Relating with migrants.Ethnopsychiatry and Psychotherapy

8/7/2019 Relating with migrants.Ethnopsychiatry and Psychotherapy

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331Ann Ist super sAnIt 2009| Vol . 45, no . 3: 331-340

reseArch from AnImAl testIng to clInIcAl experIence

S mm r . A ter an historical review o cultural anthropology, transcultural psychiatry and ethnopsychiatry, we will examine the literature on intervention with migrants within mental health system.In the rst part, we will consider the therapeutic relationship with Arab-Muslim patients and look atspeci c issues such as gender di erences, individualism, sociality, stigma, religion. The second partwill be ocused on cultural mediation, migration and amily intervention and post-traumatic stressdisorder and, nally, the experience o being a oreign therapist. Conclusions will discuss the impor-tance o culture, individuality and universality o human su ering, when treating a oreign patient.

Key words: migration, psychotherapy, ethnopsychology, cultural competence, ethnopsychiatry, health and culture. Ri ss (La relazione con i migranti: etnopsichiatria e psicoterapia). Dopo avere dato dei cennistorici di antropologia culturale, psichiatria transculturale ed etnopsichiatria si passa ad esaminarela letteratura che descrive gli interventi nel campo della salute mentale e ettuati con i migranti.Nella prima parte si prendono in considerazione dei suggerimenti tecnici quando si ha a che arecon pazienti arabi musulmani e si analizzano questioni come di erenza genere, individualismo/col-lettivit, stigma, religione. Nella seconda parte si descrivono altre questioni: mediazione culturale,migrazione e intervento rispetto alla amiglia, Disturbo Post Traumatico da Stress per nire ad ana-lizzare il caso in cui ad essere straniero il terapeuta. Nella conclusione si rifette sullimportanza ditenere in considerazione, oltre alla variabile cultura, anche la peculiarit di ogni singolo paziente eluniversalit della so erenza umana.

Parole chiave: migrazione, psicoterapia, etnopsicologia, competenza culturale, etnopsichiatria, salute e cultura.

Relating with migrants: ethnopsychiatryand psychotherapy

Em e e C r pp , Cris i M sce i, P rizi Br , M r P ci,C r C meri Pie r Bri

Istituto di Psichiatria e Psicologia Clinica, Universit Cattolica del Sacro Cuore, Rome, Italy

IntRoduCtIonMigratory processes have brought together di er-

ent cultures. In countries like Canada, USA, UK,and France, where there is already the third-genera-tion o immigrants, many authors consider cultureas a key variable when relating to a oreign patient.Native culture is needed or a better understandingo how customs, belie s, religion, values, gendersand also attitudes towards mental health service a -

ect individual personality and the way psychologi-

cal and physical distress is expressed. Mental healthpro essionals need to consider all o these actorsin order not to misinterpret what the patient saysor does. In addition, they should be aware o allprocesses that migration implies not only at the in-dividual level, but also in relation to amiliar andsocial contexts: indeed, the complexity o premisesand consequences requires sociological and psycho-analytical views on migration [1].

This article wants to primarily be a review onpsychiatry, psychotherapy and migration. For suchcause we wont bring our clinical experience but wewill make re erence to the most meaning ul scienti carticles published on the matter. We will primarily

ocus the attention on the psychodynamic perspec-tive and this decision is motivated by two major ac-tors: rst, because it articulates the narrative dimen-sion o the migrants internal experience and, sec-ond, because we sustain that some theoretical andclinical postulations and phenomena on which thepsychoanalytical practice ounds him are a universalcommon to the human condition.

HIStoRICal BaCkgRound:CultuRal antHRoPologyThe birth o cultural anthropology may be traced

back to the publication o Edward Burnett TylorsPrimitive culture , in 1871 [2]. In this work he re ers toculture as a set o belie s, abilities and customs thatman necessarily acquires since he belongs to society.

Nowadays, cultural anthropology is mostly inter-ested in investigating the relationship among di er-ent cultures co-living within metropolitan contextsand, more speci cally, it takes into account conceptslike acculturation ( i.e. cultural trans ormation o society as a result o the interaction between twodi erent cultures), inculturation ( i.e. transmission

Address for correspondence: Emanuele Caroppo, Universit Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy.E-mail: [email protected].


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332 Emanuele Caroppo, Cristian Muscelli, Patrizia Brogna, et al.

o culture rom one generation to the next) and as-similation ( i.e. when a minority group gives up itsculture in order to accept the dominant culture).

There are di erent cultural anthropology tenden-cies and schools:

1. Malinowski [3], a unctionalist, is regarded asthe leading gure o the British school. In hisconception, culture is not reducible to exter-nal actors such as biology, geography or cli-mate: di erent cultures can coexist in the sameclimatic area and one culture can develop in di -

erent climatic areas;2. in the American school, instead, the cultural

unctionalist relativism prevails. The leadinggure is Franz Boas [4] who deems culture as

the capacity to use reason rather than biologicalinheritance. In addition, he distinguishes cul-ture, peculiar to man, rom society which is

a notion common to all animals;3. the so-called French school stresses the histori-

cal and sociological perspectives. Durkheim em-ploys the concept o collective consciousnessto indicate the synthesis o individual conscious-nesses and the original morality o the group.In his anthropological contribution, he takesinto account the question o social structure [5],the ormation o religious ideas and the devel-opment o moral ideas [6]. Durkheims nephew,Mauss, studies magic and primitive populations[7-9]. Claude Levi-Strauss [10] paves the way tostructuralism and applies the concept o struc-

ture to social organizations. Furthermore he ex-amines myths [11-14];4. in the Belgian school Arnold Van Gennep is cer-

tainly one o the most representative gures: hehas devoted himsel to ethnographic studies onseveral European ethnic groups [15];

5. also Ferdinand de Saussure can be regarded asa leading gure with his structural analysis o language [16];

6. in Germany, it is worth mentioning Wundtand his works People Psychology and RatzelsEthnology [17];

7. in Russia, V. J. Propp studied in depth linguisticsissues [17] and olktales; his major contribution,in act, has been the structural analysis o airy-tales [18];

8. in the Roman school, Ernesto De Martino is oneo the leading gures in the eld o history o religion with his research on origins o cults andreligious myths.

HISTORICAl bACKGROUND:TRANSCUlTURAl PSyCHIATRy IN ITAlyThe relationship between migration and mental

disorders had been studied in Italy be ore the 1970s.In the eld o Transcultural Psychiatry, and despitethe di erences between their methodological ap-proaches, Benedetti [18], De Martino [19] and Frighi[20] addressed numerous issues, some o which are

still o great interest and importance: the e ectso cultural values on psychiatric epidemiology, thedamages on mental health caused by cultural chang-es, the main clinical rameworks amongst di erentcultures, the comparison between western psychiat-ric therapeutic methods and indigenous methods.

The 1970s and 1980s witness the publication o many contributions by di erent thinkers such asErnesto De Martino [20], Terranova and Cecchini[21]. Several con erences were organized and re-searchers rom all over Italy were given the oppor-tunity to meet and discuss their ideas. Among themwe want to mention: Luigi Frighi, Matteo Vitetta,Colucci dAmato, Francesco Remotti, FilippoBarbano, Michele Risso, Bruno Callieri, SalvatoreInglese, Antonio Iairia, Giuseppe Beneduce andPiero Coppo.

In 1982, in Turin, the SIPT (Italian Society o

Transcultural Psychiatry) was established andRovera was appointed President. Issues like thera-peutic relationship, cultural identi cations and pro-jections, acculturation, cultural transition, discul-turation and cultural relativism were examined inrelation to the concepts o norm and deviance.

Between the 1990s and the end o the century, newinitiatives within the eld o Cultural Psychiatryfourished: university courses, con erences, seminarsand an increasing number researchers interestedin the subject. All o these activities led to Italysparticipation in the WACP First World Congress inChina, in 2006.

In more recent times, it is worth mentioningthe speci c Master degree in Migration, Cultureand Psychopathology o ered at the UniversitCattolica del Sacro Cuore in Rome (director: PietroBria; scienti c-academic coordinator: EmanueleCaroppo).

HISTORICAl bACKGROUND:ETHNO-PSyCHIATRyBeneduce [22] provides an extensive account o the

development o ethno-psychiatry. To begin with, thebirth o transcultural psychiatry dates back to thepublication o Kraepelins analyses o his studies ondementia praecox [23], a ter his journey to Giava;generally speaking, transcultural psychiatry dealswith the comparative study o treatment and illnessprocedures in di erent cultures. The term ethno-psychiatry appears or the rst time in Carothersswork [24] within the eld o colonial psychiatry.

With regard to colonialism, Franz Fanon de-nounces how violence and humiliation were infictedon colonized populations to emphasize western andwhite peoples supremacy [25, 26]. Western medi-cine, diagnostic classi cation and treatment meth-ods were imposed with no respect or traditionalpractices o treatment; Fanon notices how the truedoctor-patient relationship was totally lacking andhow the patient was o ten very scared by white doc-tors and hospitals. Fanons conclusion is that there


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333r elAtIng wItH mIgrAnts

is real need or an understanding o the historical,cultural and social contexts when dealing with clini-cal issues [27].

Ethno-psychiatry, thank to George Devereux, be-comes an autonomous subject where anthropology,psychiatry, psychoanalysis and history o religionmeet [28]. The concept o culture becomes there-

ore crucial [29] although, according to Devereux,it cannot account or every individual behaviour.Furthermore, the author stresses how observationis infuenced by the observers subjectivity and howethnocentrism is relevant when dealing with someonecoming rom a di erent cultural background [30].

Devereux also studied shamanism in depth.According to his view, through the observation o shamanism, the investigation o the ethnic uncon-scious, as well as belie s, therapeutic methodologiesand treatment e ciency, is made possible [29].

Finally, Beneduce [22] outlines some Italian ore-runners o ethno psychiatry:

- E. De Martino, religion historian, who studiedmyth, olk medicine, possession, shamanism andmourning [31-33];

- A. Di Nola, De Martinos student, who has ex-amined the meaning o religious ceremonies inCentral Italy, traditional medicine, olk eastsand magic [34-37];

- Michele Risso, who worked on Italian migrantsin Switzerland [38].

OVERVIEW OF ISSUES RElATED TOPSyCHOTHERAPEUTIC INTERVENTIONSWITH MUSlIM-ARAbSGrinberg, in his studies on migration rom a psy-

choanalytic standpoint [39], pointed out how depar-ture always implies separation: any separation leadsto a crisis, since there is a rupture with the past andwith the homeland. Nevertheless, instead o consid-ering it as a single trauma, it is pre erable to speak o a whole o actors which, in the long run, can a ectphysical and mental health. The dramatic change mi-grants experience brings a disorganization that eachperson will deal with at di erent times, according toher personal resources. In general, a bond with thegood internal object enables the Ego to tolerate andprocess the experienced changes.

The choice o leaving might be supported or ob-structed by amily, and the decision can also bepassively su ered (that being the case o children).Sorrow or leaving ones amily can be so deep that itwill outcome into a projective de ence mechanism inwhich the individual will eel persecuted by her ownsu ering and will experience her amily as hostileand re using.

Upon arrival, manic de ences can take place in or-der not to experience loss and abandoning: the indi-vidual idealizes the host country and per ectly ad-justs to the new social and working li e; postponeddepression is what Grinberg calls the exhaustion o manic de ences and the arise o depressive eelings.

Sometimes, persecutory or con usional anguishtakes place and can develop, in most severe cases,into psychotic breakdowns. Individual su ering,once it has been acknowledged and not denied, canlead to progressive assimilation o the new culture.The individual who manages to adjust regains herprojectuality and will keep on idealizing the imageo the home country.

Finally, the author takes into account the returnmoment. When the person goes back home, a ter along time spent elsewhere, she is likely to nd a real-ity which is very di erent rom what she expected:

riends, relatives, houses, society, all have changedover time and new conficts can arise between whostayed and who le t.

According to the sociologist Zan rini [40], the re-turn to ones own home can be shocking or manyreasons: everyday li e in the home country is easily

idealized when living ar away rom it; migrants canengage in aggressive and arrogant attitudes - giventheir experiences abroad; women may not nd a joband opportunities or their emancipation; amiliesneed to reorganize themselves in order to welcomethe returning amily member.

Gender differencesWithin the therapist-patient context, gender di -erences may play a crucial role especially when they

are relevant to either o the two cultures.In Arabic communities man is considered to be

the strongest, and a womans duty is that o getting

married and looking a ter children, rather than purs-ing any pro essional career: within this perspective,divorce is viewed as a stigma. A divorced womanwould there ore lose her children and could re-mar-ry to a widower or become a married mans secondwi e. There is a speci c male hierarchy: a man is thehead o the amily and is under his athers author-ity; his ather needs to respect the clan leader who islower than the head o the tribe. Compared to theyoung, the elderly respect Arabic society more, andtheir respect is seen as a sign o wisdom and experi-ence. The therapist should not minimize the patientsparents authority or attempt to change amily hier-archical rules. As ar as gender di erences are con-cerned, the therapist dealing with a emale Muslimshould be aware that a straight gaze means sexualavailability and that when women glance down itis not necessarily because they are shy or insecure;in act, it would be use ul to explain to them howthis behaviour might be misunderstood by westernpeople. Similarly, the encounter between a emaletherapist and a male patient might be di cult as herauthority will not be recognized [41].

Society based on individualism collectivismIslamic belie s and practices deeply a ect Arabian

li estyle. The Koran teaches the value o pity, hu-mility and compassion towards human beings, andunderlines the importance o patience, loyalty, in-tegrity and control o impulses and desires. The in-


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dividual able to take care o others will be loved andrewarded by God: clearly the wel are o all mem-bers is vital to the community. This actor shouldbe taken into account i the clinician belongs to atype o society where individualism, sel -achieve-ment, independence, psychological emancipation

rom parents and personal identity are regarded asthe most important goals. In such a society, socialroles are internalized by the individual and senseo guilt comes rom the inside; but in the Arabicsocieties guilt is attributed rom outside, romthose members o society who exert control overeveryone else. The individual is there ore destinedto remain isolated. For this reason, when treatinga patient coming rom this cultural background, itis recommended to ask other amily members toparticipate in therapeutic sessions. The presence o another member o the amily does not have to be

considered a sign o dependence but as the normaltendency o the Arabic amily: all members willexpect to be questioned by the therapist and willmake an e ort to solve the problem [41].

Dwairy suggests practicing what he calls analysiso culture, a method that can be very use ul whenthe patient comes rom a culture in which collec-tivity is more important than individuality [42]. Insuch a society, a person knows that needs, desires,instincts, values and judgments are collective andnot individual: the person needs to turn down herown wishes (or express them when she is alone). Alikely consequence is the occurrence o confict be-

tween amily (or social) values and repressed indi-vidual needs and desires; there ore, rather than deal-ing with the repressed contents, the therapist shouldhelp the client to nd alternative values, less strictbut still within her own system o belie s, and closerto her personal needs. This is consistent with Becksapproach that holds that oppressive thoughts shouldbe replaced by more unctional ones. The therapistshould keep in mind that in a society where repres-sion comes rom the outside it is much more impor-tant to develop competences and skills rather thande ence mechanisms. Happiness, indeed, is relatedto social acceptance [44].

StigmaAnother aspect to be taken into account is the

stigmatizing role attributed to the psychiatrist orpsychologist. Women, in particular, may eel theirmarriage plans put at risk because o the thera-peutic relationship. Psychiatrist and psychologistscan be viewed with mistrust rom Arabic patientsespecially when their religious values are ignoredinstead o being respected as source o com ortand relie . Since distress is usually expressed withphysical symptoms, patients expect to receive pre-scriptions or medication without any need o talk-ing about personal problems; physical symptomsare more easily accepted and depression is o tendescribed as an oppressive eeling to the chest oras an abdominal pain [45]. For instance, depres-

sive, manic and hypomanic patients seem to lackmood-related symptoms, and when they are askedwhether they eel sad or euphoric they answer noor I dont know. The same can be said or cogni-tive symptoms related to guilt and lack o sel -es-teem [41].

O ten, the communication style used to describesymptoms appears impersonal and rather ormalbecause it is quite di cult to talk to someone un-

amiliar about personal problems and also becausepatients are a raid they could damage their amilyshonour: the inexperienced pro essional might as-sume she is acing resistance [41].

Dwairy [42] suggests metaphor therapy orArabic patients as it can give access to unconsciouscontents without necessarily having to bring themup to consciousness. This method is particularly

unctional or those patients who are not able to ace

repressed contents and show low levels o individu-alization and problem solving skills. The basic teneto the metaphor therapy is that problems should berepresented by means o metaphors (Arabs have ahighly metaphorical language taken rom the Koran)and solutions should be searched in symbolic termswhich can then be applied to real li e. Dwairy [42]illustrates an example and a possible interpretation:an Arabic patient, who represses her anger towardsher parents, eels like a dam, surrounded by an aridlandscape, and orced to contain the increasing wa-ter pressure: the risk she eels is that o an explosionand the ensuing destruction o the surroundings.

When the therapist asks to think o a solution byusing this image the patient answers that holes inthe dam would help water to fow slowly out andthe land would bene t rom the water and becomegreen and fourishing. Through the same metaphor,the patient learns that her conscious anger towardsher parents could help her to improve, rather thandamage, her relationship with them. Acquired con-sciousness would later help the patient to progres-sively modi y her behaviour towards her parents and

nd a good compromise.

ReligionReligious aspects are essential to the everyday

li e o Muslims. There are ve main principles o which the therapist should be aware: the rst is thatIslam believes in one God and in Mohammed, hisProphet; the second is that a Muslim needs to say 5prayers every day a ter ablutions meant to puri y thebody. Knowledge o these two precepts is o greatuse: as an example, mental health pro essionals canencourage the person to take care o hersel sincethe body is Gods gi t and should not be abused. Ingeneral, meditation and prayer are very supportivewhen experiencing di culties and they can be usedin therapy: i a patient asks to pray in ront o thetherapist, such request should be ul lled. The lacko desire or praying can be seen as a symptom o distress and can come along with a deep sense o guilt [46, 47].


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The third principle o Islam is asting duringRamadan. This precept can be ound in other reli-gious practices and may not be understood or it maybe discouraged by a non-practicing or non-believingclinician. For a Muslim, instead, it is o extreme im-portance or many reasons: to puri y soul and body,to gain sel control and not to orget the poorestwho su er hunger every day. The ourth principlesays a Muslim needs to help people in need throughcharity; the th orders a journey to Mecca once ina li etime.

According to Carter and Rachidi [46, 47] two cur-rent approaches can help to reconcile western andeastern principles:

1. Rogers approach includes di erent conceptswhich are consistent with Muslim belie sys-tems: authenticity, honesty, positive and uncon-ditioned consideration, acceptance, empathy,

understanding, active listening. Furthermoreit implies that who turns to a therapist is look-ing or sel -realization, personal ul lment, in-creased responsibility and establishment o ad-equate social relationships;

2. cognitive therapy takes into account emotionsand values o each individual in order to identi-

y constructive actions leading to personal hap-piness. Cognitive approachs goals are both thato identi ying dys unctional thoughts and thato teaching patients not to be catastrophic: pa-tients need to learn how to be objective withoutrisking to commiserate others or themselves.

Right decisions and productive actions are madepossible by the practice o rational thoughts.Generally, it is recommended to present thetherapist as an authority able to show what isto be done in order to solve the problem: thatis exactly what happens with traditional healers.The Arab community o ten shows an externallocus o control which means that responsibility

or what happens is external: this applies espe-cially to those who believe in jinn, sorcery andthe evil eye [41]. The therapist should respect theimportance given to traditional healers and tosupernatural entities in general.

CUlTURAl MEDIATIONDealing with a patient who comes rom a totally

di erent cultural context and who cannot speakthe host country language requires help rom a cul-tural mediator. A cultural mediator can assist both

or translation and de-codi cation o cultural is-sues related to the experienced distress. Beneduce[22] suggests some rules which should be ollowed

or a success ul linguistic-cultural mediation: thetherapist should reject the typical dual relationshipand pay attention to the trans erence and countertrans erence reactions elicited by the presence o themediator in the setting; the therapist should also tol-erate her rustration when not able to understandwhat is happening between the patient and the me-

diator; the mediator should try to identi y personalconficts brought up in the therapeutic session andshould be helped by the therapist in order to domi-nate trans erence-counter trans erence processes. Ingeneral, a pro ound respect between mediator andpsychotherapist is necessary: respect is at the base o cooperation, which enables treatment itsel .

Nathan [48] has created an ethno-psychoanalyticinstrument which implies the use o di erent pro-

essionals (doctors, psychiatrists, psychologists)each with a di erent cultural background: the pa-tient is welcome to bring anyone into the group ( i.e. relatives, riends or neighbours) and they all try tobuild a new shared background. Salvatore Ingleseexplains that the purpose is to create a group con-tainer where the patient can establish hersel asi she were within her original cultural ramework(). The containers unction is crucial because

migration inevitably entails the dissolution o thepatients cultural rameworks (). Nathans mostrecent intention is () to show that the distinctionbetween wild and scienti c thought is an ideo-logical mysti cation per ormed in order to imposethe will o the strongest [48, p. 16-17]. Any prob-lem a patient brings to the group is analysed romseveral point o views and interpreted in several di -

erent ways until a re ormulation o what has beensaid and a proposal o e ective intervention is madeavailable.

MIGRATION, SOCIETy, FAMIlyAND FAMIly THERAPyFollowing Zan rini [40], migratory processes can

be explained according to di erent sociologicalrameworks. According to network theory migra-

tion can be de ned as a set o social relationshipsinfuencing one persons decisions. The choice o acountry is normally a ected by the act that some

riends have already migrated to that country andwill presumably provide the new migrant with di -

erent sorts o support: help with housing and em-ployment, bureaucratic procedures, adjustment tothe di erent culture. This theory explains why mi-gratory fows to a country continue despite the scar-city o job opportunities. In addition, the thoughto a relative working abroad causes a eeling o comparative deprivation and awareness o onesown poverty. This actor brings other individuals tomigrate and spread a migration culture.

Migration, however, has social costs or the oneswho leave and or the ones who stay. As a mat-ter o act, an upsetting o amily balances occurs.Moreover, we need to acknowledge an importantchange: it was typically a man who migrated to sup-port nancially his amily, while women were calledwhite widows; the new trend is that o a emalemigration and a subsequent rede nition o relation-ships: wives are o ten the main nancial sources andthey gain power compared to their husbands whothere ore lose their traditional role. Sometimes wom-


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en who migrate are divorced or widows and in thiscase too they provide or the support and educationo their children.

Children, granted to grandmothers or aunts (mi-gration orphans), can experience consequences ontheir psychological and emotional well-being dueto the absence o their mothers. Zan rini [40] saysthis cannot be considered a general rule, though.Sometimes the distancing o one parent means animprovement o the childs condition, especiallywhen there is some confict in the parental couple;also, it is important not to orget that children canhope or a better uture compared to what their com-patriots can expect.

Social support is crucial: a culture o migrationwould unction as a justi cation and mothers wouldnot be blamed or leaving their children at home. Onthe contrary, they would be supported since their e -

ort is viewed as a generous sacri ce. Without anysocial-cultural justi cation, sense o guilt would in-crease distress in the mothers, and children would bevictims o stigmatization by their own community.

Given these premises, during a amily therapy it isimportant to ocus on the changes that society, am-ily and individuals go through. Symptoms that on-set or get worse with migration, such as depression,anxiety, psychosomatic illnesses, addictions and be-havioural problems, can all be experienced by any

amily member in any place and at any time: at thetime o departure rom home or later during the trip,at a crucial time (physical illness, divorce or grie ) or

when they go back home. The amily therapist stress-es the complex interactions between the di erent ac-tors and their context [49].

Falicov [49] highlights some signi cant implica-tions that the migratory process has on a relationallevel, particularly when amily members live in di -

erent places. Separations rom and reunions withones own amily cause tension, especially betweenmothers and children; needless to say, sometimeshost countries policies make reunions di cult to re-alize. Women, quite o ten turn to mental health unitsbecause they experience depressive eelings causedby separation rom their children. In this case, it issuggested to the mother not only to keep in contactwith children but with the temporary caregiver tooand to increase contacts through phone calls, inter-net, or even sending toys, clothes and pictures.

Another aspect that should not be underestimatedis that the contact with the new culture leads to aconfict between tradition and modernity: in the cou-ple, the woman becomes more aware o her rightsand claims an equal position with the husband. As aconsequence o these negotiations between the two,a racture can occur. Even reunions with children canbe traumatic because they may be like an encounterbetween strangers: a typical example is that o a rebeladolescent and a mother who, while abroad, hasmade a new li e and had new children. In these cases,the therapist tries to help the amily by asking themto bring letters, photographs and pictures which can

remind them o events prior to and ollowing migra-tion. This helps not only to recall their story, but alsoto give signi cance to migration by inspiring mutualempathy between those who le t and who remainedat home. When the whole amily moves abroad,conficts between parents and children might be re-quent: these conficts correspond to those betweentradition and modernity. Parents are likely to be toostrict and rigid with their children, and the therapistneeds to enhance mutual understanding by motivat-ing parents to adjust to the host culture [49].

The process o acculturation can be problematicat the time o migration but we should not orgetthat also going back to the home country involvesre-acculturation and re-adjustment to home rules:in a very short time the migrant is asked to orgether previous li e style [50]. Acculturation depends onmore than a ew actors: education level, occupation,

use o media, political involvement, social relation-ships, etc.

In conclusion, the therapists task is to help ami-lies to acknowledge cultural and intergenerationalconficts, and to adjust their belie system by keepingsome cultural values and assimilating new ones.

POST TRAUMATIC STRESS DISORDERAND MIGRATIONFrom what has been discussed so ar, it is evident

that migrants have to go through several strugglesor micro traumas which require good adaptation

skills. Along with a list o vulnerability actors [51,52] (Table 1) , also protection actors can be outlined[52]: social support, social integration, preservationo cultural identity and traditional cultural practices(rituals, language and traditional activities).

Migration can be highly traumatic. This is thecase o escapes, as it happens or re ugees. It is wellknown how atrocious journeys are to Europe andhow requently migrants die during those journeys.

Ta e 1 | Mental health vulnerability actors in migrants

Age (migrating rom adolescence on can infuence the occurrence o

mental disorders)Separation rom places, people or dear objects

Loss o roles and their identi cation

Stress or traumas prior to migration that derive rom social or politicalsituation

Signi cant aspects o the migratory process (e.g. , di cultiesencountered during the journey to Italy)

Low possibilities o nding support within the home community andpoor social network

Negative attitudes o native population and perceived discrimination

Di culties with understanding and speaking host country language

Cultural shock caused by the inadequacy o interpretative codes

(proportional to the distance between native culture and host culture)and acculturation-induced stress.

Poor socio-economic conditions in the host country


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Such experiences in which li e itsel is jeopardizedcan lead to develop post traumatic stress disorder(according to DSM IV-TR criteria) [53].

Morrison et al. [54, 55] outlined a parallelism be-tween negative and positive schizophrenia symp-toms and PTSD: fashbacks, images, intrusivethoughts, hyper alertness and possible paranoia arevery similar to schizophrenic positive symptoms,while emotional withdrawal, emotional fatteningand de-realization are common to schizophrenicnegative symptoms. The authors suggest that psy-chosis and PTSD represent responses to traumaticsituations. In both cases, avoidant behaviours ordys unctional control strategies, as well as autobio-graphical memory distortions are activated. Ellasone Ross [56] suggest the presence o a subcategory o trauma that can provoke psychotic disorders.

Nowadays quite a ew techniques are used to treat

PTSD [57]. Hypnosis is o ten accompanied by phar-macological, cognitive-behavioural or psychody-namic treatments [58]: this technique aims at the cre-ation o alse memories [57]. Group therapy is used

or patients who had a traumatic experience within agroup: patients narrate their stories to the group and

eel supported without being judged. Papadopoulos[59] believes group therapy with re ugees is betterthan other methods or two major reasons: becauseit helps to come out rom the condition o with-drawal that ollows a trauma, and because the grouphelps to establish good a ective relationships withreal people in a real context. Cognitive-behavioural

therapies help to work on anxiety symptoms withina sa e therapeutic context [60]. Its major techniquesare: exposure therapy (progressive exposure toanxiety-inducing stimulus), systematic desensitiza-tion (relying on counter-conditioning principle andbased on the association o positive stimuli and mus-cular relaxation with an anxiety-inducing stimulus),stress inoculation therapy (the patient learns newcoping strategies); cognitive therapy is not based onexposure and the treatment consists o modi yingirrational or dys unctional thoughts. EMDR (eyesmovement desensitization reprocessing) is quite a re-cent technique which relies on the assumption thatsome in ormation has been stored into memory in adys unctional way as a consequence o the trauma.Even the most recent theories on memory [61] sug-gest that pathology is caused by memories o experi-ences that have not been success ully processed. Thetechnique o EMDR ollows a xed schedule and itis divided in di erent phases [62]: the patient needsto ocus on the most meaning ul aspects o the trau-ma while associating, at the same time, eye move-ments and other bilateral stimulation. EMDR is setup on neuroscienti c ndings: this practice wouldactivate new neural pathways that would allow there-processing o traumatic memories. Through theEMDR technique it is possible to work on the mostdistressing images associated with the trauma, andalso on emotions and emotional distress arisingwhen remembering the event.

Analytical psychotherapy or PTSD seems to bedi cult because the patient is a raid to experiencetraumatic memories again within the trans erencerelationship [57]. Severe traumas like war, imprison-ment or tortures, lead to an interruption o the nor-mal psychological development and alter the personin her whole. The eeling o alienation experiencedin such situation is made worse by the condition o being an exile: the patient, who has fed to a oreigncountry a ter a trauma, has to deal with the loss o her own culture and relationships, and needs to acematerial di culties. As Ghislaine Boulanger says[63], the therapeutic setting becomes very impor-tant: long term imprisonment or torture experiencesare characterized by unpredictability and, as it hasbeen observed, daily habits and activities are impor-tant in such situations. For these patients the thera-peutic setting guarantees stability and security: the

setting becomes an important therapeutic actor initsel [64], a basic element that could be re erred toWinnicotts concept o holding. Hence, Boulanger[63] holds that narration o traumas allows symboli-zation: through the narration, the patient becomesan active witness o her own events and emotions.

Un ortunately, the way to rebuild one personscapacity o trust is very long and di cult and notalways success ul. Even the analyst needs to handlemany di culties especially at a counter trans erencelevel; the trans erence- counter trans erence rela-tionship is very delicate as it could trigger a torturer-victim relationship with which the patient might not

be able to cope.

A SPECIFIC INTERPRETATION OF PTSDMarwan Dwairy [44] presents interesting com-

ments on the case o Palestinian children duringthe Israeli occupation [65]. These children are con-stantly subject to stress and traumas (among which,such rightening events like night time incursions o Israeli soldiers into their homes). It has been saidthat the constant experience o war are has madethem somehow addicted to violence. In his studies,Dwairy examines PTSD rom a collective point o view: it is the whole society, in act, that undergoesthe strain induced by occupation and daily violence.According to Dwairy [44] some criteria can describea collective response to post-traumatic stress, al-though he believes that they should be viewed asa healthy reaction rather than as a disorder. As anexample, just be ore the inti ada, slumber and avoid-ance had been the collective response to the pres-ence o Israeli soldiers.

THE MIGRANT PSyCHOANAlySTWe are quite used to think o migrants as people

who ask or help, as patients. It would be interesting,instead, to change perspective and see what happenswhen the therapist is a migrant. Akhtar [66] has in-vestigated the subject and described two speci c cas-


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es: when the patient is a local and when the patientshares the analysts same background.

In general, implicit cultural meanings always e ecttherapy: there ore, when the psychoanalyst is a oreign-er misunderstandings are likely to happen. Accordingto Akhtar, a basic rule should be that o taking a neu-tral attitude, equidistant rom both cultures.

When the patient is local the analyst should won-der why the patient has chosen a oreign pro ession-al: one possible interpretation is that there couldbe an unconscious desire to nd the lost object o childhood ( e.g. , perhaps an A ro-American nurse-maid who suddenly le t?). The patient might alsowant to protect hersel rom her own shame or earo ailure and might have chosen a oreign analystbecause it is common sense that oreign analysts areless competent.

When there is cultural diversity, and even more

when there are visible somatic di erences, manyprojections and stereotypes could infuence ree as-sociations. So, while it is necessary to control the waydiversity a ects ree associations, it is important notto neglect the patients personal meanings.

The oreign analyst does not lead the interview inher native language and may not understand meta-phors, double meaning expressions, allusions, puns.When this happens the patient can be interrupted toask urther explanations: what is important to un-derstand is whether this interruption can be negativeand, at any rate, it should not occur too o ten.

The analyst may want to make a comment using

her own native language; in that case, some ques-tions would be pondered:- What happened during the talk that induced her

to switch languages?- Would it be o use to translate what has been al-

ready said in another language?- Would it be pre erable to translate straight away?- Can the patient be traumatized by the analysts

speaking in her own language? Could that makethe relationship more spontaneous instead?

Another issue that needs to be considered is thatthere could be a reversal o roles rom a linguisticpoint o view. A disparity o roles in the therapeu-tic relationship is generally accepted and the analystis the one who leads the talk: when the therapist isa oreigner, though, the patient might be more com-petent at the linguistic level. To a patient character-ized by narcissistic vulnerability the poorer linguisticcompetence o the analyst may be seen as weaknessand would there ore be an obstacle to the narcissisticidenti cation with the idealized therapist [67].

When the therapist and the patient are both or-eigners and speak the same language the risks mightbe a collusion about nostalgic issues and the impos-sibility to investigate prohibited subjects; also theswitch o aggressiveness rom internal to external,might be eased through a mechanism o projection.

It is important to avoid cultural rationalization o intra-psychic conficts. Akhtar [66] reports the caseo a Jewish woman, daughter o a holocaust survivor,

who called to set an appointment. She said that shewas a ervid Zionist and asked whether the analyst wasArabic because she would not give her money to a ter-rorist. Akhtar comments that an ethnic rationalizationmay hide the patients sado-masochist attitude.

Another element that should be taken into accountis the acculturation gap between the therapist andthe patient. Although rom the same country, theymight hold di erent belie s and there might be di -

erences concerning Ego and Super-Ego. The mostlikely case is that o the westernized therapist:the therapist is likely to have been living in the hostcountry or many years and to be more adjusted tothe new culture. The cultural gap is also linguistic:the therapist could realize he has lost command o the native language while the patient has a morecomplex vocabulary; the therapist might then eelashamed or envious.

At other times, instead, the therapist serves as abridge between the past and the uture. The therapisthas gone rom her primary objects and early experi-ences to her new identity, and this is exactly what thepatient asks or [67]: the therapist becomes the symbolo what the patient would like to be. Similarly, the pos-sibility o speaking the same native language can bevery practical because the language spoken in the hostcountry can easily symbolize super-egoic eatures withthe subsequent risk o repressing some contents [68].The native language, instead, allows easier access tochildhood memories, ree associations, emotions andunsolved conficts [69]. Nevertheless, since the oreign

language could represent paternal super-egoic eatures,the use o ones native language in the therapeutic talkcan imply collusion. In other words, the will to keep the

oreign language out o the therapeutic relationshipwould signi y the wish or a pre-oedipal condition.

Finally, it is important to understand whether the re-jection o the oreign language corresponds to the rejec-tion o the entire new culture. Akhtar [66] points outthat, although it is use ul to understand the peculiari-ties o the patient-therapist relationship, the universal-ity o human beings should not be orgotten.

CONClUSIONSThe premise o this paper is that the increasing

number o migrants 1 requires a care ul refection ontherapeutic techniques.

We started rom a review o some studies on Arabcommunities and ound them use ul or mental healthpro essionals working with migrants: it seems clear tous that a therapist should always try to suspend her per-sonal belie s and philosophy could serve the purpose[71]. Ancora [72] speaks o a journey the therapistmakes in new worlds, a journey made possible by thecombination o daily pro essional practice and a wish

or exploration. The therapist should be able to de-compose and then later recompose hersel , to

1As reported in Dossier Caritas [70] Istat has pointed out an in-crease o hal a million units.


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leave and return to hersel , in a sequence whichis meant to build a shared plat orm or the treat-ment.

Western treatment techniques have been imposedon colonized populations, and some authors, such asBourdieu [73], have spoken o a symbolic violence.Colonizers, indeed, imposed behavioural rules, reli-gious belie s, educational and health systems, andeven worse orms o coercion like the enrolment inthe colonial army or orced labour. Ceremonies,traditions, bodies o these people had been alreadyjudged as in erior [] certain that it was the Europeanmans duty to ree these people rom barbarity, igno-rance and poverty [22, p. 33]. Porot [74], a colonialpsychiatrist, de ned North A ricans as primitive,ignorant and credulous. Even Fanon pointedout the impossibility or a oreign practitioner towork in a colonial environment where whites and

hospitals are eared by the local population [26].Nowadays, we try to be aware o our prejudices

and ethnocentrism in order not to infuence our re-lationship with the migrant. Bhui et al. [74] speako the possibility o acquiring cultural competencewhich would enable pro essionals to better under-

stand the concept o illness within a speci c culturalcontext. Furthermore, it is crucial to be genuinelyinterested in knowing di erent cultures, developingan empathic attitude as well as the awareness o theexpectations and prejudices peculiar to patients andhealth pro essionals.

A ter so much emphasis on culture it would beuse ul to warn pro essionals about the possibility o being ascinated by exoticism with the risk o miss-ing the real purpose: the encounter between twopeople.

S. Inglese (in Principi di Etnopsicoanalisi by T.Nathan, p. 18 [48]) argues that cultural material isthe container and not the content o discourse; the

nal purpose is the identi cation o the idiosyncrat-ic level (individual psychic confict) lying beneathcultural construction. (...) The pro essional is alsoexposed to the risk o viewing the patient as a mere

in ormant o her culture (counter trans erence as-cination) and becomes insecure about her right tointervene according to her approach.

Received on 6 March 2009.Accepted on 16 July 2009.

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