Psychotherapy with Immigrants
Mubasher Naseer
It is estimated that in 2015, there were close to 244 million international migrants and 16 million refugees, not including Palestinian refugees (Migration Policy Institute, 2017; Pew Research Center, 2017). Increasingly, mental health professionals have been called upon to address the unique needs of immigrants and refugees. Despite a long history of neglecting sociocultural dimensions of intrapsychic and interpersonal experience within psychoanalysis, contemporary scholars recognise the importance of examining the diverse experiences of immigrants and refugees and the role of culture, language, race, gender, ethnicity, social class, and intersectionality in the psychotherapy process (Ainslie et al., 2013).
Despite the existence of significant research on the mental health care challenges of migrants, particularly refugees and asylum seekers, less attention has been paid to treatment approaches. Below is a brief review of the psychodynamics of the immigration process.
Immigration from one country to another is a complex psychosocial process that affects an individual’s personality. The dynamic shifts resulting from an admixture of cultural shock and mourning over the losses inherent in migration gradually give way to psycho-structural change and the emergence of a hybrid identity. Leaving one’s own country involves profound losses. Often, one has to give up familiar food, native music, unquestioned social customs, and even one’s language. The new country requires individuals to adapt to an unfamiliar language, visually different landscapes, new festivals, music, heroes, psychically unearned history, and social and political concerns. However, alongside the various losses is a renewed opportunity for psychic, educational, and economic growth. New channels of self-expression become available. There are new identification models and different ideals—immigration results in a sudden change from an “average expectable environment” (Hartmann, 1950, pp. 113-141) to a strange and unpredictable one. This process, though challenging, also presents a unique opportunity for personal growth and development, fostering a sense of resilience, adaptability, and optimism that can inspire us all.
Factors Affecting the Outcome of Immigration
The anxiety consequent upon this “culture shock” (Ticho, 1971; Handlin, 1973; Garza-Guerrero, 1974) challenges the stability of the individual’s psychic organisation. Another threat to it is the mourning over the losses inherent in immigration. The coexistence of culture shock and mourning causes a severe shake-up of the individual’s identity. Integration into the new culture requires the immigrant to give up part of their individuality, at least temporarily. Since moving from one location to another involves the loss of country, loss of friends, and loss of previous identity, the dislocation experience may be examined in terms of the immigrant’s or the refugee’s ability to mourn and resist the mourning process. The extent to which the individual can intra-psychically accept their loss will determine the degree to which an adjustment is made to the new life.
Many factors determine the psychological outcome of immigration (Park, 1928; Brody, 1973; Favazza, 1980; Grinberg & Grinberg, 1989; Waters, 1990). One of the most important factors is whether immigration is temporary or permanent. Second, the degree of choice in leaving one’s country also affects the subsequent adaptation. In this context, it is noteworthy that parents may be voluntary or involuntary emigrants. Still, children are permanently exiled: they are not the ones who decide to leave and cannot choose to return to their country of origin at will (Grinberg & Grinberg, 1989, p.125). Understanding the role of choice in immigration can foster empathy and a deeper understanding of immigrants' psychological challenges and the importance of choice in their journey.
Another significant point is the time to prepare oneself to leave a place. A sudden departure precludes anticipatory mourning and might complicate subsequent adaptation. The possibility of revisiting the home country affects the outcome of the migratory process. Those who can quickly and frequently visit their country of origin suffer less than those barred from such emotional refuelling. The effects of immigration on identity might differ in intensity with the age at which immigration occurs. Children, for instance, are more open to learning and adapting to the new environment and, as a result, are less traumatised. At the same time, their dependence on caretaking adults who are psychologically stressed might render them more vulnerable.
Furthermore, the reasons for leaving one’s country also play a role in determining success or failure in adapting to the new environment. The reasons for escaping one’s homeland also play a significant role in success. Regarding external reality, was it an individual fleeing financial hardship, political persecution, or ethnic strife, or was one heading toward new opportunities or broader horizons? The emotions with which the host culture receives the migrant also play a role in the latter’s assimilation and associated identity change. The complexity of these reasons and their impact on the immigration experience is a crucial aspect to consider.
Context of Migration
A psychodynamic understanding of the impact of migration on individuals and communities considers the distinct pre- and post-migration contexts of immigrants and refugees. Specifically, refugees migrate because they are forced from their homes due to war, political, religious, ethnic persecution, and environmental disasters. Many refugees are displaced and relocated multiple times before reaching their final destination of resettlement (APA, 2012). They are at high risk for severe physical, sexual, and emotional trauma and, at times, for torture, and they may have lived in several refugee camps before arriving in their adopted country (APA, 2010; Robjant et al., 2009). In contrast to refugees, adult immigrants typically have a choice in leaving their birth countries. The reasons for migrating to a new country are varied, such as fleeing poverty and political and social unrest, seeking educational and employment opportunities, and reuniting with family members (APA, 2012). The premigration context of immigrants, like that of refugees, can involve experiences of interpersonal, social, and political trauma, which may be the impetus for the decision to migrate (Ainslie et al., 2013).
The psychodynamic perspective on the migration process emphasises the full range of intrapsychic, interpersonal, and social experiences that involve complex affective states. Many immigrants and refugees experience various types of anxiety, such as separation anxiety, disorienting anxiety, and depressive anxiety (Akhtar, 2011; Grinberg & Grinberg, 1989). Akhtar (2011) has described in detail the detrimental effects of environmental change and loss of familiar objects on an individual’s ego, such that feelings of disorientation and regret may overwhelm an initial sense of excitement when the person encounters a new, unfamiliar physical and cultural landscape. Anxiety, sadness, confusion, and grief may coexist with feelings of hope and optimism among immigrants and refugees. Further, experiences of psychological distress coexist with individual and collective resilience among these individuals and communities and shift over time and context (APA, 2012).
Acculturation
The following section discusses two aspects of the acculturation process: family life and social location.
Immigrant families often face new challenges, as the structure of the family and the functions of different family members can change, sometimes, dramatically. Gender roles can be transformed in some families after migration in ways that affect the day-to-day lives of parents, children, and extended family members such as grandparents. Often, immigrant parents struggle with observing and helping their children navigate the adopted countries’ cultural context and, at the same time, retaining their cultural, religious, and linguistic heritage. Immigrant parents tend to rely on other immigrants of similar ethnicity in negotiating parenting in the adopted country, as similarities in language, culture, food, and religion bring a sense of security and emotional refuelling (Akhtar, 2011). For many immigrants and refugees, there is a strong desire to pass on the heritage culture as a way of maintaining a sense of cultural continuity and connection with the people in their former country from whom they are separated.
Parents’ conscious and unconscious affective experiences of migration, experiences of oppression, cultural attachments, and wishes and fears accompanying migration and separation from the country of origin are transmitted intergenerationally and internalised by children (Eisold, 2012; Saketopoulou, 2015; White, 2015). Importantly, cultural perspectives transform for parents and children throughout the lifespan, re-engaging old and presenting new intrapsychic and interpersonal conflicts. Children of immigrants and refugees struggle with their parents’ dreams and aspirations as they recognise their parents’ resilience in surviving obstacles of reaching the new country and coping with an unfamiliar context. On the one hand, the second generation is driven to attain what their parents were unable to access; on the other hand, they look to engage in the dominant culture beyond the constraints of their parents. Parents’ and children’s unique acculturation trajectories can contribute to intergenerational conflicts, which can be a source of stress for family life and individual psychological health (Sherry & Orenstein, 2014). Conflicts and external demands of acculturation (e.g., adjusting to workplace or school, racism) are usually left unspoken within the home and remain invisible to people outside the house.
Social Isolation
Immigrants and refugees experience significant shifts in social isolation as various aspects of identity, such as those related to gender, race, ethnicity, religion, language, social class, physical disability, and immigration status, carry different psychological meanings and social consequences in the adopted country. The implications of social location can be considered through an examination of social mirroring, which is a concept that extends Winnicott’s (1971) conceptualisation of mirroring to describe the range of messages received by immigrants outside of their homes, particularly in the dominant culture. When immigrants and refugees experience postmigration contexts as accepting of their ethnic, linguistic, and religious heritage, they have access to a broader range of choices about acculturation and identity development in the new country. However, negative messages regarding their social location (e.g., race, culture, gender, religion, social class, disability, national origin, and immigration status) constrict the range of options, contributing to defences that promote isolation, invisibility, and resentment toward the dominant culture.
Bicultural and Bilingual Identity
Identity development among immigrants and refugees involves negotiating the physical and psychological distance between the country of origin and the adopted country (Akhtar, 2011). The negotiation consists of using various defences, including splitting (idealisation and devaluation) of one’s country of origin and/or adopted country, withdrawal (affiliation only with one’s cultural group), and counterphobic assimilation (development of an “as-if” identity in which one rapidly identifies with the host culture (Akhtar, 2011; Lijmaer, 2001) These defences are central to the immigrants’ and refugee’s sense of psychological home, a point of reference that can shift across the life span (Tummala-Narra, 2009).
Some psychological theories assume a linear process in the development of acculturation and cultural identity; psychoanalytic theories assume a dynamic, fluid understanding of cultural identity (Tummala-Narra, 2016; Yi, 2014). Cultural identity for immigrants and refugees is a culmination of psychological connections with the family, cultural groups, language, and physical environment (e.g., country of origin, dominant society); intrapsychic and interpersonal conflicts; unconscious wishes and fears; and defences adopted to navigate multiple, contradictory cultural, linguistic, and physical spaces and belief systems. Cultural identity is also considered a dynamic process that transforms the psyche and interpersonal relationships across the lifespan. Cultural beliefs and practices shift across context and time, shaping and reshaping one’s sense of self and others.
Conclusion
Working with immigrants and refugees in psychodynamic therapy involves engaging with multiple layers of intrapsychic, interpersonal, and sociocultural experiences, which shape identity, relational life, and psychological well-being. The heterogeneity of experiences among immigrants and refugees stands alongside shared experiences of separation, loss, and trauma. Cultural change, identity, and relationships are negotiated in adaptive and maladaptive ways, mainly in the unconscious, across the lifespan. Psychodynamic psychotherapy offers a critical space for immigrants and refugees to mourn separation, loss, trauma, and discontinuity and to bridge cultural experiences and transform identity. The therapist is uniquely positioned to become attuned to multiple cultural narratives and aspects of identity, witness painful memories, and help patients discover new possibilities for defining themselves amid cultural adjustment and change.