Theme 7 – Migration, mental health and intercultural clinical practice
Vignette 1-2
• (Helman, 2007 – Chapter 12: Migration, globalization and health)
• (Bhugra, 2004 – Migration and mental health)
• (Bhugra et al., 2014 – EPA Guidance mental health care of migrants)
• (Jurado et al., 2017 – Factors associated with psychological distress or common mental
disorders in migrant populations across the world)
• (Levitt et al., 2005 – Immigration stress, social support, and adjustment in the first
postmigration year: An intergenerational analysis)
Vignette 3-5
• (Nagayama Hall, 2001 – Psychotherapy Research With Ethnic Minorities: Empirical, Ethical,
and Conceptual Issues)
• (Sue, 2006 – Cultural competency: From philosophy to research and practice)
• (Tanaka-Matsumi, 2019 – Culture and psychotherapy, searching for an empirically supported
relationship)
• (Bhui et al., 2003 – Cultural Adaptation of Mental Health Measures: Improving the quality of
clinical practice and research)
• (He & Van den Vijver, 2012 – Bias and equivalence in cross-cultural research)
VIGNETTE 1
Why do we see a difference in this model of vulnerability and resilience in this model?
How does immigration affect stress and mental health?
(Helman, 2007 – Chapter 12: Migration, globalization and health)
HEALTH RISKS OF MIGRATION
Each type of migration carries its own specific range of health problems and risks, and its own
specific needs in terms of medical care. For refugees, in particular, there is often a loss of autonomy,
especially in camps → can affect the mental and physical health of migrants, as well as their
relationships with other people.
Some of these health risks are heart disease, cancers, drugs, mental disorders, marital breakdown,
domestic violence, etc. EG: Studies on effects of migration on blood pressure found that the longer
migrants lived in a city, the higher their blood pressures.
Mental Illness
Migration often seems to carry an increased risk of mental illness. Often this risk is not only higher
than the native-born population in their new country, but also higher than that of their countries of
origin. These risks seem to affect some groups of migrants, but not others.
➢ However, some studies point out that studies of mental health of immigrants are difficult to
interpret unless one controls for factors such as age, social class, occupational status, ect.
Researchers point out that being a migrant does not necessarily lead to mental illness → A number
of other factors are also relevant, such as employment status, housing conditions, and the reactions
of the host society. Such factors as xenophobia, discrimination, racial prejudice and harassment are
all likely to contribute towards the immigrant’s mental and physical ill health, as are the economic
and political conditions prevailing in the host community.
Studies suggest that some immigrant groups are more vulnerable to certain mental disorders and
illnesses than others. EG: Irish immigrants in England have a health status as poor as, or worse than
some of the other ethnic groups from south Asia → increased rates of suicide, alcohol abuse and
mental health problems.
,Mental illnesses may range from depression to acute psychotic breakdowns, self-neglect, suicide
attempts, drug or alcohol abuse, domestic violence, and antisocial behaviour, especially among the
youth. Some may become withdrawn or emotionally numb, other may freeze their identity at the
moment that they left their homes, never put the experience behind them, and never move on
psychologically.
Impact of Migration on Family Structure
Migration can strengthen or fragment an immigrant family → can affect mental health. In many
cases migration has a positive effect, by enhancing family cohesion, cooperation and emotional
closeness. In other, external forces such as discrimination, unemployment, the demands of the
labour market, ect. may all lead to an extended family break-up.
Within the family, new family dynamics often appear after migration. Migration involves a major
sense of discontinuity in everyday family life. The migrants often find themselves in limbo, separated
from their homelands, yet feeling not quite at home in their new environment.
Inversions of Migrant Family Structure
The discontinuities are especially marked if the family comes to an urban environment in the
developed world from a very traditional, rural environment.
❖ Generational inversion: A situation where the children born or raised in the new country,
understand the language, culture and technology better than their parents → gives them a
new power over their parents and inherited tradition. The (grand)parents are now
dependent on the young for knowledge of the world, not the other way round → may cause
embarrassment.
❖ Gender role inversion: Occurs in more traditional communities, when the women of the
family become more independent after immigration. In some communities, the women of
the family may become the only breadwinner, particularly if the husband cannot find
employment or is disabled. Some men are more affected by refugee status than women, as
the dependent life of a refugee often involves a loss of their prior status as decisions-makers
and bread-winners.
❖ Time inversion: A situation where the past seems to be more important than the present or
the future. It occurs especially when the future is uncertain, and even threatening. It is a
state of continuous nostalgy, regretting the move, and grieving losing instead of gaining. For
younger ones, especially born in the new country, it may be unsettling and even emotionally
destructive.
❖ Space inversion: A situation where, especially in the first years after migration, the
proportion of unfamiliar space occupied by the migrant seems to be much greater than that
of familiar space. ‘There’ becomes much more real and important than ‘here’. This may be
emotionally difficult for the children, trying hard to adjust to the new country, and to make
their new lives. In a globalized world, this will probably become more common, and people’s
identities will be made up increasingly in both global and local elements.
The overall effect may be to decrease migrants’ sense of identity, as well as family cohesion, and thus
the degree of social support that it offers its members. They act by reducing the authority of parents
and grandparents, diminishing the power of tradition, increasing martial and intergenerational
conflict, and altering key life-cycle rituals. Together with the negative effects of the host environment
they can induce mental distress or sense of alienation and anger.
Refugee Health
Unlike voluntary migrants, refugees frequently have had no change to prepare psychologically (and
practically) for this sudden move, or to anticipate its consequences. It may separate family members
from one another, and they may be forced to abandon elderly or ill relatives as they flee. All these
factors can have serious long-term consequences for mental health.
,Physical and Psychological Disorders: Refugees generally suffer from a higher incidence of physical
and mental health problems than the general population (e.g., anxiety or depression). Because many
refugees have experienced periods of malnutrition, poor hygiene and sanitation, as well as physical
or psychological trauma (earlier experience of forced migration, as well as of their current situations).
Also, different types of social disruption may arise in refugee families’ communities, from marital
breakdown and violence, to substance abuse.
Migration and Mental Health: Theories of Causation
Although migration does seem to carry with it an increased risk of mental illness, the exact reasons
for this are complex and not fully understood.
Multi-Migration: Moving from one country to another often involves several different types of
migration simultaneously. In their new environment, migrants may encounter unfamiliar climates
and habitats, different ways of earning a live, different types of family structure, and hostility from
the host culture. Migrants from traditional societies often enter a new environment where almost all
the building-block of their previous worlds (e.g., religion) no longer play an important part and are no
longer valued. The resultant culture shock can be traumatic, and can affect their psychological and
physical health, as well as their relationships with one another.
Push-pull: Why left migrants their homes in the first place? → voluntary (pull), or involuntary (push)?
These 2 overlap → one may be pushed to migrate from an country by poverty, while at the same
time feel pulled towards new economic opportunities elsewhere. Pull migrants may experience
major disappointments if they fail to succeed in their new environments. Push migrants may
experience difficulties in adjusting to their new environment due to constantly grieving over the past.
• The role of new context, and whether it is welcoming or hostile, generous or exploitative, will
have major effects on mental health.
Selection-stress: Cox summarized 3 hypotheses that try to explain the high rate of mental illness
among migrants:
- Selection hypothesis: Certain mental disorders incite/encourage their victims to migrate.
- Stress hypothesis: The process of migration creates mental stress, which may precipitate
mental illness in susceptible individuals.
- There is a non-essential association between migration and certain other variables, such as
age, class, and culture conflict.
In the first group, restless and unstable people are believed to migrate more often, in an attempt to
solve their personal problems → disorders result from the complex interplay of many different
factors. These include material and environmental deprivation such as overcrowding, high
unemployment, racial discrimination, etc. Also, language difficulties play an important part,
especially among female immigrants who arrive later in the country than their men folk and who are
confined within the home and family.
Host vs Migrant: Factors like ‘how welcoming or discrimination is the host community?’ can impact
on the refugees, their health status, and whether they are willing or able to ingrate. Refugees feel
that widespread racism and ignorance, at the personal and institutional levels, are the most
fundamental barriers to integration, and this has major emotional impact on them and their families.
Those from well-educated or middle class families felt particularly humiliated by their loss of social
status. Some policies are more welcoming than others.
Psychosocial Transitions: Migration is often a traumatic experience because it involves major
disruptions in the individual’s life space of assumptive world; those parts of the environment in
which the self-interacts and in relation to which behaviour is organized, isn’t familiar → other
, persons, material possessions, home and work → can view these as separate from his self. These can
effect involuntary and voluntary migrants (less severe).
Cultural Bereavement: Some groups have suffered a permanent traumatic loss of their familiar land
and culture → especially unwilling migrants such as exiles and refugees. The grieving for the lost
home may last for many years, or even a lifetime, which can cause pathological and atypical grief
reactions, from severe depression, withdrawal, to drug or alcohol abuse, psycho-somatic disorders,
and forms of antisocial behaviour.
Variations in Mental Illness Rates Among Migrants
Within both migrant populations and ethnic minorities, certain groups seem to have different rates
and forms of mental illness. Some factors seem more significant in some groups than in others, and
the best way to compare groups would be to add up all these negative factors to find a score
indicating the risk factors for that community.
Pathogenic and Protective Factors
Within the migrant community, some cultural attributes may actually be dangerous to their health
and social functioning → These can include a rigid division among the sexes, the social isolation of
women, multiple religious taboos, and so on.
Some factors seen to protect migrants against some of these mental health risks. These can include:
1. If they migrate as a family unit, rather than individuals. 2. If after migration the family remains as a
coherent, constant unit of support for all its members. 3. If they have entrepreneurial ambitions and
skills. 4. If they have financial resources to pay for education, decent housing, and medical care. 5. If
they have fluency in the new language, as well as numeracy. 6. If they have education, and portable
professional, intellectual or physical skills. 7. If they have local family or other contact in the new
country. 8. If they have a coherent religious or cultural world view, especially if this reinforces family
cohesion. 9. Personality factors → Some migrants are more positive and proactive in their approach,
other less so. Many successful migrants are good social strategists, have personalities that enable
them to reach out to others, and have the ability to build up supportive social networks. But, positive
personality factors may not be sufficient for success, as the refugees also need the support of social
and other institutions in their new country.
Management of Migrant Mental Health Problems
Psychotherapy
The approaches of the industrialized world (e.g., psychotherapy, counsellor, psychiatrists) may be
unsuccessful in relieving the migrants’ distress. One problem with psychotherapy is that this form of
Western talking therapy may be quite inappropriate for same clients from traditional societies,
because if focusses only on the individual and not on the family.
Psychotherapy for migrants always has to be sensitive/respective to these cultural concerns,
especially to the unique and traumatic experiences of being a refugee. Therapy may require the
services of a trained interpreter, the use of community support groups, or even the use of religious
figures or traditional healers.
Psychiatry
The practice of psychiatry is increasingly influenced by globalization and migration.
Psychiatric treatment of migrants, especially the elderly, may also difficult owing to difficulties in
access, as well as cultural factors than can influence the presentation, help-seeking behaviour, and
acceptability of psychiatric treatment.
Traditional Healing
Refugees may prefer their own traditional healers and remedies, when dealing with their mental
health needs. Folk healers can provide a greater sense of continuity and a more holistic and spiritual
