The Stranger in Our Midst

Psychiatric TimesVol 33 No 11
Volume 33
Issue 11

These few stories of refugees remind us what a stress to one’s sense of self the immigrant experience entails. They emphasize how important this perspective is when we are asked to evaluate and treat those recently here in the US, and sometimes those who have been here for a generation.

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You shall not oppress a stranger, for you know the feelings of the stranger, having yourselves been strangers in the land of Egypt.

You shall not subvert the rights of the stranger or the orphan, remember you were a slave in the land of Egypt.

When strangers reside with you in your land, you shall not wrong them . . . You shall love them as yourself.

Like many people in the US, I’ve been thinking a good deal over the past months about immigration. It’s hard not to because the topic has been one of the political firebombs of the 2016 presidential campaign. With what is widely reported to be the largest worldwide migration of people in the recorded history of the world, the issue will be with us for many years, no matter who has won the election. But, I’ve been reflecting more on the personal aspects for the immigrants and their families rather than the political.

All 4 of my grandparents came to the US from Europe in the years that led up to World War I. I especially remember hearing about my grandmother on my mom’s side. She was sent from what was then Russia by her mother after her father had disappeared and was assumed to have been murdered in an act inspired by extreme religious persecution. My grandmother left for the US at age 16, alone and speaking no English, bound for Kansas City, where cousins lived. I never tired of hearing about how, knowing no one on the ship, scared, and hungry, she was befriended by a man who shared with her his large bunch of bananas. As I heard in repeated telling, she pretty much ate nothing but those bananas during her entire voyage to the US. I’ve often tried to imagine what that experience was like and how it affected her.

This past summer I saw 2 plays that further stimulated my thoughts. The first is a work in progress called Queens, as in Queens, NY, by Martyna Majok, a young playwright who came to the US from Poland. Her play focuses on the lives of 6 young women immigrants, all of whom have come recently to NY, all of them alone and with few resources other than their ambitions. Although an unfinished work, it illuminates a critically important aspect of the immigrant experience: that in coming to a new country, even if motivated by a striving for a better life, everyone gives up multiple important aspects of their identities-of their psychological selves. The characters reveal that creating a new sense of self is a core psychological process for the recently arrived immigrant.

The second play, also a work in progress commissioned by the Public Theater in NY, is by the young hip-hop artist born in Somalia, Keynaan Cabdi Warsame, known by his stage name, K’naan. When he was 13, he and his mother came to NY where they lived for 6 months until moving to Toronto. Before the performance started, he told the audience his work clearly had been informed by some of his own traumas, including the death of his closest childhood friend just days after K’naan left Somalia.

K’naan’s play concerns 2 young adult friends from Somalia who come to NY. The story takes place during the political upheaval in Somalia that caused not only his family, but tens of thousands of others to leave Somalia. A key driving force of the plot focuses on what can only be called a traumatic de-idealization. This occurs in the play when one of the character’s idealization of the US as a land of milk and honey is quickly shattered by his personal experience of being a stranger in a strange land. Similar to the other play, this one focuses on the personal experience of the immigrant.

Finally, as I was returning to the airport to fly home at the end of a work trip, I learned the man driving my taxi was an Ethiopian refugee. A married father with a young son, he left Ethiopia with his family to escape the devastation and poverty there with high hopes for a better life. In our nearly hour-long conversation, he talked about his hopes and aspirations but also about his frustrations and periodic despondency. A trained and certified accountant with a good job in Addis Ababa, he told me that unlike refugees from certain other countries, he has no source of US government support. To support his family, he has had to drive a cab, and he cannot take time off from work to re-train to meet US licensing standards. He represents another large group of immigrants with frustrated dreams and fragmented identity.

We don’t hear much, if any, discussion of these aspects of the immigrant experience in the current public discourse. We’ve all seen so many pictures in the media of the desperate, shocked, or vacant-appearing expressions on the faces of those who have risked everything they know to leave their home lands. We’ve seen so many of these newscasts that people have come to think of the immigrant experience in terms of a heart-rending event: a family member dying on a sea voyage, being turned away at a border, living in a squalid refugee camp. It’s not just the events themselves that are on my mind but these families’ experiences of them that occupies my thoughts.

Too often, our over-stressed mental health care system can barely accommodate the refugees seeking our help-likely only a small fraction of those in need.

I’ve focused on telling you these stories with the aim of reminding all of us what a stress to one’s sense of self the immigrant experience entails. And, to emphasize how important this perspective is when we are asked to evaluate and treat those recently here in the US, and sometimes those who have been here for a generation. There are so many things that make up one’s sense of self: country, friends, family, culture, customs, work, heroes, and our home itself, just to name a few. Nearly all of these, and in many cases, all of these, are lost when someone leaves his or her homeland. And, these losses are magnified when the migration occurs under conditions of duress.

Too often, our over-stressed mental health care system can barely accommodate the refugees seeking our help-likely only a small fraction of those in need. As is too often the case, there are many impediments to making the core focus of treatment the individual’s fragmented self. The problem is not just because we are so busy. I’ve seen recent immigrants from countries in the Middle East, the Horn of Africa, and Latin America in our clinic, all of whom were severely depressed and anxious, many of whom were likely suffering from violence-related PTSD. They could all have potentially benefited from psychotherapy, which was available, but almost all refused treatment-often because of culture, customs, and language impediments.

Recently I saw a woman who was severely depressed and despondent, but for whom no medication had been helpful. On multiple occasions, against the urging of her husband who was her translator, she had refused our offers of psychotherapy. Her husband, desperate for help, was taking her back to Iraq, in hope that seeing old friends and family would alleviate the pain of the death of their young son who had been killed by Isis just before the family was to leave for the US.

The outcome was better when I evaluated a Spanish-speaking woman who was severely depressed after 2 family members were murdered in her home country. Even my rusty Spanish was enough for her to feel an alliance with me, something that had not occurred with English-speaking clinicians, and which seemed increase her willingness to talk through her reactions to the traumas she had experienced.

In the 1970s, the psychoanalyst Heinz Kohut1 became well known for his emphasis on the psychological importance of what he called the cohesive self, made up of multiple components of identity and self-regulating capacities. He asserts that stress, loss, physical harm or illness, and psychological injury to one’s self-esteem could all cause a psychological decompensation and produce what he called a fragmentation of the self.

Depression, anxiety, and rage were all symptoms of this decompensation. To him the primary goal of therapy was to help reestablish a cohesive self, which included the ability to be self-aware, self-reflective, and self-regulating. He viewed all of these capacities as essential for normative adaptive functioning. One doesn’t need to be a psychoanalyst to know how important this perspective is for understanding some of the psychological problems in today’s immigrant populations and for being able to develop effective treatments.

When an acute loss of multiple aspects of identity is paired with the trauma experienced by many immigrants before, during, and after fleeing from their countries, the psychological toll is immense. It takes uncommon psychological resilience to cope with these factors without suffering severe and disabling distress.

I hope many of you who have insights to share about effective treatment approaches to dealing with this public and personal health nightmare will post comments on our website in response to this column. Perhaps in this way we can better help each other learn more about the most effective treatment approaches and foster a profession-wide discussion and promulgation of new programs and protocols.


1. Good Heinz Kohut (1913-1981). Accessed October 5, 2016.

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