Edited by Tom Dening, Alan Thomas, Robert Stewart, and John-Paul Taylor
Oxford Textbook of Psychiatry of Intellectual Disability
Edited by Sabyasachi Bhaumik and Regi Alexander
Oxford Textbook of Inpatient Psychiatry
Alvaro Barrera, Caroline Attard, Rob Chaplin
Oxford Textbook of Attention Deficit Hyperactivity Disorder
Edited by Tobias Banaschewski, David Coghill, and Alessandro Zuddas
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Oxford Textbook of Migrant Psychiatry
EDITED BY Dinesh Bhugra
Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, UK
Associate Editors
Oyedeji Ayonrinde
Department of Psychiatry, School of Medicine, Queen’s University, Kingston, ON, Canada
Edgardo Juan Tolentino Jr
Department of Psychiatry and Mental Health, Clinical Faculty, Ateneo School of Medicine and Public Health, Pasig, Metro Manila, Philippines
Koravangattu Valsraj
Amrita Institute of Medical Sciences, Kochi, Kerala, India and Manasvi, Kochi, Kerala, India
Antonio Ventriglio
Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Foreword
The number of migrants continues to grow steadily in an increasingly globalized world, owing to a multiplicity of interrelated economic, social, and security factors. While migration can benefit migrants, their families, and both their origin and destination communities, a toxic narrative that tends to stigmatize migrants and consider them a problem rather than a resource dominates the public and political discourse on migration in several countries in Europe and beyond. Developing a better understanding of all aspects of migration can help in demystifying the negative perception of migrants and to support communities in benefiting the most from migration and to better respond to the challenges that it can pose.
In any migration experience, people need to redefine personal, interpersonal, socio-economic, and cultural aspects of their lives, which brings about changes in individual, family, group, and collective identities, roles, and value systems. These psychosocial challenges of migration can be a source of stress and are augmented when migration and displacement are occurring as a result of conflicts, human rights violations, environmental degradation, and natural catastrophes. In addition to the psychological impact these often-protracted situations can have on the affected migrants, undignified travel and transit conditions, family separation, loss of loved ones, difficult bureaucratic procedures to deal with upon arrival, and challenges in the integration process can all take a toll on the migrants’ psychological well-being. In addition, certain migratory paths, like the ones of victims of human trafficking, of children who travel unaccompanied, of those migrants who are detained for purely administrative reasons can have a profound, long-standing impact on their mental health and psychological well-being.
The consideration that migration as a global reality needs to be addressed, in all its dimensions, has triggered important policy developments at the highest level. A first-ever intergovernmental agreement, the Global Compact for Safe, Orderly and Regular Migration (GCM), was endorsed by the majority of countries in the world and formally endorsed by the United Nations (UN) General Assembly in December 2018. The aspirational Compact aims at reaching a shared collaborative approach to address migration challenges and maximize its benefits, while contributing to positive development outcomes, including towards the achievement of the Sustainable Development Goals. It inter alia advocates for the highest attainable standards of physical and mental health for migrant workers, and for the provision of unrestricted or specific mental health care services for specific migrant groups. These include children, especially unaccompanied and separated children, migrant women and survivors of sexual and gender-based violence, migrants in detentions, and victims of hate crimes. The inclusion of mental health in the GCM is a leap forward in the acknowledgement of mental health as
a relevant aspect of international efforts to better manage migration and works towards positive migration outcomes. The Compact calls for action by a wide range of stakeholders, including policymakers, civil society organizations, and equally importantly, international organizations, academia, and the health workforce.
The International Organization for Migration (IOM), was founded in 1951 and became a Related Organization to the UN in 2016. As part of its mandate to protect and promote the human dignity and wellbeing of migrants, the IOM has provided health services to people on the move throughout all phases of the migration process and has supported governments in both origin, transit, and destination countries. Mental health and psychosocial support have been an integral part of IOM migration health-related services for a wide range of migrant populations, displaced, returnees, and conflict-affected, and host their communities in all parts of the world. By working with partners, member states, migrants, and other key stakeholders, the IOM Mental Health, Psychosocial Support and Intercultural Communication Section was established in the late 1990s to strengthen the capacity of the IOM, partners, and countries in relevant mental health and psychosocial services provided to migrants.
The IOM is therefore grateful to Professor Dinesh Bhugra for bringing together some of the most renowned experts in the field of mental health and migration to contribute to a compendium of chapters reflecting on different aspects of migration and psychiatry. This publication provides us with an extensive background of the topic and aims to advocate for and improve the support for migrants. This textbook will be a valuable tool and a point of reference to support practitioners in establishing links between fieldwork, policy development, and academic research. The various contributions reflect the existing debate in the domain of migration and mental health, a field where many questions are still open, and research is often inconclusive. Interestingly, the IOM’s views, experiences, and practices are in line with some of the chapters and differ slightly or substantially from others. Yet, the IOM praises the very publication that provides a sound basis to feed and direct the international debate on migrant mental health, while raising awareness, sharing experiences, and improving practices.
I trust this textbook will be a valuable tool, especially for mental health students, who will surely encounter migrants in their future clinical, policy-making, or activist practices. Migration is a feature of today’s world; it is a fact of life. It is the duty of us all to contribute to preparing young professionals, many of whom will be migrants themselves at some stage in their lives, to respond to the wide range of challenges migration can create to mental health care provision, including language barriers, cultural beliefs and practices, and administrative and financial hurdles to find access to health services,
as well as human rights and political implications of working with migrants. The IOM strongly believes that investing in and supporting the mental health of migrants is the way forward to ensure social cohesion in our diverse societies and will come with longterm benefits, allowing migrants to be active and productive members of society, and facilitating successful integration and peaceful co-existence with their host communities.
Jacqueline Weekers Director, Migration Health Division International Organization for Migration
DISCLAIMER
The opinions expressed in this book are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM). The designations employed and the presentation of material throughout this book do not imply the expression of any opinion whatsoever on the part of IOM concerning the legal status of any country, territory, city or area, or of its authorities, or concerning its frontiers or boundaries.
IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants.
Preface
Migrant psychiatry is the branch of psychiatry and the discipline within the specialty that deals with the impact of migration on the mental health of those who have migrated and those who work with these groups and provide services to them. The aim of this book is to draw global experiences together in a helpful narrative to clinicians, researchers, and policymakers. The nature of migration is often assumed to be homogenous, but it is not. Even if people migrate for similar reasons, their experiences post-migration can be very different and the process of settling down in new cultures can be very individual and varied. Furthermore, those who migrate for economic reasons may have very different experiences than those who migrate for political reasons. Highly skilled migrants may choose to migrate because of pull factors, whereas those who are escaping conflicts or wars can attribute their reasons to push factors. There are differences in definitions of migrants, refugees, and asylum seekers, and, again their decisions to migrate and postmigration settling down can have variable consequences on their functioning and mental health. In general, the process of migration has been divided into three stages: pre-migration, migration, and post-migration. Even though these stages are often treated as distinct stages, they are not, and they tend to overlap with one another, creating individual experiences that impact upon the individual’s mental health. Depending on the reasons for migration, the planning and preparation for the actual act will vary, and some migrants may be better prepared than others.
Embedded within the process of migration are specific vulnerable groups, such as women, children, and young people, older adults, and lesbian, gay, bisexual, and transgender individuals. Service planning and service delivery must take these differences into account. Another major challenge in planning and providing
psychiatric services in any setting is the experience of acculturation of the migrants. The process of acculturation can occur at both individual and group levels, and it is crucial that policymakers take that into account and plan services accordingly. Xenophobia and racism can contribute to a sense of alienation that migrants, refugees, and asylum seekers may face in the new country. In addition, quite often the individual’s identity as a migrant tends to trump any other identity, which may add to the stress and create difficulties in settling down. As a result of globalization, many highly skilled migrants may choose to migrate and these groups include healthcare workers, especially international medical graduates, who not only bring with them specific skills but also face specific challenges.
It would not have been possible to put together this volume without the sterling contribution of authors who delivered their chapters promptly. I am grateful to them for their contributions. I would like to thank Jacqueline Weekers of the International Organization for Migration, who kindly wrote the Foreword.
I also thank the following: my associate editors, Oyedeji Ayonrinde, Edgardo Juan Tolentino Jr, Koravangattu Valsraj, and Antonio Ventriglio, for their input; Andrea Livingstone, who has been a rock in seeing the project completed, and thanks is an inadequate word to express my appreciation and gratitude; and the wonderful team at Oxford University Press—Pete Stevenson, Rachel Goldsworthy, and Lauren Tiley—for their unstinting support and assistance with a smile.
I very much hope that this volume highlights myriad experiences and explores the needs of clinicians, researchers, and policymakers to create and build a better world, one where when people migrate, they are looked after.
Dinesh Bhugra
Contents
Abbreviations xv
Contributors xvii
SECTION 1
Background
1. Introduction 3
Dinesh Bhugra
2. Geopolitics of migration and refugees 19
Albert Persaud, Antonio Ventriglio, Koravangattu Valsraj, and Dinesh Bhugra
3. Political and institutional determinants of migration policies 29
Toni Ricciardi and Sandro Cattacin
4. Prejudice, ethnic discrimination, and double jeopardy in migrants 39
Cameron Watson, Edgardo Juan Tolentino Jr, and Dinesh Bhugra
5. Global cultures as a consequence of globalization of mental health 45
Driss Moussaoui, Vishal Bhavsar, and Dinesh Bhugra
6. Gender perspectives in migration 55
Rangaswamy Thara and Aarthi Raman
7. A psychosocial approach to working with victims of trafficking with means of sexual exploitation 63
Catarina Alves and Nadia Morales Gordillo
8. The new face of exploited children in Europe 73
Olivier Peyroux
9. Mental health needs of lesbian, gay, bisexual, and transgender migrants 81
Rebecca Hopkinson, Eva S. Keatley, and Joanne Ahola
10. Urbanization and its impact on migrant mental health 89
Layla McCay and Natalia Banulescu-Bogdan
11. Trauma and migration 97
Joanne Stubley
12. Collective trauma 105
Umaharan Thamotharampillai and Daya Somasundaram
SECTION 2
Pre-migration
13. Mental health issues of child refugees and migrants 117
Jaswant Guzder
14. Vulnerability, psychopathology, and creativity of the children and adolescents of migrants 127
Marie-Rose Moro, Laelia Benoit, Manon Lebozec, Sevan Minassian, Alice Titia Rizzi, and Rahmeth Radjack
15. Effects of migration on women’s psychosocial health: focus on the Mediterranean region 137 Mauro Carta, Giulia Cossu, and Caterina La Cascia
16. Experiences of elderly migrants in a new country 141
Fungai Mhlanga and Rosemary Mhlanga
17. Families migrating together 149
Renos K. Papadopoulos
18. Psychosocial and mental health impacts of migration on ‘left-behind’ children of international migrant workers 159
Michaella Vanore, Kolitha Prabhash Wickramage, Delanjathan Devakumar, and Lucy P. Jordan
19. Forced migration 171
Patricia Foxen
20. Out-migration and social capital 181
Nicholas Spina
21. Micro-migration 189
Uriel Halbreich
22. Disability and forced migration 193
Rebecca Yeo
SECTION 3
Migration
23. Internal migration 203
Bharathram Sathur Raghuraman and Santosh Chaturvedi
24. General health needs of migrants and refugees 209
Androula Pavli and Sotirios Tsiodras
25. Physical migration 219
Oyedeji Ayonrinde and Nicolette Busuttil
26. Physical and psychological resilience and migration 231
Bex Willans and Sarah Stewart-Brown
27. Migration governance and mental health 243
Guglielmo Schininá
28. Refugees and asylum seekers 251
Tom K.J. Craig
29. High-skilled migration and mental health: challenges and solutions 259
Antonio Ventriglio, Susham Gupta, and Cameron Watson
SECTION 4
Post-migration
30. Sociocultural phenomenology of world migrations 265
Renato D. Alarcón
31. The cross-cultural assessment of migrants 275
Neil Krishan Aggarwal
32. Refugee and asylum seekers’ experiences 281
Rachel Tribe and Angelina Jalonen
33. Principles for the management of physical and mental health care in migrants 291
Vishal Bhavsar
34. Managing relationships and psychotherapy 297
Kenneth Po-Lun Fung
35. Community-based mental health care and narrative exposure therapy 305
Kevin Pottie, Azaad Kassam, and Douglas Gruner
36. Migrant acculturation and adaptation 311
John W. Berry
37. Cultural bereavement, cultural congruity, and identities 319
Cameron Watson, Antonio Ventriglio, and Dinesh Bhugra
38. Intercultural mediation in mental health care 325
Adil Qureshi, Olga Ananyeva, and Francisco Collazos
39. Working with interpreters 335
Rachel Tribe
40. Migration and mental health care in the European Union 343
Guglielmo Schininá and Geertrui Lanneau
41. Refugees, torture, and dehumanization 351
Vladimir Jović
42. Refugee, migrant, and asylum seeker experiences: the Balkan perspective 359
Dusica Lecic-Tosevski and Bojana Pejuskovic
43. Needs of child refugees and economic factors 367
Dimitris C. Anagnostopoulos, Kalliopi Triantafyllou, and Nikos G. Christodoulou
44. Media setting the agenda: the various shapes of media othering 375
Elisabeth Eide
45. Immigration: migrant perspective 383
Shahram Shaygani
46. Early assessment of mental health and options for documentation of torture in newly arrived asylum seekers 387
Nora Sveaass and Birgit Lie
47. Safety for children: how can we support parents and caregivers in reception centres and early phases of resettlement? 395
Ragnhild Dybdahl and Helen Johnsen Christie
48. Women and migration: psychopathology 403
Vandita Shanbhag, Madhura Bojappa, and Prabha S. Chandra
49. Children and vulnerable groups services 413
Diana Miconi and Cécile Rousseau
50. Ethics and migrant psychiatry: principles, challenges, and solutions 423
Nicholas A. Deakin, Antonio Ventriglio, and Dinesh Bhugra
51. Mental health of refugees in primary care 431
Edvard Hauff and Reidun Brunvatne
52. Separate or integrated services? 439
Sofie Bäärnhielm, Mike Mösko, and Aina Basilier Vaage
53. Specialist services: practice 449
Sverre Varvin
SECTION 5
Psychotherapeutic techniques
54. Handling cultural differences between patient and clinician 459
Joseph Westermeyer and Jerome Kroll
55. Therapeutic skills and therapeutic expectations in the treatment of migrant individuals and their families 467
Samuel O. Okpaku
56. Psychiatric disorders in refugees and immigrants: treatment goals and planning 475
J. David Kinzie
57. Psychopharmacology and refugees, asylum seekers, and migrants 483
David C. Henderson
58. Psychotherapy and refugees 493
Francesca Brady, Cornelius Katona, Eileen Walsh, and Katy Robjant
SECTION 6
Special issues
59. Intercultural counselling and psychotherapy with new immigrants and refugees 505
Rachel Tribe
60. Post-traumatic stress disorder in refugee and migrant mental health 513
Lisa Andermann, Pushpa Kanagaratnam, Dawit Wondimagegn, and Clare Pain
61. Race and racism’s impact on mental wellness 523
Oyedeji Ayonrinde and Shadé Miller
62. Psychiatric emergencies in asylum seekers 533
Georgios Schoretsanitis, Dinesh Bhugra, and Aristomenis Exadaktylos
63. Suicide among refugees: the silent story 543
Lakshmi Vijayakumar, Sujit John, and A.T. Jotheeswaran
64. Acculturation and suicide-related risk among Latin American migrants 553
Lillian Polanco-Roman, Cristiane Duarte, and Roberto Lewis-Fernández
65. Resettlement stressors and family factors in refugee child and adolescent psychopathology 567
Matthew Hodes, Roman A. Koposov, and Norbert Skokauskas
66. Identifying service needs 575
Meryam Schouler-Ocak
67. Separate services or integrated services 581
Jessica Carlsson and Marianne C. Kastrup
68. An early intervention framework for the emotional health and well-being of unaccompanied minors 589
Ana Draper and Elisa Marcellino
69. Transforming identities: meeting the needs of refugee and asylum-seeking children in a child and adolescent mental health service in the National Health Service 597
David Amias, Karen Partridge, Sherry Rehim, and Nsimire Aimee Bisimwa
70. International medical graduates’ contributions to psychiatry—a historical review 607
Nyapati Rao, Saeed Ahmed, and Dinesh Bhugra
71. Dynamics of international medical graduates’ migration: challenges and opportunities 613
Nyapati Rao, Saeed Ahmed, and Dinesh Bhugra
72. Developing psychiatric services for migrants, refugees, and asylum seekers 623
Stanley Yip, Kenneth Javate, and Dinesh Bhugra
73. Use of telepsychiatry for the management of mental health problems in migrants 633
Keith Hariman, Antonio Ventriglio, and Dinesh Bhugra
74. Returning migrants: mental and physical health needs 643
Antonio Ventriglio, Matthew Kelly, and Dinesh Bhugra
75. What next? 649
Dinesh Bhugra
Index 651
Abbreviations
AAD Adversity-activated development
ACT Acceptance and commitment therapy
AED Accident and emergency department
AI Artificial intelligence
AIDS Acquired immune deficiency syndrome
APA American Psychiatric Association
AS Acculturative stress
ATM Automated teller machine
AVRR Assisted voluntary return and re-integration
CAFTA Central America Free Trade Agreement
CAMHS Child and adolescent mental health services
CASH Comprehensive Assessment of Symptoms and History
CASP Contact and safety planning
CBI Classrom Based Intervention
CBT Cognitive behavioural therapy
CCS Cultural Consultation Service
CDC Centers for Disease Control and Prevention
CFI Cultural Formulation Interview
CI Confidence interval
CME Continuing medical education
CP Creative play
CPS Child Protection Services
CPSTD Complex post-traumatic stress disorder
CPT Cognitive processing therapy
CRPD Convention for the Rights of Persons with Disability
CRT Collaborative resiliency training
CRTV Center for Rehabilitation of Torture Victims
CSL Community service learning
CSO Civil society organization
CTP Centre for Transcultural Psychiatry
CV Community volunteer
CVI CAPE Vulnerability Index
CYP Cytochrome P
DCCIS DSM-5 Cross-Cultural Issues Subgroup
DPS District psychiatric centre
DRC Democratic Republic of Congo
DSM-III Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition
DSM-III-R Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
EBPP Evidence-based practice of psychology
ECFMG Education Commission for Foreign Medical Graduates
EHC Electronic health card
EMDR Eye movement desensitization and reprocessing
EPA European Psychiatric Association
EPCACE Enduring personality change after catastrophic experience
ESOL English as a second language
ESS European Social Survey
EST Empirically supported treatment
EU European Union
FP Framework Programme
GCM Global Compact for Safe, Orderly and Regular Migration
GHQ 28-item General Health Questionnaire
GME Graduate medical education
GMH Global mental health
GNI Gross national income
GP General practitioner
GPS Global positioning system
HBF Helen Bamber Foundation
HBV Hepatitis B virus
HCV Hepatitis C virus
HIV Human immunodeficiency virus
HPSA Health professional shortage areas
HR Hazard ratio
HTQ Harvard Trauma Questionnaire
IAN International Aid Network
IASC Inter-Agency Standing Committee
ICD International Classification of Diseases
ICD-10 International Classification of Diseases, 10th Revision
ICD-11 International Classification of Diseases, 11th Revision
ICDP International Child Development Programme
ICM Intercultural mediator
ICRC International Committee of the Red Cross
IDP Internally displaced person
IMG International medical graduate
IMH Institute of Mental Health
IOM International Organization for Migration
IPT Interpersonal psychotherapy
IPV Intimate partner violence
IQR Interquartile range
ISA Identity Structure Analysis
ISIS Islamic State in Iraq and Syria
ITQ International Trauma Questionnaire
JCPMH Joint Commission Panel for Mental Health
KIDNET Narrative exposure therapy for children
LAC Latin America and the Caribbean
LAMI Low- and middle-income
LGBT Lesbian, gay, bisexual, and transgender
LGBTI+ Lesbian, gay, bisexual, transgender, intersex, and other
LIP Life is Precious
LMIC Low- and middle-income country
mhGAP Mental Health Gap Action Plan
MHPSS Mental Health and Psychosocial Support Network
MIPEX Migrant Integration Policy Index
MRSA Methicillin-resistant Staphylococcus aureus
MUA Medically underserved area
NAKMI Norwegian Centre for Migration and Minority Health
NATO North Atlantic Treaty Organization
NCD Non-communicable disease
NET Narrative exposure therapy
NGO Non-governmental organization
NHS National Health Service
NICE National Institute for Health and Care Excellence
NSI National Statistics Institute
OCF Outline for Cultural Formulation
ODA Overseas Development Aid
OECD Organisation for Economic Co-operation and Development
PE Prolonged exposure
PFA Psychological first aid
PHC Primary health care
PHS Primary health service
PM Poor metabolizer
PRS Protracted refugee situation
PSMH Psychological and mental health
PTSD Post-traumatic stress disorder
RCT Randomized controlled trial
RELATE Relationship-building, Exploration of individual and sociocultural meaning, Laying off of cultural assumptions, Address sociocultural issues, Therapeutic use of culture, and Evaluation of impact
UNCRC United Nations Convention on the Rights of the Child
UNHCR United Nations High Commission for Refugees
UNICEF United Nations Children’s Fund
URM Unaccompanied refugee minor
USMG US medical graduate
USMIG US international medical graduate
USMLE US Medical Licensing Examination
VPD Vaccine-preventable disease
WHO World Health Organization
WPA World Psychiatric Association
Contributors
Neil Krishan Aggarwal Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, US
Saeed Ahmed Nassau University Medical Center, East Meadow, New York, US
Joanne Ahola Weill Cornell Center for Human Rights, Weill Cornell Medical College, New York, US
Renato D. Alarcón Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, US, Universidad Peruana Cayetano Heredia, Lima, Perú
Catarina Alves Department of Sociology, Universitat Autònoma de Barcelona, Barcelona, Spain
David Amias Children, Young Adults and Family Department, Tavistock and Portman NHS Foundation Trust, London, UK
Dimitris C. Anagnostopoulos Department of Child Psychiatry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
Olga Ananyeva School of Social and Behavioural Sciences, Tilburg University, Tilburg, The Netherlands
Lisa Andermann Department of Psychiatry, University of Toronto, Toronto, Canada
Oyedeji Ayonrinde Department of Psychiatry, Queen’s University, Kingston, Canada
Sofie Bäärnhielm Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Natalia Banulescu-Bogdan Migration Policy Institute, Washington, DC, US
Laelia Benoit Department of Medicine and Adolescent Psychiatry, Maison de Solenn, Cochin Hospital, University of Paris, Inserm, CESP, Paris, France
John W. Berry Department of Psychology, Queen’s University Kingston, Kingston, Canada
Vishal Bhavsar Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Dinesh Bhugra Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Nsimire Aimee Bisimwa Children, Young Adults and Family Department, Tavistock and Portman NHS Foundation Trust, London, UK
Madhura Bojappa Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
Francesca Brady Helen Bamber Foundation, London, UK and Woodfield Trauma Service, Central and North West London NHS Foundation Trust, UK
Reidun Brunvatne formerly of Vestfold Migrasjonshelsesenter, Tønsberg, Norway
Nicolette Busuttil School of Law, Queen Mary University of London, London, UK
Jessica Carlsson Competence Centre for Transcultural Psychiatry (CTP), Mental Health Services of the Capital Region of Denmark, University of Copenhagen, Ballerup, Denmark
Mauro Carta Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
Sandro Cattacin Department of Sociology, Institute of Sociological Research (IRS) University of Geneva, Geneva, Switzerland
Prabha S. Chandra Department of Psychiatry, National Institute of Mental Health and Neuroscience, Bangalore, India
Santosh Chaturvedi Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
Helen Johnsen Christie formerly of Regional Center for Child and Adolescent Mental Health, Oslo, Norway
Nikos G. Christodoulou Department of Psychological Medicine, Queen’s Medical Centre, Nottingham, UK
Francisco Collazos Department of Psychiatry, Hospital Universitari Vall d’Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
Giulia Cossu Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
Tom K.J. Craig Health Service and Population Research, King’s College London, London, UK
Nicholas A. Deakin London Business School, London, UK
Delanjathan Devakumar Institute for Global Health, University College London, London, UK
Ana Draper Creative Therapies, Coram, London, UK
Cristiane Duarte Department of Psychiatry, New York State Psychiatric Institute, Columbia University, New York, US
Ragnhild Dybdahl Department of Social Work, Child Welfare and Social Policy, OsloMet—Oslo Metropolitan University, Oslo, Norway
Elisabeth Eide Department of Journalism and Media Studies, OsloMet—Oslo Metropolitan University, Oslo, Norway
Aristomenis Exadaktylos Department of Emergency Medicine, University Hospital, Bern, Switzerland
Patricia Foxen Center for Latin American and Latino Studies, American University, Washington, US
Kenneth Po-Lun Fung Department of Psychiatry, University of Toronto, Toronto, Canada
Douglas Gruner Department of Family Medicine, University of Ottawa, Ottawa, Canada
Susham Gupta East London NHS Foundation Trust, London, UK
Jaswant Guzder Department of Psychiatry, McGill University Montréal, Canada
Uriel Halbreich Bio-Behavioral Research, SUNY-AB, Buffalo, US
Keith Hariman Department of General Adult Psychiatry, Castle Peak Hospital, Hong Kong, China
Edvard Hauff Institute of Clinical Medicine, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
David C. Henderson Department of Psychiatry, Boston Medical Center, Boston University School of Medicine, Boston, USA
Matthew Hodes Division of Psychiatry, Imperial College London, London, UK
Rebecca Hopkinson Department of Psychiatry and Behavioral Medicine University of Washington, Seattle, US
Angelina Jalonen Therapeutic Services, Refugee Council, London, UK
Kenneth Javate Department of Psychiatry, Medical City Hospital, Manila, Phillipines
Sujit John Department of Research, Schizophrenia Research Foundation, Chennai, India
Lucy P. Jordan Department of Social Work and Social Administration, University of Hong Kong, Pokfulum, Hong Kong
A.T. Jotheeswaran Department of Maternal, Newborn, Child, Adolescent and Ageing, World Health Organization (WHO), Geneva, Switzerland
Vladimir Jović Center for Rehabilitation of Torture Victims, IAN, Belgrade, Serbia
Pushpa Kanagaratnam Department of Psychiatry, University of Toronto, Toronto, Canada
Azaad Kassam Department of Psychiatry, University of Ottawa, Laurentian University, Lakehead University, Canada
Marianne C. Kastrup Own firm, Frederiksberg, Denmark
Cornelius Katona Helen Bamber Foundation, London, UK and Division of Psychiatry, University College London, London, UK
Eva S. Keatley Department of Physical Medicine & Rehabilitation, Johns Hopkins, Baltimore, US
Matthew Kelly Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
J. David Kinzie Department of Psychiatry, Oregon Health and Science University, Portland, US
Roman A. Koposov Regional Centre for Child and Youth Mental Health and Child Welfare, Northern Norway, University of Tromsø— The Arctic University of Norway (UiT), Tromsø, Norway
Jerome Kroll Department of Psychiatry, University of Minnesota Medical School, Minneapolis, US
Caterina La Cascia Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
Geertrui Lanneau Regional Office for the European Economic Area, the European Union and NATO, International Organization of Migration, Brussels, Belgium
Manon Lebozec Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Paris, France
Dusica Lecic-Tosevski Serbian Academy of Sciences and Arts, Belgrade, Serbia
Roberto Lewis-Fernández Department of Psychiatry; New York State Center of Excellence for Cultural Competence, Hispanic Treatment Program, and Anxiety Disorders Clinic, Columbia University and New York State Psychiatric Institute, New York, US
Birgit Lie Specialized Department for Psychosomatics and Trauma, Sorlandet Hospital, Kristiansand, Norway, Kristiansand, Norway
Elisa Marcellino Department of Psychology, Mental Health, Improved Futures and NHS, London, UK
Layla McCay Centre for Urban Design and Mental Health, London, UK
Fungai Mhlanga Hamilton Multicultural Services Trust (HMST), Hamilton, NZ
Rosemary Mhlanga Hamilton Multicultural Services Trust (HMST), Hamilton, NZ
Diana Miconi Division of Social and Cultural Psychiatry, McGill University, Montréal, Canada
Shadé Miller Department of Psychiatry, Queen’s University School of Medicine, Kingston, Canada
Sevan Minassian Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Inserm, CESP, Paris, France
Marie-Rose Moro Department of Medicine and Adolescent Psychiatry, Cochin Hospital, University of Paris, Inserm, CESP, Paris, France
Mike Mösko Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Driss Moussaoui Ibn Rushd University Psychiatric Centre, Casablanca, Morocco
Samuel O. Okpaku Center for Health, Culture, and Society, Nashville, US
Clare Pain Department of Psychiatry, University of Toronto, Toronto, ON, Canada and University of Addis Ababa, Ethiopia
Renos K. Papadopoulos Psychosocial and Psychoanalytic Studies, University of Essex, Colchester, UK
Karen Partridge Department of Education and Training, Tavistock and Portman NHS Foundation Trust, London, UK
Androula Pavli Travel Medicine Office, Hellenic Centre for Disease Control and Prevention, Athens, Greece
Bojana Pejuskovic Associate Professor, Clinical Department for Psychotic Disorders; Head, Education Unit, Institute of Mental Health, School of Medicine, University of Belgrade, Belgrade, Serbia
Albert Persaud The Centre for Applied Research and Evaluation-International Foundation. (Careif), Centre for Psychiatry: Barts and The London, Queen Mary’s School of Medicine & Dentistry, London, UK
Olivier Peyroux Department of Sociologist, Trajectoires, Montreuil, France
Lillian Polanco-Roman Department of Psychiatry, Columbia University, New York, US
Kevin Pottie Departments of Family Medicine and Epidemiology and Community Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
Adil Qureshi Department of Psychiatry, Vall d’Hebron University Hospital, Barcelona, Spain
Rahmeth Radjack Department of Medicine and Adolescent Psychiatry, Cochin Hospital, Inserm, CESP, Paris, France
Aarthi Raman Department of Psychiatry, Schizophrenia Research Foundation, Chennai, India
Nyapati Rao Professor of Psychiatry, Stony Brook School of Medicine, Stony Brook, US
Sherry Rehim Camden Looked After Children & Refugee CAMHS, Children, Young Adults and Family Department, Tavistock and Portman NHS Foundation Trust, London, UK
Toni Ricciardi Institute of Sociological Research (IRS), University of Geneva, Geneva, Switzerland
Alice Titia Rizzi Department of Medicine and Adolescent Psychiatry, Maison de Solenn, Cochin Hospital University of Paris, Paris, France
Katy Robjant Freedom from Torture, London, UK and Vivo International, Konstanz, Germany
Cécile Rousseau Division of Social and Cultural Psychiatry, McGill University, Montréal, Canada
Bharathram Sathur Raghuraman Department of Psychiatry, National Institute of Mental health and Neurosciences (NIMHANS), Bangalore, India, and Forensicare (Victorian Institute of Forensic Mental Health), Melbourne, Australia
Guglielmo Schininá Global Mental Health, Psychosocial Response and Intercultural Communication Section, International Organization for Migration (IOM), Brussels, Belgium
Georgios Schoretsanitis Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, US
Meryam Schouler-Ocak Psychiatric University Clinic of Charité at St. Hedwig Hospital, Berlin, Germany
Vandita Shanbhag Post doctoral Fellow in Women’s Mental Health, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
Shahram Shaygani Psychiatrist, Psychoanalyst, Department of Addiction, Trasoppklinikken, Oslo, Norway
Norbert Skokauskas Regional Centre for Child and Youth Mental Health and Child Welfare, Middle Norway, Norwegian University of Science and Technology, Trondheim, Norway
Daya Somasundaram Department of Psychiatry, University of Jaffna, University of Adelaide, STTARS, Glenside, Australia
Nicholas Spina Department of Political Science, Slippery Rock University of Pennsylvania, Slippery Rock, US
Sarah Stewart-Brown Warwick Medical School, University of Warwick, Coventry, UK
Joanne Stubley Lead Clinician Tavistock Trauma Service, Tavistock and Portman NHS Trust; Member British Psychoanalytic Society, London, UK
Nora Sveaass Department of Psychology, University of Oslo, Norway, Oslo
Umaharan Thamotharampillai Department of Psychiatry, Jaffna Teaching Hospital, Jaffna, Sri Lanka
Rangaswamy Thara Schizophrenia Research Foundation, Chennai, India
Edgardo Juan Tolentino Jr. Makati Medical Center, Makati City, Philippines
Kalliopi Triantafyllou Department of Child Psychiatry, Medical School, National & Kapodistrian University of Athens, Athens, Greece
Professor Rachel Tribe Department of Psychology, University of East London, London, UK
Sotirios Tsiodras Department of Internal Medicine, Attikon University Hospital, National Kapodistrian University of Athens Medical School, Athens, Greece
Aneta Tunariu School of Psychology, College of Applied Health and Communities, University of East London, London, UK
Aina Basilier Vaage Department of Mental Health for Young Adults, and Refugees, Transcultural Centre, Stavanger University Hospital, Stavanger, Norway
Koravangattu Valsraj National Health Service, Amrita Institute of Medical Sciences, Kochi, Kerala, India and Manasvi, Kochi, Kerala, India
Michaella Vanore Maastricht Graduate School of Governance/United Nations University-MERIT,
Maastricht University, Maastricht, The Netherlands
Sverre Varvin Department of Health Sciences, Oslo Metropolitan University, Oslo, Norway
Antonio Ventriglio University of Foggia, Foggia, Italy
Lakshmi Vijayakumar Department of Psychiatry, SNEHA—Suicide Prevention Centre, Chennai, India
Eileen Walsh Helen Bamber Foundation, London, UK and Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
Cameron Watson Barts Health NHS Trust, London, UK
Jacqueline Weekers Migration Health Division, International Organization for Migration (IOM), Geneva, Switzerland
Joseph Westermeyer Department of Psychiatry, University of Minnesota and Minneapolis VAMC, Minneapolis, US
Kolitha Prabhash Wickramage Global Migration Health Support Unit, Migration Health Division, International Organization for Migration, UN Migration Agency, Manila, Philippines
Bex Willans Warwick Medical School, University of Warwick, Coventry, UK
Dawit Wondimagegn College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
Rebecca Yeo Department of Politics and International Studies, University of Bath, Claverton Down, UK
Stanley Yip Castle Peak Hospital, Hong Kong
SECTION 1 Background
1. Introduction 3
Dinesh Bhugra
2. Geopolitics of migration and refugees 19
Albert Persaud, Antonio Ventriglio, Koravangattu Valsraj, and Dinesh Bhugra
3. Political and institutional determinants of migration policies 29
Toni Ricciardi and Sandro Cattacin
4. Prejudice, ethnic discrimination, and double jeopardy in migrants 39
Cameron Watson, Edgardo Juan Tolentino Jr, and Dinesh Bhugra
5. Global cultures as a consequence of globalization of mental health 45
Driss Moussaoui, Vishal Bhavsar, and Dinesh Bhugra
6. Gender perspectives in migration 55
Rangaswamy Thara and Aarthi Raman
7. A psychosocial approach to working with victims of trafficking with means of sexual exploitation 63
Catarina Alves and Nadia Morales Gordillo
8. The new face of exploited children in Europe 73 Olivier Peyroux
9. Mental health needs of lesbian, gay, bisexual, and transgender migrants 81
Rebecca Hopkinson, Eva S. Keatley, and Joanne Ahola
10. Urbanization and its impact on migrant mental health 89
Layla McCay and Natalia Banulescu-Bogdan
11. Trauma and migration 97
Joanne Stubley
12. Collective trauma 105 Umaharan Thamotharampillai and Daya Somasundaram
1 Introduction
Dinesh Bhugra
Setting the scene: migrant psychiatry
Migration is a well-recognized global activity and phenomenon. People have been moving around the globe for millennia and have settled far away from their countries or place of birth. We are using the term migrant in this volume and this will include refugees and asylum seekers, although these are legal definitions and the purpose of migration will vary. The push and pull factors have been identified as leading to migration. Often labour or low-skilled migrants are pushed as a result of natural or man-made disasters or geopolitical factors, whereas high-skilled migrants are often pulled towards or attracted to generally high-income countries for better salaries, training, education, and better employment opportunities, and, consequently, higher standards of living. Migrants also help those left behind by sending money back and supporting through material goods and assisting in many ways. High-skilled migrants tend to be university graduates and/or may have specialist skills that are required in the receiving country. It has been shown in a large number of studies that migrants are more likely to demonstrate higher-than-expected rates of various psychiatric disorders, although at the same time they are likely to have better levels of resilience and well-being. An additional point that must be considered but is often ignored is the sense of belonging that feeds into identity development. Thus, for migrants, home can remain an imaginary place where one feels at home nowhere and yet paradoxically feels at home everywhere. This creates further tensions and problems in the acculturative processes and may influence where help is sought from while looking for health care and who the first point of contact is. In this sense, home is not a building or place, but the notion of belonging and being comfortable.
This chapter aims to set the scene for the discipline of migrant psychiatry using a number of approaches. Often, for migrants, their identity as a migrant tends to trump everything else. Thus, it is helpful to know not only their identity formation, but also micro-identities. Furthermore, racism and racial responses are specifically targeted at some part of identity, be it religion, gender, sexual orientation, or a combination of these. The basic principles of identity formation that affects all migrants and how their identity as a migrant can be abused and stigmatized and often trump other identities. We will also look at socialization and then offer signposting of the rest of the volume, using pointers as highlighted by the authors.
Identity formation
When studying the identity formation of migrants, including refugees and asylum seekers, it is clear that often this identity takes precedence over other identities. For example, often a migrant nurse or migrant doctor will be seen as migrant first and nurse or doctor second.
Erik Erikson (1) offers a clear and helpful model of identity formation and describes the theory of psychosocial development of the individual. These stages describe basic virtue and how that fits in with the development of an individual’s identity. He went on to delineate eight stages—five of which occur before the age of 18 years and the other three beyond this stage; personality develops in a predetermined order, building on each previous stage. Each stage, once completed successfully, leads to a healthy personality and the acquisition of basic virtues (which can be seen as characteristic strengths enabling the person to cope with any crisis). It is entirely possible that after migration, individuals and their families may well need to re-learn some of these stages. Theoretically, it is possible that in the first 18 years after migration, similar identity development stages may need to be traversed, which needs further exploration. His eight stages of identity formation are worth noting. Some of these stages are crucial for post-migration settling and each carries with it basic virtue, which can be linked with stages of migration and basic values such as hope, care, and love. This is not to compare migrants with children but to highlight stages of identity.
Theoretically, it is possible that a migrant may have to re-learn and manage these stages after migration, but perhaps at a faster pace. These stages are not discrete and may run into each other.
These post-migration features and stages can be related to and become a part of the acculturative processes.
Trust vs mistrust
For infants, this stage is important to confirm that their caregivers are trustworthy. The stability of these relationships and, to a degree predictability, will provide consistency of care and the individual infant will learn to trust. It can be argued that in the early stages after migration, the migrant may be looking for trust and support from parental authority figures. Such stability in terms of support and access to services will enable them to develop the virtue of hope confirming that if there were to be a crisis, others especially those in positions of power, will support and offer assistance. Thus, in a way, the early stages of attachments on the part of the migrant may well enable them to function effectively.
Autonomy vs shame
In this stage children start to assert their independence and it is important for parents to give them support and assistance, if needed, combining giving them independence with a level of protection without displaying anxiety or overinvolvement. If migrants are criticized or controlled, they may feel inadequate and resentful, affecting their self-esteem and contributing to a sense of alienation.
Initiative vs guilt
During this period children become more assertive and this may be misinterpreted as aggression. The tension is about getting the balance right, otherwise parents feel frustrated and the child may develop feelings of guilt. This stage, when applied to migrants, may not last long and may well lead to the virtue of purpose.
Industry vs inferiority
This stage after migration is likely to be incredibly significant for migrants. The children interact more with their peer group and look for receiving approval by demonstrating certain competencies, especially learning of language, which are valued by the society and the child starts to develop pride in their own accomplishments. If the migrants are acknowledged they too may start to develop a sense of accomplishment and competence.
Identity vs role confusion
In adolescents this stage provides them with the search for a sense of self, individuation, and personal identity through intense exploration of personal values, beliefs, and goals. Children are likely to become more independent, beginning to look at their future and material needs such as a career, housing, relationships, etc. In this stage, the adolescent learns the roles they have to play in the future and sexual and occupational identities come together. A similar stage for migrants is when they start to settle down and plan their own and their families’ futures. Fidelity as a virtue is the result of this stage.
Intimacy vs isolation
This stage focuses on forming intimate and loving relationships with longer-term commitments. Success at this stage leads to the virtue of love. For a migrant this is, perhaps, the most adult and stable stage that can help them accomplish things.
Generativity vs stagnation
This stage involves people making their mark on the world, feeling useful, and having a proactive role in community activities, etc. Success in these domains inevitably makes a person feel valued and raises their self-esteem. It can be argued that finding a way to contribute to the larger good makes individuals feel useful and successful, otherwise individuals can become stagnant and stale.
Ego integrity vs despair
This stage begins around the age of 65 years and helps the individual to accept their life and achievements in a coherent and holistic way. Success in this stage will lead to the virtue of wisdom. These stages are descriptive and are not dissimilar to some stages in Hindu scriptures, where an individual is expected to spend the first quarter of their life in celibacy, the second quarter devoted to family, the third quarter dedicated to the community and society,
and the final quarter to broader precepts of life by giving up material things.
Identity formation
Before we explore the identity formation of migrants it will be helpful to briefly describe the process of how identity is formed and how individuals re-socialize. Identity refers to not only how others see us, but how we see them seeing us. The basis of identity is the concept of the self and its relationship with society. We know that concepts of the self vary across cultures, from egocentric to sociocentric, and then other dimensions outlined by Geert Hofstede (2) start to play a role too. Self is the primary component of the identity formation process. Erikson’s model, described earlier, offers one approach. The relationships between the mind and the self and interactions with society are critical. Identity has been described by Sheldon Stryker (3) as the social position that the self not only possesses, but more importantly internalizes. However, such an internalization will be influenced by a number of social and psychological factors.
Identity formation begins with a process of self-categorization in which the individual realizes and internalizes the roles they are expected to take on and perform. Thus, in some ways identity relies on others’ expectations of the individual. Combined with child rearing, which is strongly influenced by cultural values and practices, selfidentity formation takes place. Both cultural factors and internalized factors will play a role in the formation of identity.
It has been argued that the process of identity formation begins with a self-categorization in which individuals realize and normalize the roles that are expected of them (4), and after an incorporation of their selves with these identities an interaction with other identities, as well as structures, begins (5). These authors go on to suggest that with such an interaction, the identities start recognizing the existence of identities of others, as well as other structures, and a positive relationship can begin. The nature of the group then can influence the identity and the individual can then become the reference point for the individual’s identity. Thus, re-socialization into total institutions and changes in identity can be explained and understood in such a context.
McCall and Simmons (6) propose that the process of identity formation begins with the realization by the self about the roles that have been assigned to it by the self, as well as by the society and/ or the group the individual belongs to or might wish to belong to. They describe a hierarchy of prominence with three factors: the degree of support the self receives from others to shape the identity; the degree of the self’s commitment to the identity they accept; and the degree of extrinsic and intrinsic rewards given by structures and other identities. Higher levels can reflect higher amounts of social acceptance, which will also influence higher levels of internalization of norms of the group. Thus, if an individual is offered a higher role, they become more committed to the cause of the group because their identity is strongly influenced by relationships with others. For a migrant, the process of fitting in or being excluded from the larger group will influence not only how they perceive and then interact with the main group, but also within the group they belong to, as some of them may have better connections with the main group, thereby creating a multi-tier group. Identity formation has to be seen as a dynamic ongoing process so that individuals may have flexible identities in some aspects, but somewhat rigid identities in
others. Thus, identity has self-identified, other-identified, self- allocated, other-allocated, and self-generated roles.
The multiple or micro-identities offer an interesting way forward in understanding identities as some of these micro-identities get ignored and others get prominence at different times. For example, gender or religion may take precedence over other, less obvious identities. Individuals gain their meanings through multiple or micro-identities.
Multiple or micro-identities
There is little doubt that all of us have multiple or micro-identities. Multiple identities have been described as being positive for the individual in that these provide alternate solutions to problems in daily life and allow individuals to function better. As Thoits (7) and Linville (8) suggest, multiple identities give meaning to what is happening around the self. There is no doubt that identity formation is almost completed in adolescence, but it may continue in adulthood and beyond, as described by Erikson. The identity of a migrant as a migrant often trumps all other micro- or multiple identities. Even rich migrants carry this with them; for example, rich Russian oligarchs are described thus. Marcia (9), building on Erikson’s model, describes two dimensions—an exploration of developmental alternatives in various salient identity-defining domains and selection of alternative, as well as engaging in, relevant activities towards the implementation of these choices. Thus, for a migrant, the status of being a migrant will differ from that of a refugee or asylum seeker and in line with labelling theory, such labelling will encourage them to behave as a migrant or refugee or asylum seeker. However, identity formation has been described as involving changes to identity that are characterized by progressive developmental shifts (10, p. 355). Thus, the formation of identity after migration should be of great interest to researchers. Often in such cases, identity as a citizen tends to take precedence over any other micro-identities. The question of whether identity is stable or prone to change cannot be answered by an either/or phenomenon. It is entirely possible that some components are more stable than others. Thus, it is likely that there exists a hierarchy of identities. Development of profile similarity will be of particular interest in the context of the process of acculturation. This may be to do with attitudes and behaviour in a number of parameters. Thus, wearing similar clothes, changing language style and accent, and also diet, etc. would reflect developing profile similarity.
If we see identity formation as a search for a new sense of sameness and continuity in order to avoid role confusion as described by Erikson, it becomes relevant that migrants will need to find that sense of sameness and continuity in their identity in the context of acculturative behaviour and resulting stress may reflect pressures on identity. As noted earlier, Marcia (9) distinguishes processes of commitment and exploration in identity formation where commitment reflects whether individuals make choices and stick to these. However, exploration refers to comparison of different possible commitments prior to making a choice. Therefore, migrants may need to learn to gather new commitments and give up some older ones, and the tension between the two may contribute to a sense of bewilderment. Even making choices is not easy for migrants as they may not be cognizant with all other options and choices. Crocetti et al. (11) add a third dimension, which is about reconsideration (where the individual questions current commitments and considers alternatives). Luyckx et al. (12, 13) propose five dimensions.
Commitment is split into making and identification with commitment, whereas exploration is divided into exploration in breadth and commitment making. In some individuals nominative exploration is of interest because it refers to ‘endlessly mulling over what direction to pursue in life, without coming to a satisfying solution’ (14). The identity formation cycle and identity evaluation cycle are both important and may provide an overlap.
As Waterman (10) has noted, the individual’s sense of identity strengthens as they grow older, so where does this leave the migrants? It has been suggested that levels of reconsideration (low levels of stable identity) increase between the age of 12 and 16 years (15), so how is this likely to impact upon young migrants? Thus, establishing a sense of stability can be quite important. The linkages of identity formation with externalizing behaviours (such as aggression, delinquency, and substance abuse) and environments in general need further detailed research. Furthermore, as identity formation is influenced by relationships, the migration of individuals may well be different from those who migrate as a family and, not surprisingly, their post-migration identity formation may well differ, and this must be explored further. Conflicts with friends have been shown to negatively influence identity in adolescence (16); therefore, it is entirely possible that post-migration adjustments (if faced with conflict or rejection by peers and/or the new society) may lend to problematic behaviours.
In the period of post-migration, the question of ethnic identity deserves further exploration. Among various factors mentioned are environmental, as well as personal, factors. John Hewitt (17) suggests that personal identity offers a sense of continuity, integration, identification, and differentiation constructed by the individual in relation to the self and not (necessarily) to the community. However, it is likely that after migration there may well be a sense of discontinuity, which may require a period of time to recover from. Such a rupture in continuity is likely to create a sense of bewilderment, bereavement, shock, and conflict, and may well take a significant period of adjustment in the new society and environment. Integration into the new culture may follow at its own pace or the individual may choose to remain bicultural. Such a decision is (a) often not a single snap decision, but a step-wise one; and (b) will be influenced by the individual’s community, peers, and kinship along with members of the new community.
Cinoğlu and Arıkan (5) question the manner in which identity may change and this is related to values that they argue are subject to change and help formulate the new identity. There is no doubt that personal identity moulds and is shaped by other identities and behaviours (18, p. 22). For example, identity as a worker or an employee gives a sense of satisfaction and contentment and may well mean that when local laws prohibit refugees from working with underemployment as a major issue (19), the number of migrants moving in and out will vary (20), thereby raising further external factors affecting fluidity of identity.
Analysing cultural and migrant identities
Identity Structure Analysis (ISA) refers to the structural representation of an individual’s existential experience (21). It is based on understanding of the relationships between self and other agents organized in a stable way over a period of time, but which change in response to new experiences (22–24). Social, economic, political, and technological factors impinge upon the overall well-being of
