with little interruption; improving the coordination of services; and providing information about refugees’ rights and entitlements and services available to both refugee themselves and social care and mental health professionals working with them (Giacco and Priebe 2015). The refugee populations are heterogeneous groups with different cultural backgrounds, experiences, and expectations, making it more challenging for mental health services and practitioners to generalize their service provision to meet the needs of refugees from a traditional culture. One such challenge is differences in conceptualization of mental illness and help-seeking behaviors, belief systems, and cultural expectations and expression of emotional problems. Western health practitioners are predominantly trained in and draw from the biomedical model, which mainly focuses on the biological explanation of the cause of physical and mental illness and tend to overlook sociocultural influences including individual’s cultural concepts of health and illness, cultural meanings, and expression of emotional difficulties and psychological distress. Erroneous interpretations potentially arising from misunderstanding of refugee client’s cultural meanings, experiences, and frame of reference could hinder therapeutic process and establishing and/or maintaining the therapeutic relationship. In addition, in some traditional cultures while mental disorders are highly stigmatized, psychological problems/psychiatric disorders are somatized as this is more culturally acceptable than revealing personal information to a stranger which could imply vulnerability and weakness. Somatization due to stigmatization, which may lead to refugees seeking physical explanations and pharmacotherapy as opposed to talking therapy for their psychological problems, could lead to conflict within the dyad, which may eventually lead to disengagement (Farsimadan 2011). Many refugees have no knowledge of or a poor command of the language of the host country. There is clear evidence of the impact of psychological therapy for those who are not fluent in the language of the country they reside in (Tribe and Thompson 2017). Working with a qualified interpreter and enabling the refugee client to share their problems and concerns in their own language through the interpreter has been known to be effective influencing the therapeutic outcome. Research with refugees who have endured trauma suggests that the outcome of psychotherapy mediated by a qualified interpreter is similar to that conducted under direct communication (D’Ardenne et al. 2007; Brune et al. 2011).

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Research on the effects of ethnic matching between therapist and client on therapy process and outcome suggests that other things being equal, ethnic similarity may reduce the social distance and enhance the likelihood of shared beliefs and experiences between client and therapist, thus facilitating the therapeutic alliance and outcome (Gray-Little and Kaplan 2000). In a similar vein, it could be extrapolated that having a shared language, culture, and experiences may facilitate therapeutic process and engagement at a deeper level, allowing the therapist with the help of the interpreter to enter into refugee’s frame of reference, thoughts, feelings and meanings, which in turn may facilitate the therapeutic outcome. Thus, consideration needs to be given to matching service user and interpreter for ethnicity, age, and gender where possible. However, matching should be discussed in advance with service users so that their preferences can be taken into account rather than assumed (Tribe and Thompson 2017). Nevertheless, the challenge may present itself when, at times even if an interpreter is available, lack of direct communication may complicate the process due to the “interpreter’s effect.” For instance, more often than not the interpreter comes from a different cultural background to the therapist, thus, they may misunderstand the language and the meaning of the information they are conveying. More importantly, before settling in the host country, interpreter themselves may have had similar traumatic experiences, and as such, past traumatic experiences may be evoked in interpreter during the session leaving them feeling stressed and/or re-traumatized. To remedy this, in their Working with Interpreters Guidelines for psychologists Tribe and Thompson (2017), recommend offering interpreter debriefing at the end of the session and providing support and supervision to interpreter when required, being mindful of the risk of vicarious traumatization. As ethnic matching between client and therapist may not be an option; Farsimadan et al. (2011) suggest that the onus is on the therapist to gather as much information as possible on the cultural background of their client and familiarize themselves with the “other’s” culture, beliefs, values, and needs. Nevertheless, how practical is this? How much knowledge of how many cultures is really enough and possible? Could this unwittingly lead to making assumption or adopting a “cookbook” approach? Farsimadan and colleagues argue that making assumptions about “other’s” culture may be more problematic than not knowing, as clients seem to note cultural incompetence more than cultural competence, thus, even when the therapist thinks they understand their client’s cultural background, adopting a culturally sensitive approach and an open attitude of not knowing enough, may be best. It is important to familiarize/socialize the client with the concept of therapy and how it can help them as the experience of seeing a stranger to talk about their traumatic experiences in order for it to get better may be an alien concept to a traditional client. There may be a tendency to view the therapist as a family member or friend, so it is important to be mindful of boundaries in therapy and reiterate to them the role of a therapist, a mental health professional providing them with psychological support. When working with refugees and asylum seekers It is essential to pace information and prevent overloading newly arrived refugees who may be traumatized,

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disorientated, bewildered (Boyles 2015), potentially with memory and concentration problems thus, unable to take in large chunk of information given to them. It is therefore, crucial to regularly check their understanding and repeat if required (Boyles 2015). Utilizing a problem-solving approach and conducting needs assessment at initial phase of therapy and in a way “bringing order to chaos” may facilitate engagement in therapy. This may include identifying individual’s and their family basic needs and referring them to professionals and services that can offer them support and practical help with, e.g., registering their children with schools, GP, and providing support and advice regarding their entitlements to welfare benefits, housing, and legal matters. In the case of refused and/or destitute asylum seekers where possible sign post them to refugee charity organizations to be assessed to receive assistance in the form of food parcel or hot meal, clothing, furniture, travel expenses, etc. This requires therapist working closely with refugee client’s care coordinator, social care practitioner, support workers, and the interpreter. Some refugees may be experiencing a great deal of distress due to guilt and shame they may be feeling for leaving family behind, not knowing of their whereabouts or well-being. If they are interested, they could be put in touch with the Red Cross to find out about their family. It is important to remember in a traditional culture “one” is always part of the extended family and not separate; therefore, the concept of “collectivism” as opposed to “individualism,” and focus on the family system and interpersonal relationships are likely to be central to working with a refugee from a traditional culture. Conducting a needs assessment enables the therapist to gain a deeper insight into their refugee client life, their family’s structure, and dynamics, which in turn may facilitate rapport and trust essential for establishing and maintaining the therapeutic relationship. Once their client’s basic needs are attended to, then the therapist may begin to think about their emotional/psychological well-being and assess their psychological needs. In doing so, therapist’s main aim should be provision of a safe, secure space within which their refugee client can explore their concerns. It is important that the therapist allows the client to tell their story their way and to facilitate ventilation and validate their experiences and distress while containing them. The therapist needs to convey to their refugee client the ability to hear painful material therefore, be mindful of their nonverbal communication, e.g., facial expressions and their body language, and at the same time be congruent and validate their client’s painful and traumatic experiences (Boyles 2015), while applying empathy and compassionate listening, without judgment. Nevertheless, the therapist needs to be mindful of and avoid re-traumatizing them by pressing for more information if they are not ready. Conducting psychological assessment and sharing the formulation with the client provides a framework for the client to understand the impact of different factors in their life (e.g., predisposing, preceding, precipitating, and perpetuating) on their mental health well-being. For those who have been through traumatic experiences, sharing formulation tends to reduce distress. Similarly, psycho-educating and familiarizing the individual and their family regarding the condition (e.g., symptoms,

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current treatment options, including medication and talking therapies and their benefits and side effects and prognosis, etc.) tend to increase their insight into their problem, ease their distress, and improve engagement in therapy. Furthermore, normalizing or de-catastrophizing refugee client’ fears and anxiety that may have developed from stressful and confusing experiences, e.g., hallucinations following a traumatic experience/s may also aid reduce stress and improve coping. The main aim of normalization is to facilitate understanding, reduce fear of “going mad,” and to stabilize. One way of achieving this could be through re-attribution of some distressing symptoms, for example, in the case of hallucinations talking about normal situations in which hallucinations may be experienced including sleep and sensory deprivation; organic (drug induced, illicit substances, medication, fever, and convulsion); bereavement; trauma (PTSD, sexual abuse); trance state in religious ceremonies (Kingdon and Turkington 2005) may be beneficial. In addition, using strengths-based strategies to build refugee’s confidence and empower them is beneficial. This could entail eliciting individual’s own interests and strengths and protective factors by tapping into and reinforcing their own resources. Encouraging them to talk about their past including their interests, education, employment, and skills as well as encouraging meaningful 1:1 activity and supportive relationships, improving their social skills, promoting a healthy lifestyle, developing inner strengths through any other potentially available resources for healing including music, art, drama to improve self-esteem and reduce isolation and stigma is also helpful. Moreover, introducing stress management techniques and coping strategies to help the refugee client manage and cope with their stress, for instance, introducing relaxation techniques including Progressive Muscle Relaxation and promoting sleep hygiene is useful. Nevertheless, consideration for a referral to a psychiatrist for Psychotropic medications (antidepressant, antipsychotic, mood stabilizers) and medications for chronic pain may be required to alleviate their distressing symptoms and enabling them to feel safe and engage in therapy. When the client is stabilized, ready, and engaged, therapeutic work on past experiences, trauma, and loss may begin. Loss may be multiple and multilayered including loss of control over the situation leading to migration, loss of family and support network, status and employment, and dignity and pride. Although majority of refugees wish to tell their story, which may be therapeutic (Cienfuegos and Monelli 1983), it should not be assumed that every refugee must go through this process in order to recover (Summerfield 1995). Bracken et al. (1995) argue that every culture has its own framework for mental health and help-seeking behavior in a crisis. For instance, Mozambican refugees resort to forgetting as their cultural way of coping with distress, whereas Ethiopian refers to it as “active forgetting” (Summerfield 1996). Therefore it is important to remember that “one size doesn’t fit all.” When providing therapy to their refugee clients from a traditional culture, the “other,” as mentioned above, there are a number of factors that Western therapists should take into account. As with a client from the mainstream culture, respect for

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difference be it gender, age, sexual orientation, etc., as well as “uniqueness” of the individual client is paramount. In addition, the focus of therapy should be on assisting the refugee resettle in the host country, helping them manage and cope with their post-migration stressors as well as enabling them to work through their experiences of loss, trauma, and violence, if they so choose. As stated earlier, majority of the refugees have been capable, educated, and working professionals before leaving their homeland. The therapist, in collaboration with the refugee client, should aim to facilitate the process of integration. Far from “passive,” “needy” welfare claimants, throughout history refugees have been scientists, inventors, creators of businesses and jobs, and contributed to the improvement of the way of life in their adoptive countries. Albert Einstein, Sigmund Freud, Michael Marks cofounder of Marks &Spenser, Rashmi Thakrar businessman who set up the multimillion-pound company Tilda Rice in the UK, Labor politician brothers Ed and David Miliband the sons of a Belgian Jewish refugees, and Sir Mo (Mohamed) Farah the most successful British track athlete, to name a few, have all been either refugees themselves or have refugee background. In light of specific challenges in provision of mental health care to refugees, some of which are mentioned above, the absence of an information service/resource center for refugees and asylum seekers and those working with them, formed the premise for the development of UEL Refugee Mental Health & Wellbeing online portal, which is discussed next.

Development of UEL Refugee Mental Health & Wellbeing Online Portal Portal Background and Objectives The idea for the online Portal for refugees and asylum seekers came about following a BPS CPD workshop on working with refugees and asylum seekers co-ran by Professor Rachel Tribe & Dr. Mala German, on 28 September 2015, which the author happens to attend. During the workshop the author offered to make an email list linking all the attendees to discuss any issues relating to working with refugees and asylum seekers in the future. Subsequently, it was felt that in the absence of a resource/information center for refugees and financial cutbacks in health and social care provision and in light of the number of mental health and social care professionals working with refugees and refugees themselves seeking access to information and resources, a portal could provide a lifeline. Thus, in collaboration with Professor Rachel Tribe, at the University of East London, as the project leader and the author as the researcher and content developer, work on developing the online portal for R&AS began in October 2015. The main objective of the Portal is to allow psychologists and other mental health and social care practitioners in a variety of settings including NGOs, community and charity organizations working with refugees and asylum seekers, locally, nationally, or internationally (e.g., in refugee camps and settlements) to easily access an

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abundance of resources and practical tools, which have been developed by health care professionals and academic research bodies with extensive experience and expert knowledge of working with refugee population. The Portal also aims to be utilized as a first-stop resource by refugees themselves who can freely access a wealth of information all in one place and in the privacy of their home, for those who fear stigmatization, and face their many challenges and rebuild their life in the host country or wherever they are, internally displaced or residing in refugee camps, where there may be few mental health practitioners. In line with the ethos of civic engagement at the University of East London, the online portal adopted an interdisciplinary approach sought to bring together colleagues and students from a number of UEL schools and services as well as facilitating collaboration with local community and charity organizations working with refugees in East London and nationwide. As such, the team contributing to the development of the portal included Paul Dudman, University of East London Archivist; Dr Lucia Berdondini, a senior lecturer in Psychology; Dr Patricia Smith, a senior lecturer in Physiotherapy; and Jidung Dung, then a PhD psychology student. From the outset, the author offered to be the researcher and content developer and identify resources for the Portal using their “insiders’ perspective” and subsequent experiences working with refugees and asylum seekers in the UK. The team was motivated and excited about the role that the portal could potentially play in providing a free on-line service to refugees and asylum seekers, organizations and professionals working with them, especially at the time when due to economic recession austerity measures were being introduced by the UK government including financial cutbacks in health and social care provision. All the work on the project has been carried out on an honorary basis. In addition, the team provided a 4-day training for UEL students, entitled the “Building Bridges: developing and using skills as a bilingual student to assist vulnerable migrants and refugees,” a London Scholars Programme, LSP, as part of UEL Civic Engagement initiative. Twelve bilingual scholars from UEL’s various schools including law, civil engineering, sport therapy, and public health were recruited and completed the program in 2017. The project celebrating the dual cultural heritage and bilingual language skills of many UEL students provided teachings on interpreting and translating skills, psychology and counseling, diversity, and human rights in order to improve a sense of inclusion and community cohesion among scholars and the wider community. One of the objectives of this training program was to translate some pages on the portal in a variety of languages spoken by the scholars. As a result, with the help of the scholars these pages were translated into Bulgarian, Hungarian, Farsi, and Spanish. Arabic, Cantonese, French, Hindi, Polish, Portuguese, Turkish, and Urdu translations were added subsequently.

Process of Developing Portal’s Resource Center The search on national and international databases/websites, evidence-based research, governmental and nongovernmental organizational guidelines, charity

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organizations, and agencies that offer services to refugees and asylum seekers began in October 2015. While searching the above, a number of categories of resources for the website were created including Mental Health Resources in English; Translated Mental Health Resources; Guides & Downloads on Mental Health and Social Care of Refugees & Asylum Seekers; Audio and Video Resources; Relaxation Techniques and Exercise Audios; Directory of Services & Organisations for Refugees, Asylum Seekers & Migrants; and References on Mental Health & Wellbeing of Refugees, Asylum Seekers & Migrants. Once the categories were identified then search for information under each category began. The information in each category was then organized in a format to fit the category. As a result, the initial Resource Centre, RC, on the online portal was created (Refugee Mental Health and Wellbeing Portal 2016). The strategy adopted was that once the search on one resource was exhausted the work on another would begin and this resulted in regular movement between the categories to ensure the information collected were up-to-date and current. This continued up until a week before the launch on 9 June 2016. Initially, there were seven categories of resources; these have risen to ten at present. The RC is updated yearly and new categories are added to it regularly by the author, as such in 2019 the children section was added to the portal’s RC (Appendix 1, as updated in 2020). Those who have used the RC point out that the users are appreciative of its various categories of sources. As seen in Appendix 1, the RC includes the comprehensive Directory of Services and Organisations for Refugees, Asylum Seekers & Migrants. The Directory divides the services and organizations into nationwide, regional, international, and London-based as well as providing website links to useful mental health charity organizations and services that offer support, advice, and information, which may be beneficial to refugees, asylum seekers, and professionals and services working with them. The RC also contains the Translated Mental Health Resources page, which provides links to reputable national and international websites and databases containing an abundance of translated health resources and information in a number of languages. In addition, this page offers translations in a number of languages including Arabic, Bulgarian, Cantonese, Farsi, French, Hindi, Hungarian, Romanian, Spanish, and Urdu, introducing some of the portal pages and resources. Furthermore, on its Guides and Downloads page the RC offers information on many challenges faced by refugees and asylum seekers on matters such as education, health care, social welfare, legal and human right issues, etc., informing them of as well as assisting them seek their rights and entitlements while resettling in the UK. The RC further consists of the Therapeutic Approaches with Refugees page, which provides evidence-based research that have either reviewed and/or used various therapeutic models including Culturally-Sensitive, Narrative, Systemic Family, Creative Arts therapies, to name a few, to treat refugees and asylum seeking population. Audio and Video Resources, Relaxation Techniques and Exercise Audios, Presentations and Teachings on Working with Refugees, and Personal Experiences & Stories of Young Refugees, form the other sources in the RC.

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Conclusion Political unrest, violence, genocides, natural disasters are among some of the reasons why desperate refugees flee their homeland to reach to safety be it their neighboring countries, settlements, or further afield. A combination of pre- and post-migration stress factors together with stressors that refugees endure during migration journey, which is usually fraught with dangers and risks, exposes them to further experiences of loss, trauma, and violence. As a result, by the time they arrive in the host country they are good candidates for and in some cases in urgent need of medical, psychiatric and or/psychological interventions. As mentioned above there are numerous challenges facing mental health services providing mental health care to refugees and asylum seekers. In addition, refugees and asylum seekers have been the subject of much negative sociopolitical and media attention in recent years. This, together with the rise of far-right politics and politicians in the West blaming refugees for their countries’ depleting resources and unrest may have adversely impacted national legislation and funding relating to the provision of care to refugees, their entitlements to health and social care, and training and supervision programs for mental health professionals working with refugees, etc. As such, mental health services and practitioners need to be more proactive and creative in the provision of mental health care to refugees. The question that arises here is that are mental health services and practitioners working with refugees doing enough to alleviate the current refugee care crisis? The development of the Refugee Mental Health & Wellbeing Portal at the UEL was a response to and the fruit of such inquiry. The online portal was set up in 2016; however, this project is ongoing and maintaining it is crucial in assisting refugees and asylum-seeking population and those working with them. In order to continue to provide a relevant and up-to-date source since its development, the RC has been regularly updated as there are always new resources to be included. For instance, new laws and policies come into force on a regular basis that could affect refugees’ rights and entitlements and as a consequence new guidelines are published. Furthermore, exiting therapeutic models are regularly adapted to fit the refugee population and/or new approaches are developed or new organizations and services may set up or the existing ones may alter services they provide, etc. As a result, the information and resources in the field are constantly evolving; thus, any feedback/suggestion from Portal’s users to help keep it current is greatly appreciated. Box 1 Post-Migration Stressors as Possible Predictors of Mental Health Problems Among Resettled Refugees

Internal Stressors • Loss – Control – Family/social support/network (continued)

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Box 1 Post-Migration Stressors as Possible Predictors of Mental Health Problems Among Resettled Refugees (continued)

• • • • • • • •

• • • • • • • •

– Status/employment – Personal livelihood (belongings, property, money, etc.,) – Pride/dignity Language barriers Unemployment and financial problems Fear of destitution Shame & guilt Homelessness or overcrowded accommodation Children/family uprooted Dealing with uncertainty and unknown future Problems with adjustment & transition – Unfamiliarity with systems, e.g., legal, education, social, health care – Changes in roles and family structure – Cultural differences/shock Feelings of helplessness and hopelessness Ongoing grief PTSD symptoms Chronic pain Anxiety Depression Substance abuse Psychosis

External Stressors • Detention & detention centers • Delays in decision making • Fear of refusal and/or deportation • Prejudices, stereotypes, and biases • Perceived discrimination and racism • “Us” and “Them” • Marginalization and alienation

Box 2 Therapy and Therapeutic Considerations with Refugees & Asylum Seekers

• • • •

Refrain from labels & assumptions Refugee populations are heterogeneous Work through qualified interpreters Pace information and avoid overloading (continued)

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Box 2 Therapy and Therapeutic Considerations with Refugees & Asylum Seekers (continued)

• Utilize a problem-solving approach • Conduct a needs assessment • Build rapport, trust & establish, maintain therapeutic relationship – Convey ability to hear painful material – Compassionate listening – Allow ventilation – Validate experience and distress – Avoid re-traumatization – Empathic understanding – Nonjudgmental attitude • Conduct psychological assessment & develop formulation • Share psychological formulation • Psycho-educate and familiarize • Normalize & stabilize • Use strengths-based strategies • Introduce stress management strategies • Therapeutic work on past and traumatic experiences, when ready • Work through loss and grief • Work toward integration

Appendix 1 Resource Center Resources on the Mental Health & Wellbeing Portal can be utilized as a first stop Resource Center for refugees and asylum seekers as well as mental health and social care professionals, organizations, and agencies working with them in the UK and internationally by refugees in camps, internally displaced people, and professionals working with them. The resources include: • • • •

Resources on Refugee & Asylum Seeking-Children Mental Health Resources in English Translated Mental Health Resources Guides & Downloads on Mental Health and Social Care of Refugees & Asylum Seekers • Therapeutic Approaches with Refugees & Asylum Seekers • Audio and Video Resources • Relaxation Techniques and Exercise Audios

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• Presentations & Teachings on Working with Refugees & Migrants • Personal Experiences &Stories of Young Refugees &Asylum Seekers • Directory of Services & Organisations for Refugees, Asylum Seekers & Migrants The Resource Center and its various resources have been researched and developed by Dr Farkhondeh Farsimadan, a chartered counseling psychologist, who is an Associate Fellow of the British Psychological Society and an HCPC registered psychologist. The resources can be accessed via the links provided. https://www.uel.ac.uk/research/refugee-mental-health-and-wellbeing-portal https://www.uel.ac.uk/research/refugee-mental-health-and-wellbeing-portal/ resource-centre

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Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT (2004) Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in the Netherlands. J Nerv Ment Dis 192:843–851 Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brahler E (2009) Depression and anxiety in labour migrants and refugees: a systematic review and meta-analysis. Soc Sci Med 69(2):246–257 Refugee Mental Health & Wellbeing Portal (2016) Farsimadan F, University of East London. https://www.uel.ac.uk/research/refugee-mental-health-and-wellbeing-portal. https://www.uel. ac.uk/research/refugee-mental-health-and-wellbeing-portal/resource-centre Slobodin O, De Jong JT (2015) Mental health interventions for traumatised asylum seekers and refugees: what do we know about their efficacy? Int J Soc Psychiatry 61:17–26 Summerfield D (1995) Assisting survivors of war and atrocity: notes on “psychosocial” issues for NGO workers. Dev Pract 5:352–356 Summerfield D (1996) The impact of war and atrocity on civilian populations: basic principles for NGO interventions and a critique of psychosocial trauma projects. Relief and Rehabilitation Network Overseas Development Institute, London Tribe R, Thompson K (2017) Working with interpreters in health settings: guidelines for psychologists. The British Psychological Society, BPS. https://www.bps.org.uk/sites/bps.org.uk/files/ Policy/Policy%20-%20Files/Working%20with%20interpreters%20-%20guidelines%20for% 20psychologists.pdf Walsh F (2007) Traumatic loss and major disasters: strengthening family and community resilience. Fam Process 46:207–227 Yesilyurt E (2007) Reflections from a refugee psychologist. Psychologist, special issue on refugees and asylum seekers 20(3):149–151

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Contents Introduction: Assessing Distress and Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychotropic Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

According to the latest figures from the UNHCR, we are now witnessing the highest number of displaced people in modern times. These displaced people have not only lost the security of familiar surroundings and kinship networks, but also many are leaving war-torn societies and have witnessed or experienced extremes of violence and abuse. It is not surprising, therefore, that mental illness is frequent in these populations. The first and universal help that can be given is with basic needs for survival and adjustment to the new reality. Only then are more targeted psychological and pharmacological therapies likely to be helpful. The current research evidence for the efficacy of these is reviewed and presented here. By and large, psychological interventions have the best evidence for efficacy in traumarelated conditions but require therapist training and are labor intensive. Also, the evidence for their efficacy comes largely from studies carried out by experts with settled populations accessing western-style service structures. A handful of inter-

T. K. J. Craig (*) Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK e-mail: [email protected] © Springer Science+Business Media Singapore Pte Ltd. 2021 D. Moussaoui et al. (eds.), Mental Health, Mental Illness and Migration, Mental Health and Illness Worldwide, https://doi.org/10.1007/978-981-10-2366-8_13

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esting adaptations of these approaches for countries with less well-developed services are described. Keywords

Refugees · Trauma · PTSD · Treatment

Introduction: Assessing Distress and Disorder According to the figures from the United Nations High Commissioner for Refugees (UNHCR 2015), the number of people forced from their homes in the previous year touched 65.3 million of which 21.3 million were refugees, half under 18 years of age. By far the majority were hosted in countries where economies are struggling to meet the needs of their own population and where mental and social services are under resourced and underdeveloped. Research carried out over the past 10 years has clearly and consistently established worse mental health among refugees and asylum seekers. Those living in institutional accommodation (hostels and other temporary residences), those unable to work because of legal restrictions, and those with higher premigration social status are at especially high risk. In short, this points to the fact that the mental health of refugees is determined as much by their circumstances after migration as by trauma preceding it (Porter and Haslam 2005) (also see ▶ Chap. 15, “Mental Health in Refugees and Asylum Seekers” by Schouler-Ocak and Kastrup, in this volume). While it seems obvious that forced migration as the result of war, famine, and persecution should be associated with the greatest levels of distress and mental ill health, even migrations that are for economic reasons can be risky as shown by the much higher rates of mental disorder among migrants to higher income countries who experience downward social mobility compared to those that improved or maintained their social status (Das-Munshi et al. 2012). In addition to the loss and humiliation implicit in this downward mobility, migrants are frequently subjected to racial and other discrimination from the natives of the host country – a fact that probably lies behind the six- to eightfold elevated risk for schizophrenia and other psychoses among the economic migrants from Africa and the Caribbean to the UK which has persisted across generations even for their offspring born and reared in the UK (Fearon et al. 2006). That the cause of this must lie in the host country is further underscored by the fact that incidence rates for psychosis in the countries of origin of these migrant groups are very comparable to that of the white British in the UK (Bhugra et al. 1996; Hickling and Rodgers-Johnson 1995), and intriguingly, it seems that the risk is associated with levels of ethnic density – being lower from localities where people of African/Caribbean background comprise a larger proportion of the population than where they are in a significant minority (Boydell et al. 2001; Schofield et al. 2011). Of course, not everyone exposed to trauma and discrimination will develop a mental illness. A great deal of distress associated with even severe hardship is selflimiting or at least responds to counterbalancing positive and protective factors in

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the individual himself, his family, and the wider society into which he is relocated. These personal and social conditions also determine whether and when a person will seek help. There is an extensive literature on why people choose to seek help for emotional disorders and the pathways into and out of psychiatric care. The route to this care is determined by knowledge of where to go for help, the availability of affordable services, beliefs about what this help may be able to provide, as well as the influence of friends and family. The upshot is that the population that makes it into the consulting room is only a fraction of the whole and not necessarily the worst affected or most in need of medical or psychological treatment. Many are actually in search of things that are beyond the control of therapists – official acceptance of refugee status, decent housing close to others with shared cultural backgrounds, and some protection from community intolerance and exclusion. So for some consultees, a doctor’s report with a diagnosis of post-traumatic stress disorder (PTSD) to bolster a case for refugee status may be the target. The first challenge facing the mental health professional therefore is to determine whether the nature and severity of the mental experiences described by the sufferer amount to a diagnosis for which there are specific recommended treatments. This is complicated by the fact that common mental disorders exist on a spectrum from subclinical, transitory conditions with a very fuzzy boundary between these and the more severe and persistent disorders. Also, diagnosis made on the basis of the functional impairment of the individual’s work and social relationships is less straightforward in someone for whom their legal status enforces unemployment; their social networks are fractured and living conditions largely imposed. Similarly, the usual reliance on whether the psychological response is beyond what would ordinarily be expected from any triggering life event or social difficulty is of little utility in the face of the overwhelming stressors faced by many refugees. To complicate matters still further are the obvious language barriers and unfamiliar ways of expressing distress. Somatization where distress is manifest in bodily symptoms is particularly common but easily misinterpreted when, for example, the complaints refer to a previous site of bodily torture or are an amplification of an existing health problem. Demonic and other spiritual explanations of abnormal phenomena can also be difficult to disentangle, sometimes leading to erroneous diagnoses of psychotic conditions and consequent unhelpful and possibly harmful intervention. The upshot of all this is that psychiatric diagnosis, always a rather nebulous concept, can be difficult to establish with certainty in refugee populations. Even epidemiological studies using carefully designed and validated clinical interview assessments accept that some degree of inaccuracy must exist. So for example, Fazel et al. (2005), in a meta-analysis a decade ago, noted rates for PTSD of 9% (99% CI 8–11%), major depression 5% (99% CI 4–6%), and generalized anxiety 4% (3–6%). A more recent meta-analysis that focused on the association of torture and trauma with PTSD found much higher rates of 30.6% (95% CI 26.3–35.2), but as might be expected, the reported prevalence varied considerably depending on factors such as the size of the sample of individual studies, how sampling was carried out, and how PTSD was assessed – self-report questionnaire methods producing rates up to 10 points higher than those based on clinical interview (Steel et al. 2009). Taken together the methodological variations

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accounted for as much as 12.9% showing the caution that needs to be exercised in extrapolating from research to the clinic particularly where studies are based on selfcompleted questionnaires and opportunistic samples. That PTSD is the most prevalent diagnosis among refugees and asylum seekers is perhaps not surprising given the traumatic experiences so many will have encountered. Indeed it is perhaps all too easy to ascribe the diagnosis without critical scrutiny of the precipitating trauma and the reported symptomatic response. As a result there has been a gradual tightening-up of diagnostic criteria over the past decade. According to the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, American Psychiatric Association 2013), the stressors are those of actual or witnessed death, serious injury, or sexual violation that the person suffers themselves, direct witnesses as they happen to others or learns that such extreme trauma has happened to close family or friends. The responses to the trauma are defined in terms of mentally reexperiencing the threat, avoidance of distressing memories and reminders of the event, a broad array of mood and negative cognitive responses, and marked arousal manifest not only as the flight responses of fear and avoidance but also the “fight” dimension of aggressive outbursts, reckless and self-destructive behavior, hyper-vigilance, and sleep disturbances. Of particular interest for a refugee, population exposed to the most extreme traumas is the proposal for a dissociative subtype. Here symptoms of depersonalization and derealization are prominent and presumed to represent a defense against overwhelming stressful experience and so allow the individual to be able to continue functioning. These symptoms are experienced by 15–30% of those with severe trauma histories and are more common in men and those who have experienced repeated trauma and childhood abuse. They also have considerable comorbidity with depression, suicidality, and impaired function (Wolf et al. 2012; Stein et al. 2013; Panagioti et al. 2012). This co-occurrence of mental health problems is extremely common among refugee populations. For example, diagnoses of PTSD and depression overlap in two-thirds of the studies where multiple diagnoses were recorded in the metaanalysis referred to earlier. Overlap of mental health problems with substance abuse or addiction and with learning disability also relatively common as is co-occurring physical ill health. These comorbid conditions complicate assessment and treatment, masking diagnosis and raising the possibility of reduced treatment effectiveness and adverse drug interactions.

Treatment General Approaches Before turning to examine the research evidence for which treatments are most effective, it is important to recognize that a great deal of morbidity can be attributed to the challenges and stressors that refugees face adjusting to a new life in a foreign country on top of the losses of homeland and support in the host countries. So the

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first, most important intervention is a social one. Ensuring that basic needs (shelter, food, security) are met, which access to welfare benefits or employment is facilitated, sorting out schooling for children and dealing with housing issues may well be of much greater benefit than jumping straight into a specific therapeutic intervention. For many locations where there are large numbers of refugees, addressing these basic needs may be just about all that can be provided, but even where sophisticated, labor intensive treatments are available, a blind focus on individual therapy is unlikely to be very effective in the face of intractable social problems. Understanding the wider social and cultural background of the individual is also obviously key to the success of any treatment. This includes taking account of religious beliefs and awareness of social taboos that may affect treatment and how it is delivered. Typically, many members of a family are involved in the migration experience so that the person attending the clinic may well represent wider family difficulties. Relationship and childcare problems are taboo topics in most societies and those problems that may have been contained in a collective family network may surface in the new environment as the as traditional support network is lost. Domestic violence and problems with childcare might well be a hidden complication behind the clinic consultation as even disclosing personal information about oneself and the family to a stranger will be an alien experience. The fact that the therapist may not speak the patient’s language is also an obvious challenge. Interpreters are often essential both in assessment and treatment. Who to employ as the translator needs careful consideration. There may be understandable fears that confidential information will leak out or be used to deliberately harm, perhaps because the interpreter belongs to a different tribe or political party that is connected with the persecution back home or just simply the risk of gossip on the individual’s reputation. Assuming an accompanying family member can serve the role of interpreter is also undesirable, not least because they may be part of the problem for which help is being sought. In response to these challenges, a lot of attention has been paid to developing guidelines on the use of interpreter services both for assessment and the delivery of therapy (Tribe and Raval 2003). There is good evidence that therapy delivered through trained interpreters can be very effective (d’Ardenne et al. 2007). The western emphasis on the individual may also be misguided. Problem-solving that involves the family and group discussions may well be preferred over individual therapy and indeed be more effective (e.g., Hubbard and Pearson 2004). The first step must be to create a non-threatening environment in which confidential disclosure is guaranteed. Much hinges on the ability of the assessor to establish trust and a good rapport, to deal sensitively with shame and humiliation that so often accompanies disclosure of personal trauma, and to be aware of the often very distressing nature of what is disclosed even quite early in the sessions. Therapists need to be aware that avoidance of disclosing embarrassing and traumatic experiences is the rule so that the full picture only emerges over time, but also that when these are recounted, it is often as a flood of emotions that can be as challenging for the therapist as for the patients. Over and above this sensitive and supportive approach, some experts would add that the assessment of complex conditions is best supplemented by the use of structured clinical interview that focuses on specific symptoms (e.g., the Clinician Administered

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PTSD Scale ([CAPS]; Blake et al. 1995), though clearly not at the expense of a comprehensive clinical examination that explores the presence of relevant comorbidities.

Psychotropic Medication For the most part, while determining the diagnosis can be challenging, once established it serves as well as a guide to psychotropic treatment for depression, anxiety, and psychotic disorders as it does for the indigenous western populations. While there are important genetic variations in drug metabolism that need to be taken into account, people of different ethnic backgrounds on the whole show broad equivalence of response. So, for example, Lesser et al. (2011) compared symptomatic outcomes between people of white, Hispanic, and black ethnic groups in a single blind, randomized trial of drug treatments for major depressive disorder. Despite some baseline differences in sociodemographic characteristics and comorbidities, patients of the different groups had similar outcomes with no differences in remission, quality of life, or adverse events. Nevertheless, despite this global equivalence in response, it is important to remember that the individual’s response to treatment is determined by the interaction of many biological, psychological, and social factors. From the biological perspective, there is a wide variation between individuals in the speed at which drugs are metabolized. The polymorphic genes underlying the CYP2D6 enzymes that are involved in the metabolism of many psychotropic medicines result in a considerable variation in response and side effects. Some people are very slow metabolizers and others ultrafast resulting in as much as 100-fold variations in blood levels between two apparently similar individuals and hence in response and side effects as well, and this individual variation is reflected in ethnic variation as well (Chaudhry et al. 2008). Black Africans and East Asians are known to be slow metabolizers. In contrast approaching a third of Ethiopians display gene duplications, leading to ultrarapid metabolization (Cascorbi 2003; Akullu et al. 1996). To complicate matters yet further, many of these enzyme systems are also affected by the environment including dietary practices and the use of other medications or herbal remedies for the same or different medical conditions so that, for example, a slow metabolizer in one country might “speed up” on migration and adoption of a different diet (e.g., Branch et al. 1978; Chaudhry et al. 2008). Ultimately, the hope of “individualized” or “stratified” medicine is that the introduction of reliable, cheap assays will enable greater tailoring of medication to the individual, but in the meantime, general principles of careful titration apply. This is particularly relevant when the patient may also be using traditional herbal remedies, many of which could interact with prescribed medication producing unpleasant and even calamitous side effects (e.g., Izzo and Ernst 2001; LaFrance et al. 2000). But getting hold of this information is an art in itself. The first step is to assume that the patient may well be taking some home or herbal remedy and that most people will not volunteer the information as they believe that their psychiatrist will disapprove. The psychiatrist needs, therefore, to be open-minded, ask questions sensitively, and

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take time to explain the potential for adverse interactions. Even then, it is likely that patients will continue the herbal preparation, especially if the response to the new treatment does not appear to be having the desired effect. The psychological and social influences on medication use are illustrated by issues of adherence. All the usual factors that determine adherence are at work to which can be added language barriers and the fact that subjective response may well be delayed and perhaps complicated by side effects. Simple logistics, including whether the patient can get to the clinic as regularly as needed or can afford the medication will also play a part. Finally, involving the family as a support rather than as ancillary to the main recipient of treatment is key to success as they can administer and supervise adherence. While there has been a lot written about the pharmacological treatment of PTSD, the evidence is weaker than one might assume from a cursory look at the literature. Part of the problem is the wide variation in inclusion and exclusion criteria across studies. Earlier systematic reviews were modestly optimistic (Stein et al. 2006), but two more recent meta-analyses of treatment for PTSD in adults (Jonas et al. 2013; Watts et al. 2013) found only moderate evidence of efficacy for SSRIs and venlafaxine and weak evidence supporting the use of risperidone and topiramate. There are still too few comparative studies to know whether one medication is superior to another.

Psychological Therapy Beyond the general principles of good psychotherapeutic care outlined above, there are now several well-conducted clinical trials demonstrating benefit for specific psychological treatments among refugee and migrant populations. For the most part, the therapies are variants of cognitive behavior for PTSD, cognitive processing therapy, and prolonged exposure techniques (Bisson et al. 2007). These typically include psychoeducation about trauma and its impact on the individual, exposure techniques, cognitive restructuring for maladaptive beliefs related to the trauma and teaching coping skills. The research evaluating these treatments largely come from studies carried out in the West, often with indigenous patients with diagnoses of PTSD resulting from a very broad spectrum of traumatic experience. An early example of a modified CBT was reported by Hinton et al. (2005). They described a culturally adapted therapy for Cambodian refugees with treatment resistant PTSD and panic attacks. Forty patients were randomized to either immediate treatment or a waiting list. The treatment, referred to as “sensation reprocessing therapy” comprised 12 weekly sessions with content based on CBT principles including elements of psychoeducation, muscle relaxation, visualization, cognitive restructuring, and exposure to anxiety related sensations, particularly those concerning tension of the neck muscles (a fear of catastrophic rupture of the arteries of the neck with multiple autonomic arousal symptoms was common in this group of patients). There was a clinically and statistically significant improvement for patients in the intervention group compared with those in the waiting list comparison. Improvement was rapid

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and sustained, so that after the first course of CBT, 60% (n = 12) in the active treatment group no longer met diagnostic criteria for PTSD. Another approach is narrative exposure therapy (NET) that developed out of earlier experimentation with “testimony” interventions (Igreja et al. 2004). NET is a brief, manualized, and structured therapy that was specifically designed to help people who were traumatized by torture and organized violence where the sufferer has been exposed to multiple traumatic events. In contrast to the “testimony” intervention that focused on a single traumatic experience, the NET therapist works with the individual to identify and process each of multiple traumatic events. The approach aims to help the individual develop a cohesive narrative of their life, putting the trauma in context and incorporating both positive and negative experiences. Psychoeducation about how people respond to trauma is also provided. The end point includes a comprehensive autobiography that can be helpful in documenting human rights abuses (Schauer et al. 2011). In a study exploring the efficacy of NET delivered in routine care settings, Stenmark et al. (2013) randomized 81 refugees and asylum seekers with a diagnosis of PTSD to either narrative exposure therapy (NET) or treatment as usual (TAU). The patients were assessed before treatment, and again at 1 and 6 months after completion. While both NET and TAU produced clinically relevant reductions in symptoms of PTSD and of depression, patients allocated to NET had significantly greater improvement than did those who received TAU. Eye movement desensitization and reprocessing is another a widely used technique. It draws upon both CBT and therapies that focus on the recall of trauma and comprises a visualization of the traumatic event while being aware of avoidant/distracting saccadic eye movements. One recent meta-analysis comparing EMDR and CBT for trauma victims suggests that EMDR was slightly superior, but the number of studies meeting eligibility criteria was small and of poor quality (Chen et al. 2015). Lambert and Alhassoon (2015) report a meta-analysis of published controlled trials of trauma-related psychological treatments targeting PTSD or depression among adult refugees. They identified 13 trauma-focused therapies from 12 studies that met essential inclusion criteria including randomization to an established traumafocused approach and a control condition, with outcome assessed by validated outcome measures. All but two of the studies were carried out in North America or Europe but with a wide range of ethnic diversity. One study employed lay counselors to deliver the intervention (Neuner et al. 2004). In terms of the type of intervention used in each study, eight involved NET (three compared NET to a waiting list control and five compared NET to an active control), four compared trauma-adapted CBT with an inactive control, and one study compared EMDR and supportive counseling. For PTSD, these studies in aggregate had a large positive effect, moderated by the number of sessions and by the nature of the comparison group with those studies comparing therapy and active controls having the weaker effect sizes. The use of interpreters did not appear to affect outcome. The effect size for the studies where depression was the outcome was also large.

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It might be thought that early intervention, close to the traumatic experience, would be most helpful in preventing the development of PTSD. However research of single-session debriefing interventions following trauma has repeatedly failed to show benefit and has not been recommended practice for some time (National Institute for Clinical Excellence; NICE 2005). Recent studies continue to bear this out (e.g., Tuckey and Scott 2014) although the jury is still out concerning structured programs of psychological therapy that provide more than a single (often group based) debriefing. For example, Rothbaum et al. (2012) describe a program comprising 3 weekly 1-h sessions of psychological intervention including imaginal exposure to consecutive attenders at emergency rooms following trauma including rape, assault, and motor vehicle accidents. In an RCT comparing this to assessment only, patients in the treatment group reported significantly lower PTSD symptoms than the assessment only controls at 4 and 12 weeks, but this benefit largely confined to rape victims. Given that both medication and psychological therapy are partially effective, it is little surprise that guidelines recommend combination treatments. However the evidence for this is not substantial. A meta-analysis that examined the combined use of SSRI and cognitive therapy (prolonged exposure or CBT) found no strong evidence to show if there were patients receiving combined therapy versus psychological therapy or pharmacology alone (Hetrick et al. 2010). As noted earlier, co-occurring substance abuse and dependency creates further challenges for therapy. The NICE guidelines referred to earlier recommend that problems with substance dependency are dealt with first before proceeding to trauma-focused work. But in practice, there is little research to guide practice. In one of the few studies to date, Mills et al. (2012) investigated the efficacy of a CBT-based program tailored to deal with substance use as well as PTSD versus treatment as usual for 103 people with PTSD and comorbid substance abuse. At the end of therapy, patients in both groups had improved though compared to treatment as usual, those receiving the experimental treatment reported a significantly greater reduction in symptom scores. Similarly, Foa et al. (2013) report a controlled trial of 165 patients who had comorbid PTSD and alcohol dependence. The participants were randomized to one of four groups comparing naltrexone and prolonged exposure therapy alone or in combination to an appropriate control procedure involving supportive counseling and placebo medicine. PTSD symptoms improved in all groups, but the group receiving prolonged exposure was not significantly more effective than any other treatment combination. Alcohol consumption decreased across all therapies, most in the patients receiving naltrexone. There was a high drop out from all groups. Families can play a key role in supporting sufferers of PTSD and of course can be profoundly affected by the person’s behavior. They also contribute to help seeking pathways, encouraging or impeding access. Weine et al. (2008) in Chicago, USA, reported a multifamily group intervention for refugees from Bosnia-Herzegovina aimed at increasing appropriate health service utilization in refugees suffering from PTSD and other common mental disorders. A total of 197 adults with PTSD and

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their families were recruited from community centers and randomized to either the intervention (n = 110) or no-treatment control condition (n = 87). The family intervention was delivered over nine sessions over 16 weeks with approximately seven families per group. The primary subject and all family members over the age of 17 living in his/her household were invited to attend the sessions. Each session included a 15-min didactic presentation followed by a 1-h group discussion and covered a diverse range of topics including mental health problems, school problems, mental health services, and family beliefs. Each session was led by lay facilitators who were Bosnian refugees with some prior experience of working with groups as nurses, teachers, and course organizers. Outcomes were assessed at baseline, at the end of the course, and at 6, 12, and 18 months. The results showed the intervention was effective in increasing access to appropriate mental health services especially for depression. In a more recent study, Monson et al. (2012) reported a trial of CBT-based couples therapy aimed at both alleviating PTSD and improving problems in intimate relationships. A total of 40 couples were included half of whom received the specialized intervention with the remainder placed on a waiting list. Compared to the waiting list control condition, patients receiving therapy reported significantly greater improvement in PTSD symptoms and personal relationships though the study was small and groups rather imbalanced at baseline with higher dropout from the treatment condition.

Children and Adolescents According to recent UNHCR figures, of 21.3 million refugees and displaced persons in 2015, over half were under 18 years of age. There were 98,400 asylum applications from unaccompanied minors, the highest figure recorded since data collection of this population started in 2006 (UNHCR). As is the case for adults, trauma-related mental health problems are the most common. As might be expected, much of the literature on treatment of PTSD and related disorders for these children is focused on Western nonmigrant populations and, within these, issues of childhood abuse and the consequences of domestic violence. There are very few studies of pharmacological interventions in young children, and none are currently recommended by NICE good practice guidelines. As for adults, the first-line approach should be psychological. Gillies et al. (2012) reviewed 14 RCTs of psychological interventions for children aged 3–18 who had a clinical diagnosis of PTSD resulting from a wide range of traumatic experiences including sexual abuse, road traffic accidents, domestic violence, and natural disasters. Treatments included CBT, exposure-based therapy, EMDR, and supportive counseling compared to waiting list or treatment as usual control conditions. Overall the active treatments significantly reduced PTSD symptoms in the short and medium term (