Dr. Alarcón is Emeritus Professor and Consultant, Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, and Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Perú.
One of the most powerful social phenomena during the past 2 or 3 decades is, without a doubt, the continuous and seemingly unstoppable growth of the migration of millions of people across practically all countries, regions, and continents of the world. It is said that nowadays about 5% of the world population is made up of migrants. While technological advances provide the physical machinery pushing globalization ahead, migration represents the heterogeneous human component of this process—the dramatic mix of realities, decisions, collisional emotions, expectations, and uncertainties that constitute life on our planet. And as with any other human enterprise, cultural assumptions are challenged and different behaviors and potential psychopathologies emerge among all involved—migrants and hosts.
There are innumerable lines of reflection about this topic. The following paragraphs attempt to outline 10 of them—examining points of conflict or contention, special aspects of the migratory process, mental health and eventual public policy issues—from a cultural psychiatry perspective. The conceptual connections may appear obvious at times, complex or distant at others. They are, in any event, invitations to think further and explore ways to, at least, be capable of asking better questions.
1 It goes almost without saying that migrant groups or populations differ in terms of reasons, procedures, and outcomes of their experience. International agencies make clear the distinctions between migrants proper, displaced people, and refugees. The first may be the standard migrants, those who decide to leave after a rational and reasonable deliberation process dictated by occupational, professional, or financial factors, and implemented through legal channels. Displaced people are almost always forcefully “pushed out” from their usual location, many times within their own country or region, by violence (civil war, crime, terrorism, political upheaval), natural disasters, or social restlessness. Refugees are people who, having concluded that they are not compatible with the political regime, go through an established bureaucratic procedure to materialize their departure. It is clear that the emotional climate of discussions between individuals and families of these 3 kinds of migrants follows different routes and may create pathogenic conditions of varying cultural facture.
2 There are also internal and external migrations. The former occurs within contiguous geographic zones, usually in the same country. Internal migrants move from untenable to more tolerable situations, generally out of fear or in an almost desperate attempt to prevent worse developments. Typical examples are seen in countries that became true civil war scenarios (ie, guerrilla groups fighting government forces in countries like Colombia, Peru, Congo, or Cameroon). External migrations take place when international borders are crossed. Again, the psychological contexts of these 2 types of migrations are different—the sense of loss, fracture, disruption, frustration, impotence, rage, or hopelessness may reach deeper or broader levels, carrying a variety of psychopathological consequences.
3 The acculturation process, that is, the immigrant’s level of acceptability and adaptability of the host society’s habits and traditions is an important phase of the migratory experience. Social scientists speak of a fluid, mild or moderate, delayed or rejected acculturative phase—each one with potential implications of emotional stability or conflict. Occasionally, a “new” culture or sub-culture evolves out of this process. The strength of the cultural legacy brought in by the immigrant and his or her family is a key factor that results in flexibility or rigidity, adaptation or alienation. Obviously, the host society’s receptivity and attitudes toward the new neighbors are another decisive factor with outcomes of integration or rejection and their respective behavioral or clinical expressions. Acculturative Stress or Acculturation Problem are diagnostic labels included in the current versions of DSM and ICD.
4 Diagnostic issues have strong cultural implications when applied to migrant populations. A crucial topic is the validity of diagnostic criteria used in the host country vis-a-vis the clinical pictures displayed by the newly arrived. Specific behavioral, symptomatic, or syndromic presentations (ie, cultural syndromes or cultural concepts of distress, according to DSM-5) must be carefully explored in order for clinicians not to fall into stereotyping or plainly stigmatizing labeling. The use of instruments aimed at an objective estimation of cultural identity, help-seeking patterns, and explanatory models are mandatory for an objective clinical evaluation.
5 What is the most frequent psychopathology observed among migrants? It may not be PTSD, although it is indisputably the most dramatic and pervasive one. Depressive and anxiety-related disorders, a good number of them in the context of “situational” or “adjustment” conditions, abound. The causative pathogenic chain is understandable: feelings of loss, grief, panic, hopelessness, and helplessness sometimes prevail against culturally based protective factors. A growing prevalence of substance use disorders, particularly in younger members of migrant groups (some of them creating “gangs” that convey, in many cases, a self-protective as well as an aggressive message), is also a result of the loss of individual and family control, a search for unknown “solutions,” or desperate evasive modes. Physical concomitants, frequently seen in these fragile human groups, make the situation worse. A careful, comprehensive health assessment is vital.
6 Clinical epidemiology studies may show some intriguing results. One of them from the 1970s was the then-called “Hispanic Paradox,” the finding of a lower prevalence of mental disorders among Latino immigrants compared with similar groups of American probands. This went clearly against the usual assumption, documented by earliest studies among Scandinavian immigrants. The initial explanation was a self-selective process: immigrants-to-be, those capable of deciding to leave the country of origin, had to be the physically and psychologically strongest and healthiest to successfully face the new realities in the host country. An indirect confirmation of this was the finding of increased percentages of mental illness among second-generation immigrants’ children, at levels very similar to those of American-born individuals; this led the media to half-jokingly comment that “living in America makes people sick.” Nevertheless, the “paradox” was later questioned on the basis of different nativities and sociodemographic, family, and cultural characteristics that better explained epidemiological findings in Latino sub-populations.
7 Immigrant subgroups particularly vulnerable to the distressing adversities of the experience are those of special subpopulations such as children, adolescents, women, and the elderly. Victims of neglect or abuse (ie, the dramatic cases of violation of women users of “The Beast,” the train that transports migrants from Central America and Mexico to the US border), exploitative financial charges by “Coyotes” (individuals who take the immigrants through the border, only to abandon them after they reach an unknown or unfamiliar town in America), and the case of children who make the journey by themselves are situations of potentially profound emotional damage. This feature of the so-called “culture” of the migratory experience is not different in many refugee camps in the Middle East, Asia, and Eastern European countries.
8 The establishment of public health policies, with strong recognition of culturally based factors (risk promoting and protective) involved in the abusive situations described above, must be a matter of concern for national governments and international organizations, beyond emotional pronouncements of help or refusal. Even more, the translation of policies into definite actions (from helping or Assistance Homes to competent health and mental health personnel in hospital or community-based institutions) and preventive or early intervention measures, communication, and coordination with potential employers are indispensable steps. These arrangements require the will and determination of the highest governmental spheres of the countries involved.
9 The treatment of declared cases of psychopathology must be equally prompt and efficiently implemented. Community psychiatry care seems to be regaining an advantageous position in terms of policy-driven material and human resources. From the clinico-cultural perspective, close emergency medical and psychiatric consultations; availability of essential medications; and individual, family, or group psychotherapies are also critically important. Interpreters, culturally trained psychotherapists, and the use of specific cultural psychotherapies (if available) must be substantial components of a comprehensive management process.
10 In addition, most if not all of the requirements listed above necessitate the harmonious development of medical and psychiatric education norms at all levels. General and mental health professionals who work with migrant populations would benefit from education that includes topics such as globalization (and its primary components of global health and global mental health), cultural psychiatry (including diagnosis, treatment, and prevention), and the various links between migration and psychopathology. This type of training, in turn, would make possible the work of multidisciplinary teams that better understand the dynamics and expectations of migrants and help them to quickly integrate into the new environment. Preventive concepts could extend to the desirable possibilities of peaceful, mature, and durable political evolvements in the countries and regions where today’s waves of migrants come from.