© Springer International Publishing Switzerland 2015
Meryam Schouler-Ocak (ed.)Trauma and Migration10.1007/978-3-319-17335-1_77. Clinical Diagnosis of Traumatised Immigrants
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Department for Cultures, Migration and Mental Disorders, Asklepios Fachklinikum Göttingen, Rosdorfer Weg 70, Göttingen, 37081, Germany
The effects of the multicultural reality of our society also appear in our work as clinical psychologists, psychotherapists and psychiatrists. The encounter with migrants seeking psychosocial help presents challenges not only during the treatment itself; even before therapy has begun, we may have to adjust our approach during the diagnostic process. The following chapter will discuss the challenges and particularities of diagnosing migrants with mental disorders.
Migratory Phenomena Affecting Mental Health
In order to understand the genesis and course of a mental health problem, it is essential to have a look at the biography of every patient. So-called “life events” are known to be a causal factor and as such, are crucial in the understanding of mental illness: “[…] it has been established that a cluster of social events requiring change in ongoing life adjustment is significantly associated with the time of illness onset” (Holmes and Rahe 1967, p. 213). Migration requires a pronounced ability to cope with these changes in daily life. Describing this phenomenon, Berry (2006, p. 294) introduces the term “acculturative stress”: “[…] individuals experience change events in their lives that challenge their cultural understandings about how to live. […] In these situations, they come to understand that they are facing problems resulting from intercultural contact that cannot be dealt with easily or quickly by simply adjusting or assimilating to them”. Sluzki (2001, cited in Czycholl 2009, p. 28) differentiates this concept by dividing migration into five different phases, each with their typical strains. Every phase contains specific tasks of adjustment which the migrating person has to cope with. If the person has sufficient resources, he or she can pass through these without experiencing permanent, subjectively negative stress: “[…] most people deal with stressors and re-establish their lives rather well, with health, psychological and social outcomes that approximate those individuals in the larger society” (Berry 2006, p. 294). However, when these resources are missing (such as through pre-migratory mental health problems, a lack of social support, or unstable identity, i.e. of adolescents), migratory stress can cause mental health problems. Especially in the second phase after the overcompensation of one’s nativity phase after arriving in the new host society (the “phase of decompensation”), the person’s identity is challenged. This is the time when immigrants are highly vulnerable (Machleidt 2010), as the immigrant, and also future generations, is likely to experience ongoing rejection or discrimination regardless of his or her actual social integration, which is associated with mental health problems (Leong et al. 2013; Tummala-Narra and Claudius 2013). These findings point out the importance of migratory phenomena as two sided: social realities such as popular political currents, media reporting about immigrants or structural discrimination has a huge impact on the quantity of acculturative stress the individual experiences and therefore in the long run on his or her will to integrate into the host society. Berry (2006) makes a connection between a person’s desire to have contact with the host society and/or his/her wish to conserve ties with his/her native cultural origins with the amount of acculturative stress the person experiences, describing integration (simultaneously having contact with the host society and maintaining links with their cultural origins) as the less stressful acculturation strategy.
When taking a person’s history, migration, as a major life event, should be taken account of. Having insufficient possibilities to cope with acculturative stress can be a risk factor for mental health problems. Experiences of discrimination should be considered in particular.
Differences in Socialisation
When working with immigrants, professionals may encounter patients who seem to have been socialised in a different way. Several differences are reported in the literature, as discussed below (see also Özkan and Belz 2013). These descriptions should not be used as fixed, nation- or ethnicity-specific facts which apply to all members of the labelled group. Stereotypes should be avoided, as national or ethnic groups also show a high heterogeneity (Ebner 2010).
Parenting and Family Structure
Family structure and the role of different family members seem to be culturally influenced (Gün et al. 2010). The authors report that families from collectivistic contexts place more emphasis on the cohesion of the family than on individuals needs, while having clearly structured (hierarchic, paternalistic, gender- and generation-related) relationships between the family members. We observe these roles to be challenged by migration: children acquiring the host language and adapting more quickly to the new society gain more powerful positions in the family than their parents depending on how much help they receive. This loss of control can be a factor in the genesis of mental health problems in the parents. In other cases, this threat to the former role models can lead to the rigid conservation of the family structure, which can also impact on the children’s health. We also observe extreme forms of parentification as being harmful for children as well as for parents. Von Wogau (2003, p. 69) describes the challenges to gender roles as being “impacted, for example, when spouses who work acquire power which may be contradictory to former family roles”. Other authors describe differences in parenting behaviour, for example, self-control and social behaviour (Julian et al. 1994, cited in Rodriguez et al. 2006) or orientation to culture (Harrison et al. 1990 cited in Rodriguez et al. 2006). De Haan (2011) reports the interesting finding that after migration, the parenting behaviour of the culture of origin is neither preserved nor is it totally adapted to the parenting of the host society, indicating that a perspective fixed on nationality or ethnicity is not helpful in working with immigrants. Instead of stereotyped assumptions, we should have a closer look at the context of each family: “Each individual family has its own culture, spoken and unspoken rules, norms of behaviour, ideologies and myths – families have been construed as interpretive communities” (von Wogau 2003, p. 67). From this view, it is not surprising that studies looking for ethnic differences in parenting behaviour find more similarities than differences and observe other factors (maternal age, marriage status, socio-economic status) as being influential (Rodriguez et al. 2006). Earner and Rivera (2005, p. 532) give advice for our diagnostic praxis: “While newcomers tend to share many significant challenges, each family has unique needs depending on where they come from, how long they have been here, or what resources they can count on, among others. Generalisations and assumptions should be avoided in working with immigrant and refugee families”.
Tradition
Brzoska and Razum (2009) see differences of rites, traditions and values compared to the majority population as influencing health behaviour. Few patients tell us about the use of traditional healers (i.e. Hoca). More often they report more common religious practices such as fasting (i.e. in Ramadan). This aspect should be considered during medical treatment by adapting the intake time of medicine if possible and needed.
Talking about tradition in the context of immigrants, we often observe negative connotations (i.e. by focussing on the way in which interethnic partnerships or divorce are dealt with, as well as on honour killings). Here there are two important aspects to be considered. First, tradition can mean an infinity of behavioural patterns and values. Traditions (i.e. religious practices, social support) can form an important resource to help the person cope with strain (Brzoska and Razum 2009). Fassaert et al. (2011, p. 132) emphasise that “allowing migrants to preserve their traditions, might be effective measures in improving the mental well-being of migrants”. Second, it is not possible to make generalisations. Regarding immigrants or single national or ethnic groups as homogeneous is inappropriate and causes false assumptions about the individual. Brzoska and Razum (2009) summarise that clinicians should not seek a fixed recipe, but rather a flexible approach which is detached from stereotypes and orientated towards individual needs.
Sense of Shame
The affects of shame and guilt are described as being culture specific. A distinction between shame cultures and guilt cultures is made (Benthien 2011). Güç (2010) postulates that these affects are used to regulate interpersonal relationships, with shame observed more commonly in Islamic cultures, expressing the collectivistic imprint.
Regarding the willingness to report traumatic experiences, shame seems to be a relevant factor. Ebner (2010) describes greater difficulty reporting intimate details among people with a heightened sense of shame when the experiences are connected to the honour or reputation of the family. According to Wenk-Ansohn (2004), such avoidance of disclosure increases with the extent of humiliation and shame associated with the event, while the definition of sexual abuse differs between traditions. In the case of woman who has been raped, she might conceal the event in order to avoid social exclusion due to a loss of honour. During diagnosis, this can result in the patient only reporting unspecific symptoms such as pain and a fragmentary biographical description.
Concepts of Illness
The understanding of the causes, appropriate treatment and prognosis of mental illness is culturally influenced (Dogan et al. 2009). Özkan (2010, p. 116) lists different types of causality beliefs:
Magical religious causality: punishment by god and being bewitched
Natural causality: illness caused by weather conditions
Organic/medical causality: experiencing symptoms (pain)
Relational causality: environmental problems like strain at work
Emotional causality: affective conditions (loneliness, grief, lack of pleasure)
Somatic causality: emotional events causing physical conditions, e.g. “my heart stopped”
Other authors also describe somatic (Ebner 2010) and magical religious causality (Brzoska and Razum 2009; Ebner 2010; Yildirim-Fahlbusch 2003). In this context it is important to remind the reader that differing concepts of illness are not migrant or culture specific. Concepts such as those listed by Özkan (2010) can also be observed in native patients. We recommend asking the patient about his or her concept of illness in the diagnostic phase, as illness-related beliefs have an enormous impact on their coping and compliance during therapy (Brzoska and Razum 2009). Knowledge about the patient’s concept of illness also helps in interpreting the presented symptoms and in avoiding misinterpretations. According to Ebner (2010), a holistic concept (avoiding a perceived separation of body and soul or mind) results in somatic complaints being understood as being linked to psychosocial conflicts. Also, magical, religious causality beliefs could be misinterpreted as psychotic symptoms.
Somatisation
Somatisation is a phenomenon which is often reported as being specific to non-western cultures (Aichberger et al. 2008; Aragona et al. 2010; Lin et al. 1985). In practice, terms like “morbus mediterraneus”, “morbus bosphorus” or “mamma mia syndrome” are still used. Kizilhan (2009) describes how a lack of knowledge about the human body and lower tolerance to psychological strain can result in somatic complaints such as widespread pain. He also lists culture-specific syndromes with their own aetiology and culture-specific way of treatment. In actual fact, the distinction between somatising and non-somatising cultures is outdated: “Contrary to the claim that non-Westerners are prone to somatise their distress, recent research confirms that somatisation is ubiquitous” (Kirmayer 2001, p. 22). Hausotter and Schouler-Ocak (2007, p.93) explain the reported somatic complaints as a “preverbal, body-related way of conflict resolution” due to interaction problems between patient and professional. These misunderstandings may result in diagnostic and therapeutic errors (Brucks and Wahl 2003; Kirmayer 2001). Kirmayer (2001) also reports that most patients who express their distress through a somatic complaint are nonetheless able to express psychosocial aspects when asked. He postulates: “Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are not simply indices of disease or disorder but part of a language of distress with interpersonal and wider social meanings” (p. 22). The consideration of psychological factors within the diagnostic process helps to avoid these errors. In cases of low language skills, the use of translators can help the patient to express their psychosocial strain. Overall, the assumption of somatising cultures and culture-specific syndromes is an inappropriate generalisation which should be avoided in order to ensure a qualitative, individualised diagnosis and treatment.
Related posts:
The Epidemiology of Post-traumatic Stress Disorder: A Focus on Refugee and Immigrant Populations
Introduction: The Relevance of Trauma Among Immigrants
Gender and Trauma
Cross-Cultural Communication with Traumatised Immigrants
Traumatised Immigrants in an Outpatient Clinic: An Experience-Based Report
A Therapy Model for Traumatised Refugees in Denmark
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