Migrations, acculturation, cultural adaptation
Migration to cities, which in the past, was mostly intranational and more recently transnational, has increased dramatically over the past few decades. Most migrants come from rural areas, bringing values, beliefs, and expectations about mental health that are often very different from the ones they encounter in their new location. In many instances, people coming from rural areas have endured years of isolation, lack of technologic connection, poor health, poverty, unemployment, and inadequate housing.¹⁰ They need to acculturate and adapt not only to a new challenging urban environment but also to alternative systems of symbols, meanings, and traditions.

Khoa and Van Deusen,¹¹ in their study of communities with different traditions and customs, describe 3 patterns of acculturation.

• Rejecting pattern: often noted in elderly immigrants, characterized by the unwillingness to adapt to the new cultural reality.
• Assimilative pattern: frequently seen in young persons, in which the immigrant embraces the new culture.
• Bicultural pattern: the immigrant is able to integrate cultural values from the 2 cultures.

The rejecting and assimilative patterns can often be fraught with isolation, anxiety, and confusion about identity. Biculturality, on the other hand, has been seen as leading to more adaptive outcomes by reaching a compromise in a process of acculturation between 2 contrasting cultural identities. Effective mental health care of immigrants needs to consider the impact of cultural frictions on their lives. An increasing number of people that are migrating to cities are refugees from other countries (approximately 18 million worldwide), with a significant number suffering from posttraumatic stress disorder (PTSD) and other disorders. Westermeyer¹² has comprehensively and prospectively studied a large number of east Asians at the center for refugees in Minneapolis. The findings from one 10-year study show that some of the refugees' symptoms, such as depression, low self-esteem, phobia, and somatization, improved; however, other symptoms, such as paranoid and anxiety disorders, tended to persist and often interfered with the process of acculturation.

As indicated by Kirmayer,¹³ it is important for the clinician to recognize the wide variety of meaning that different cultures assign to manifestations of distress after a traumatic experience. For example, in many cultures, dissociation and somatization are considered normal reactions to a traumatic experience. As a rapidly growing number of traumatized refugees form war-torn areas move to cities, mental health professionals need to become attuned to the cultural aspects of PTSD.

Major Urban Problems
Violence Violence, an endemic reality for most cities in the world, is estimated to claim at least 3.5 million lives a year. The burden of injuries related to violence is a significant public health issue. A glaring example of how social tensions due to social polarization lead to urban expression of aggression comes from the South American and Caribbean regions, where the highest rates of homicide and criminal victimization in the world are found. In a World Bank study, Moser¹⁴ has demonstrated that increasing inequalities in urban areas in 4 Latin American countries were associated with increases in youth, gang, and community violence.

Children and women are especially vulnerable to interpersonal violence in urban areas, especially in developing countries, where cities are populated by a large percentage of children and adolescents. By 2025, 6 of 10 children will live in cities. As a result of rural- urban migration and high fertility rates, it is estimated that about 50% of the urban population in developing countries is younger than 25 years, and in Latin America, 35% of the population is younger than 14 years. In addition, there are approximately 30 million street children worldwide, and most of them are involved in illegal activities in urban areas.

Violence against children and among children is a growing urban phenomenon. Often, cultural norms determine the form violence takes and its acceptance by the urban community. Culture-specific parental attitudes towards corporal punishment range from it being viewed as child abuse to it being considered part of a healthy upbringing. A study by Baron and Straus¹⁵ in the United States found a correlation between cultural norms and extreme forms of violence. Huesmann and Guerra¹⁶ demonstrated that mass media also significantly influence children's beliefs about what constitutes accepted violence.

Children and adolescents in socioeconomically deprived urban areas are often drawn to gangs. Although not exclusively an urban phenomenon, gangs thrive in inner cities where degradation, poverty, drug use, and unemployment result in an explosive blend favoring violent solutions.

The rules and behaviors of gangs vary considerably from culture to culture and even within the same culture. They exist in 3300 cities across the United States and account for an important percentage of crime. Some gangs have morphed into powerful transnational organizations that take advantage of the hypermobility of members and their culture. Glamorized by music and the media, gangs frequently control entire cities and their communities. Given the considerable impact of gangs on physical and mental health in urban areas, it is important for mental health professionals to familiarize themselves with their code of ethics and normative rules, as well as their relationships with the community.

Domestic violence is also highly prevalent in urban areas. In both developed and developing countries, women living in urban settings are at greatest risk to be assaulted by intimates.¹⁷ The multiplicity of roles women play in society, including sexual, reproductive, marital, and family, makes the multidimensional phenomenon of violence against women heavily influenced by cultural beliefs. In addition, women have a subordinate role in many cultures that renders culturally sanctioned violence more likely to be accompanied by coercion, humiliation, and deprivation. Social support and the presence of close relationships appear to be protective against violence. Conversely, poor social relations are associated with poor health outcomes.