Internal and International Migration and its Impact on the Mental Health of Migrants
This article describes the facts and figures of today’s migration patterns and briefly presents the limits and findings of the existing research on the impact of different forms of migration on the mental health of migrants. The article aims at promoting a right-based approach to migrants’ access to mental health care, as supported by international legal instruments. Since this right is at times disregarded due to the legal unavailability and factual inaccessibility for migrants of the existing mental health services, the article proposes a series of actions that could facilitate migrants’ access to mental health care across health systems and countries.
KeywordsMental health Migration Migrants Refugees Mental illnes Psychosocial support
An estimated one billion migrants live in the world today, including those who migrate within their county or internal migrants and those who migrate between countries or international migrants (IOM 2016a). This figure makes populations’ mobility one of the defining issues of today’s global anthropology. Certain migration paths provoke extraordinary vulnerabilities and stressors to the migrants, as it is the case for minors who travel unaccompanied (Jensen et al. 2014); refugees and internally displaced people (IDP) (Salah et al. 2013) escaping from wars, conflicts, natural disasters, and famine; forced migrants (Siriwardhana and Stewart 2013); and those who end up in exploitative situations (Zimmermann et al. 2006) or in detention (Robjant et al. 2009). Most migratory paths, however, are not as obviously vulnerable, as it is for foreign students, migrant workers, transnational families, domestic workers with regular contracts, and most of those who move inspired by an upward social mobility objective.
Migration in general and vulnerable migration in particular are considered a determinant of poor mental health. This general assumption is rooted in the “unhealthy migrant myth” (Cattacin 2010) and in the global tendency to manage migration as a “risk,” but it is not consistently supported by the evidence. The research’s reliability in the domain of mental health of migrants is hampered by many factors including the different definitions of a migrant in various countries, which make comparative analysis nearly impossible, methodological biases, and the unrepresentativeness of samples (Knipper and Bilgin 2009). The existing research, however, seems to support the fact that victims of trafficking (Oram et al. 2012), migrant detainees (Robjant et al. 2009), and asylum seekers and refugees (Mann and Fazil 2006) are more at risk than the general population to certain mental disorders, including depression, anxiety, and psychotic disorders but the variance between the results of the different studies does not allow to draw definitive conclusions and regards a comparatively small number of people. In any instance, the supposed higher or lower vulnerability of migrants to mental disorder is not substantial in validating the need to promote migrants’ access to mental health care. According to the Constitution of the World Health Organization (WHO 2006) and the International Covenant on Economic, Social and Cultural Rights 1966 (OHCHR 2016), health, including mental health, is a fundamental human right, irrespective of race, gender, age, religion, political views, and socioeconomic conditions. Mental health care is therefore a fundamental right of all migrants, and yet migrants, especially the ones in irregular situations, are often excluded from mental health care, either because the relevant services are not legally available to certain categories of migrants or because language and cultural barriers, lack of outreach and information, and stigmatization of mental health problems make the available mental health services factually not accessible for migrants (Devillé et al. 2011). The exclusion of migrants from mental health care hampers one of their fundamental rights, and this alone should suffice to promote all migrants’ inclusion in mental health systems.
This chapter will describe some of the key facts and figures of today’s migration patterns and briefly present the research on psychopathology of migration, with its limits and its findings. It will then recommend a series of actions that irrespective of the type of health care and migrants’ inclusion systems applied in a country can facilitate migrants’ access to mental health care. The article will do so mindful of the importance to consider the mental health needs of migrants in the organization of the health, social, and educational systems of origin and return, transit, and destination countries but conscious that a default association between migration and mental illness not only is not consistently supported by evidence but would also risk to validate biased policies and narratives that look at migrants as “risks,” “problems,” and “burdens” for the social care and health-care systems of the host countries (Schininá et al. 2011), which are unmotivated and often unethical.
Migration: Definitions and Figures
Consistently with the International Organization for Migration’s (IOM) relevant definition, in this article a migrant is considered as “any person who is moving or has moved across an international border or within a State, away from his or her habitual place of residence, regardless of the person’s legal status, whether the movement is voluntary or involuntary, what the causes for the movement are, or what the length of the stay is” (IOM 2016b). This umbrella definition includes individuals that enjoy different sets of rights and have different life paths and is in line with definitions proposed by the International Federation of the Red Cross and Red Crescent Societies (IFRC) (IFRC 2016) and the United Nations High Commissioner for Human Rights (UNHCHR) (Al Hussein 2014), but it has been criticized by the United Nations High Commissioner for Refugees (UNHCR), since it includes asylum seekers and refugees under the definition of a migrant. According to UNHCR, this can risk to associate refugees to the mainstream negative perception of migrants and to put into question the special set of rights that refugees are entitled to (UNHCR 2015). If this definition does not find consensus among all intergovernmental organizations (IO), the situation becomes even more fragmented at the national level. A universal definition of migration that is consistently adopted in all countries worldwide does not exist (OHCHR 2012). Quite to the contrary, the definition of a migrant varies between countries, institutions within the same country (Devillé et al. 2011), and international and national laws (Blinder 2013). This has tremendous implications on the rights of migrants, their access to health and mental health services, and on the more specific domain of the research on mental health of migrants. The populations included in research on migrants differ from a study to another, complicating analysis and comparisons (Anderson and Blinder 2015). In addition, it is not universally clarified when a migrant ends to be a migrant (Devillé et al. 2011). From one side, the protracted identification as migrants of people who are residing in a new country or location can be stigmatizing. On the other side, for some, the definition of migrants should be extended to look beyond the generation that has moved from one residence to another. Although the term “second-generation migrant” is for many a contradiction in terms (Kobayashi 2008), the health and integration challenges of the direct descendants of migrants are sometimes greater than those of the people, who migrated (Ingleby 2011; Gushulak et al. 2009; WHO Regional Office 2018).
The IOM estimates that roughly one billion individuals in the world are migrants, which correspond to the 14% of the global population and include both internal and international migrants (IOM 2016a). Data on international migrants are generally more available and reliable than data on internal migrants, which has to do with the fact that regular international movements are easier to trace than those within a country. According to international statistics, the number of international migrants reached 244 million in 2015, up from 222 million in 2010, and 173 million in 2000, demonstrating a progressive increase in populations’ mobility (UNDESA 2015). This number, however, does not include all those that migrated irregularly and have not been identified and is, as such, underestimated.
Nearly two thirds of all international migrants live in Europe or Asia, and women comprise slightly less than 50% of them. Female migrants outnumber male migrants in Europe and Northern America, while in Africa and Asia, particularly Western Asia, migrants are predominantly men. The median age of international migrants worldwide was 39 years in 2015, and it has remained almost the same for over two decades (IOM 2016a).
The majority of international migrants live in so called high-income countries, and 65% of them originate from middle-income countries. The 10% only comes from low-income countries, suggesting that most international migration is the result of an upward social mobility objective rather than driven by severe vulnerability. In many parts of the globe, migration occurs primarily between countries that are located within the same region-area, with the exception of migrants coming from South and North America and the Caribbean (IOM 2016a).
Particularly vulnerable international migration paths are the ones of refugees and asylum seekers, and a direct correlation exists between migrants’ well-being and their experiences of detention. A refugee as defined by the UNHCR would be a person “who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it” (UNCHR 1967 p. 14). In 2015, there were 20 million refugees in the world (UNDESA 2016). An asylum seeker is an individual who has claimed refugee status but has not been granted this status yet. In many countries in the world, irregular international migration is criminalized, and large numbers of international migrants spend time in prison or detention due to their irregular status only (COE 2010). In some countries, even asylum seekers and refugees have to spend some time in detention, before being regularized (Nakache 2011; Amnesty International 2012). Detaining migrants based on an irregular status only is questionable for ethical, human rights, political, and financial reasons (IRIN 2015).
In 2015, an estimated 5,400 international migrants died or went missing during their movement. About 3,770 of these casualties occurred in the Mediterranean. This figure is however likely to represent a small, dramatically evident proportion of the number of migrants that die during their trip in search for a better life on land, at borders, and in deserts (IOM 2016a).
The data about internal migrants are less elaborated because internal migration is not consistently surveilled. The estimated 740 million internal migrants in the world (UNDP 2009) encompass a variety of populations including seasonal workers, those who move from the countryside to the urban centers, those who move from the province to the big towns, students, and many others (ILO 2010). Urbanization is constantly rising and will be a global challenge in the coming years (ILO 2015). In 2015, 27.8 million individuals were internally displaced (IDMC 2016), roughly the equivalent of the populations of New York City, London, Paris, and Cairo combined. Of those, 8.6 million had to flee conflict and violence in 28 countries, and 19.2 million were displaced due to natural disasters in 113 countries, in the same year (IDMC 2016). The most-affected country was Yemen, where 2.2 million individuals – or 8% of the population – had to flee their homes (IDMC 2016). As in previous years, the South and East Asia and the Pacific regions faced the largest internal displacement associated with natural disasters. Low- and middle-income countries were most affected across the world as a whole (Bilak et al. 2016).
Particularly vulnerable migration paths, both in terms of internal or international migration, are those of victims of trafficking and of children who migrate without their parents or caregivers, usually called unaccompanied or separated minors. A victim of trafficking is an individual, who has been convinced to migrate either internally or externally with false information, kidnapping, through the use of force or threat, or the abuse of his/her state of vulnerability for the purpose of being exploited sexually, in domestic servitude or as a workforce in different industries. In the most concerning situations, people can be trafficked for organ removal and trade (OHCHR 2000). A rough estimate reports that around 700,000 people are trafficked every year (IOM 2016c), but data are not conclusive. Only a small percentage of victims of trafficking is identified and assisted every year. In 2015, the victims assisted through IOM were nearly 7,000 in 115 countries (IOM 2016). Unaccompanied minors are understood to be children, who have been separated from both parents and other relatives and are not being taken care of by an adult who would be responsible to do so by law or custom (IOM 2011). “Separated children’ are children, who have been separated from both parents, or from their previous legal or customary primary caregiver, but not necessarily from other relatives. These may, therefore, include children accompanied by other adult family members” (IOM 2011 p. 2). In 2014, more than 23,000 asylum applicants in the European Union alone were registered as unaccompanied and separated children (IOM 2015).
These statistics and numbers give an idea of the scope of today’s migration trends but are not fully able to describe the variety and diversity of migration paths and populations. Under the same figures, a constellation of individuals with different legal and life course patterns endures, including refugees and asylum seekers but also labor migrants, cyclic or seasonal workers, foreign students, foreign domestic workers, intercontinental and interregional migrants, mobile and travelling populations, victims of trafficking, unaccompanied and separated children but also irregular migrants, transnational families, and maritime workers, among others (OECD 2015). Nowadays, the diversification of migrant populations is immense, fed by the general increase of the world population, the spread of mass communication and the consequent easier access to information (GCIM 2005), an increased access to cheaper means of long-distance transportation, the global transformations of the labor market, and inequalities that mass communication makes more blatant (Calhoun et al. 2005).
Migration and Vulnerability
Especially after the 1980s, at least in Europe, certain factors of the new migration, including an increase in flows from other continents and regions, the increase in arrivals from developing countries or countries in distress, as it was for migrants from East to West Europe after the Berlin Wall fall (Fiddian-Qasmiyeh et al. 2014), and finally the impossibility to control movements with the consequent increase in irregular movements, have brought to a default association between migration and vulnerability. The perceived vulnerability of migrants encompasses the perception that migrants are less healthy than the resident populations and even a potential threat to the public health systems of the receiving countries (Neumann 2014). According to Cattacin et al. (2006), this has not always been the case. Until the 1980s, migration in Europe was mainly characterized by movements of low-skilled laborers from the south to the north within and between countries. In that period, migrants were widely perceived as strong and emotionally stable, due to their willingness to take risks and face challenges for an upscale social mobility objective. Their health was assessed at the borders, and, in many countries, being diagnosed with certain disorders lead to an immediate expulsion. This contributed to the formation of the “healthy migrant” myth (Chimienti and Achermann 2007). During and increasingly after the 1980s, however, the “healthy migrant” myth has evolved into the “unhealthy migrant” myth, whereas migrants are considered not only vulnerable to health problems but also a public health threat as carriers of diseases (Kaya and Efionayi-Mäder 2007). In the field of mental health, since the 1990s, the general discourse on vulnerability of migrants has been semantically characterized by “trauma” narratives, whose pertinence is clinically and sociologically questioned by many critics (Papadopoulos 2002; Summerfield 2001).
In reality, nowadays safe and vulnerable migration processes coexist, but the latter only monopolize the political and social discourse on migration. In terms of health vulnerabilities, it is difficult and probably wrong to draw a direct cause and effect relation between migration and specific pathologies (Conféderation suisse 2006). According to the WHO, the exposure of refugees and migrants to the risks associated with population movements increases their vulnerability to some noncommunicable diseases, including psychological disorders, reproductive health problems, higher newborn mortality, drug abuse, nutrition-related disorders, and alcoholism (WHO 2016). For most experts, however, being a migrant is not to be considered as a health-risk factor in itself, and each migrant’s vulnerability to a disorder has to be considered as the result of a combination of genetic, social, economic, political, and administrative factors (Kaya 2007) and individual and family lifestyles (Lindert and Schininá 2011). Looking at systems, evident are the negative effects that the hazards of unsafe travels and the conditions of life and work of certain categories of migrants, as well as the administrative procedures related with immigration in transit and receiving countries can have on the health of a migrant (Kaya 2007), which has brought some to advocate for the consideration of migration as a social determinant of health. Davis et al. (2006) state that migrants are affected by social inequalities, which increases the likeability for them to experience risks to their physical, mental, and social well-being, in countries of destination and transit (Davis et al. 2006).
Migration and Mental Illness
Migration in the last two decades has been often associated with psychological and emotional vulnerabilities, either resulting from the “trauma” experienced by the migrants in the past (Kaya and Efionayi-Mäder 2007) or their difficulties in adapting to a new culture and way of living in absence of preexisting support networks and significant relational ties in the new country (Loue and Sajatovic 2009). According to the WHO, mental health is a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO 2014). Looking at this definition, it is true that migration can pose serious threats to the mental health of migrants. Migrants are indeed facing stressors that are at times abnormal, which regard the reasons that brought them to decide to leave, the conditions of travel and reception in the new countries, and the adaptation to the new situation (Bhugra and Becker 2005). Migrant’s conditions of work in many instances risk to be exploitative and unethical (ILO 2009), especially for irregular migrants, who work under the table and do not enjoy regular contracts and workers’ rights (ILO 2009). Migrants’ contribution to their community is made difficult by the proliferation of communities to contribute to, which include the community back home, the host one, and the migrant community in the host country, with their different expectations, functioning, and set of values (Bhugra and Becker 2005). Moreover, some host communities do not enable all migrants to fully contribute and at times proactively exclude them, due to stigma, prejudice, and punitive administrative procedures (Merritt 2015). Finally, despite their best intentions, migrants may not be in a position to demonstrate their full potential, due to administrative limitations, stigma, and brain drain and de-professionalization (OECD 2016). These factors are political, administrative, sociocultural, and socio-relational in nature and can build on preexisting socioeconomic and psychological vulnerabilities. These various stressors can bring to negative psychological outcomes, including anxieties, toxic stress, sadness, a sense of rebound, anger, maladaptation (Potochnick and Perreira 2010; Kirmayer et al. 2011), or what Renos Papadopoulos calls nostalgic disorientation (Papadopoulos 2015).
The answer to the question whether these negative psychosocial factors and related emotional outcomes make migrants more vulnerable to mental disorders is still inconclusive.
First, the heterogeneity within results of the existing research is wide (Kaya and Efionayi-Mäder 2007), which highlights how evidence is hampered by the quality of sample size and selection and the reliability of the tools adopted. The populations included in research on mental health of migrants vary from study to study, making it difficult to derive comparative or generalizable data and to conduct comparative reviews (Lindert and Schininá 2011). Most of the research is not longitudinal; it is based on self-reports or checklists rather than clinical interviews and focusses on the same set of disorders (anxiety, depression, PTSD, and psychotic disorders) (Selten and Hoek 2008). A part from the lack of exploration of other possible clinical outcomes, some critics envisage problems with the pathological categories used, as they are based mainly on a western understanding of mental illnesses and mental health (Knipper and Bilgin 2009). Finally, the way studies are designed makes it difficult to correlate specific pathologies with forms of migration, socioeconomic conditions of migrants, and contextual factors and sectors of employment (Carta et al. 2005). The limitations of conducting mental health epidemiological research on migration are, however, objective. Migration is a global phenomenon, and the definition of migration encompasses often incomparable life paths, causes, destinations, populations, industries, genders, and age groups. Analyzing all these correlations can provide a structured vision of the mental health problems at stake, but statistical cross-analysis of these data is nearly impossible and not central in the design of efficacious response programs. Moreover, being able to derive differential epidemiological data on migrants from national surveillance systems becomes impossible as soon as a migrant enjoys the same set of health rights of the resident population and is therefore not registered separately (Devillé et al. 2011) – something that, regardless of its impact on epidemiologic research, is nevertheless to be advocated.
These limits in research withholding, existing studies tend to confirm that certain categories of migrants are more likely to develop certain mental disorders than the resident population, but generally speaking, migrants are not that different from the general population.
PTSD is mainly studied in the context of asylum seekers and refugees (Gojer and Ellis 2014). Most studies confirm a higher prevalence of PTSD among these two categories than in the resident population and the other migrant populations, excluding victims of trafficking. PTSD as a syndrome has been however under scrutiny for many years, and some scholars and professionals arrive to consider it a clinical invention without validity (Summerfield 2001 and Eisenbruch 1991). It is certainly true that the variance of prevalence of PTSD across populations and contexts have called in recent years for a revision of the relevant symptomatology in the main diagnostic manuals (APA 2013), which makes most prior research obsolete. There has been some debate about overdiagnosis of PTSD, especially in crisis settings (Brunet et al. 2007). The results of most research however confirm a direct link between disruptive events experienced in the past and limitations to the functionality of a minority of affected individuals in the present moment, to various degrees of severity (Lindert and Schininá 2011).
A significant correlation between different forms of migration and depressive disorder is confirmed by various studies with different migrant populations, conducted in different host countries in various periods of time, such as Mexican migrants in the USA (Breslau et al. 2011), over 50 years old migrants in Germany (Aichberger et al. 2012), different migrant populations in Central Asia (Ismayilova et al. 2014), and in Turkish, Portuguese, Somalian, and Tamil migrants in Switzerland (Schweizerische Eidgenossenschaft, Department des Inneren 2010). Moreover, relatives left behind by migrants were found more likely to develop depression than other populations in China (Lu et al. 2013) as well. Most studies correlate or associate depression in migrants to stresses related with the adaptation to the new context, lack of social supports, and marginalization. Bhugra and Goldberg (2003) attribute the causes for depression in migrants to a combination of biological, psychological, social, cultural, and environmental factors (Bhugra and Goldberg 2003).
Even if less present in the general discourse on migration and vulnerability, a consistent and more valid body of research confirms a higher risk for psychotic disorders in migrants than in the resident populations. In their meta-analysis and review of relevant studies (1973–2003) on prevalence of psychotic disorders in various migrant populations in Denmark, the Netherlands, and the UK, Cantor-Graae and Selten (2005) conclude that a personal or family history of migration is an important risk factor for those. Tortelli et al. (2014) confirm these results for Sub-Saharan populations in France and refer to studies reaching similar results in England, Italy, Norway, and Sweden for other migrant populations. Hollander et al. (2016) studied the prevalence of psychotic disorders and other non-affective psychoses among refugees and non-refugee migrants from the Middle East and North Africa, Sub-Saharan Africa, Asia, and Eastern Europe in Sweden. In the study, refugees result more at risk of psychotic disorders: (126.4/100,000), than non-refugee migrants (80.4/100,000) and resident populations (38.5/100,000) This is a study with 1,300,000 participants compared with non-refugee migrants from the same regions of origin and the native-born Swedish population and using a sound research and statistical model (Hollander et al. 2016).
Bhugra and Jones (2001) identify few possible causes for migrants’ vulnerability to this disorder, including (1) higher rates of psychotic disorders in the countries of origin, (2) more predisposition to migrate in people with psychotic disorders, (3) the fact that migration brings to stressors that can facilitate the manifestation of psychotic disorders, and (4) misdiagnoses due to cultural misunderstandings (Bhugra and Jones 2001). These hypotheses need to be unfolded. It is not true that sending countries have always higher rates of psychotic disorders, even though sometimes they enjoy very poor mental health surveillance systems in general, which make baseline data unreliable. Moreover, results do not hold for the same populations across different host countries, hinting that the most relevant determinant is the process of integration in the new country, and not provenience, nor the act of migrating in itself (Tortelli et al. 2014; Cantor-Graee and Selten 2005). The results of studies (van der Ven et al. 2014; Cannon et al. 2010) on the selective migration hypothesis (Ødegaard 1932), according to which people predisposed psychotic disorders are more predisposed to migrate, disconfirm this hypothesis and again hints at the stress of adaptation as the determining factor (van Os et al. 2010).
As for misdiagnoses, the seminal studies on the case of Caribbean migrants in the UK (Selten and Hoek 2008; Morgan et al. 2010) and other relevant studies (Cantor-Graae and Selten 2005; Bourque et al. 2010) tend to confirm that some migrant populations in determined contexts are more prone to peculiar manifestations of psychotic disorders, which may be related with cultural norms, religious elements, and the different value given in different cultures to the concept of possession, and can remain a challenge for the western diagnostic system and defined psychopathologies (Hollander et al. 2016; Bhugra et al. 2011; Versola-Russo 2006). These differences can indeed bring to misdiagnoses.
It is worth noting that while the rates of psychotic disorders in migrants are higher in statistical terms than the ones in the general population in some studies, in general terms this problem regards an extremely small part of the surveyed migrant populations. In the study from Hollander et al. (2016) that was already presented, the difference in prevalence of psychotic disorders was of less than 50 persons every 100,000 migrants, that is, the 0.005% of the population.
There are specific categories of migrants that are more prone to develop mental disorders than other migrants and the general population, including victims of trafficking and migrant detainees. Ottisova et al. (2016) conducted an updated systematic review of 37 studies on prevalence and risk of violence and physical, mental, and sexual health problems among victims of trafficking. The researches included in the review focus primarily on female victims of trafficking trafficked for sexual exploitation, with very few studies including men and children or victims exploited in other industries. All studies, irrespective of gender and profile of the population and geographical region, confirm a very high prevalence of symptoms suggestive of anxiety, depression, and post-traumatic stress disorder (PTSD) and of psychotic disorders in men. While it is true that the wide heterogeneity within results for each mental disorder between studies puts into question investigation methods and in particular quality of sample size and selection, thematic focus, and reliability of the tools adopted, the general trend is quite clear (Ottisova et al. 2016). Studies looking at causal correlations found that sexual abuse and physical violence, longer duration of trafficking, and post-trafficking stressors (poor social support and greater unmet needs) independently predict mental disorder post-trafficking (Abas et al. 2013; Kiss et al. 2014; Oram et al. 2012). Another group at risk are unaccompanied and separated minors. Even though this is a highly diverse group (ethics, upbringing, etc.), studies show that they are prone to develop symptoms of PTSD (Huemer et al. 2013) and for emotional and behavioral problems (Bronstein et al. 2012) higher than in normal population and accompanied minors.
In addition, several studies show that detention has a negative effect on migrant’s mental health. Robjant et al. (2009) in a systematic review of 10 studies with different detained migrant populations found that anxiety, depression, PTSD, self-harm, and suicidal ideation were commonly reported in all studies and time spent in detention was positively associated with severity of distress. Steel et al. (2005), in a study aiming to investigate the longer-term mental health effects of mandatory detention on refugees concluded that past immigration detention contributed to risk of PTSD, depression, and mental health-related disability. Also in this study, longer detention was associated with higher prevalence of mental disorders, which persisted for an average of 3 years after release. Kotsioni et al. (2013) and Bacon et al. (2010) all found a direct correlation between detention of migrants, refugees, and asylum seekers and worsened mental health state.
A Right-Based Approach
In synthesis, research on migrants and mental illness is technically weak and probably not entirely ameliorable due to objective difficulties. The existing research hints to a higher vulnerability of certain categories of migrants to certain mental disorders, but it is not conclusive, and the analyzed difference regards, in any case, a very small part of the population, for severe mental disorders. Moreover, the same research seems to confirm that the determining factors of migrants’ vulnerability to these disorders are linked with the process of integration and its social aspects, including unnecessary and often arbitrary detention. Certain migratory experiences which expose migrants to sexual and political violence, exploitation, and detention are associated with a higher vulnerability to mental disorders. Those experiences, in fact, equally affect the mental health of migrants and nonmigrants but are likely to be more frequent among migrants. In all cases, nothing in research substantiates that migrants are less vulnerable than residents to mental disorders.
Mental health is a need of migrants as much as it is a need of nonmigrant populations. More importantly, mental health, as any forms of health, is a right of migrants as well as it is a right of nonmigrant populations. A consistent body of international legal instruments supports all migrants’ right to mental health care, starting from the International Covenant on Economic, Social and Cultural Rights (WHO 2008). Other instruments enunciate the right of specific categories of migrants to mental health care and psychosocial support, as it is for VoT (UN-GA 2000) and separated and unaccompanied minors (UNHCR 1997). More recently, the UN Human Rights Council readdressed the issue of mental health needs and care within a human rights framework, promoting legal access for everyone (UN-GA 2016). Prevalence studies, in this framework, are useful if they aim at improving quality and diversity of services and facilitate access. However, the very design of most studies is not really conducive to this objective and is actually aimed at justifying the need to offer mental health care to migrants. It is true that this research may be used to promote the application of the right, substantiating it with a need. On the other side, it risks to become functional to the current public discourse and national social and access policies on migration that, from the 1980s on, have progressively transformed migrants from subjects to objects and from objects to “abjects.”
The transformation of migrants from subjects to objects is embedded in what Vanessa Pupavac calls the “therapeutic governance of societies” (Pupavac 2001). She posits that in the last decades, representative democratic societies and ruling political classes have understood governance in terms of risk management rather than participation and strategy. This approach would seem to question or at least minimize the value of democracy, and it has been hampered by ideological presumptions and vested interests in the identification and prioritization of the risks that “need” to be managed, but it has gone largely unquestioned. Pupavac does not link the therapeutic governance of societies to migration governance. Yet since therapeutic governance is strictly linked with the act of defining categories based on vulnerabilities and manage them in terms of risk, it is all too easy to see how this connects to the way migration governance has been approached in the last decades and how this approach is connected with prevalence studies on mental disorders in migrants. In addition and progressively, migrants have been transformed from objects to “abjects.” Bulgarian philosopher Julia Kristeva defined the abject as neither an object nor a subject but as an entity that was radically excluded by our symbolic order of meaning to allow the intersubjective community to persist – the opposite of the object of desire (Kristeva 1982). In this sense the abject has to do, in her words, with “what disturbs identity, system, order. What does not respect borders, positions, rules” what highlights the “fragility of the law” and marks the eruption of the “real” into our lives (Kristeva 1982). We are attracted and repelled by the abject because we are attracted and repelled by “death’s insistent materiality” and from being confronted with concrete images and events that traumatically show us our own temporal and symbolic limits as individuals and as a society (Kristeva 1982). Because of their abjectization, migrants lately have become significant for us only if they are dead or if they suffer in the act of migrating. The suffering of the “abject” tends to be understood in terms of trauma and mental disorder. In reality vulnerable migrant’s presence makes us question our very symbolic and social order because migration displays all the horror that, as a society, we have tried to exclude, in order for us to persist, such as poverty, war, injustice, and pandemics. The migrant traumatizes us by reminding us that this horror still is, and therefore we call the migrant traumatized, because the migrant is indeed the carrier of the trauma he/she provoke to us and our ordered society with the testimony of the persistence of the abject and of our own temporal and symbolic limits.
This paradox lies at the center of the ongoing migration debate; the very suffering of the migrant is the only reason that makes us finally look at a migrant as more than a category, more than an object, but also the main reason why we reject him or her.
Prevalence studies, even when they are done to support migrants’ right to mental health care, risk to reinforce these narratives, especially when services are then not available or accessible to migrants or they are generally stigmatized.
To be effective and ethically sound, the general focus on mental illness of migrants should switch from a need-based to a right-based approach. This right for migrants is often overlooked. In many countries not all migrants have right to health care, with mobile populations and irregular migrants always falling out of the existing system (EYD 2015). Even in those countries where primary health care is available for all, migrants’ legal right to access secondary and tertiary health-care services is not granted or complicated by specific administrative procedures, and this is where most mental health services are located (Keith and van Ginneken 2015). Even when the legal right is granted, problems of outreach, information, language, cultural relevance, stigma, and education make those services often inaccessible for migrants (Morris et al. 2009). Switching to a right-based approach would mean to look at these obstacles to create diversity oriented and inclusive systems, and research at this point would be population and service specific, looking at ways to operationalize migrants’ right to mental health care rather than aiming at substantiating the need of it, which should be given for granted.
Some Effective Actions to Promote Migrants’ Access to Mental Health Care
A right-based approach to the provision of mental health care for migrants brings to the search for modalities that can make mental health services legally available, factually accessible, and technically efficacious for migrants. A series of recommendations that could facilitate availability, accessibility, and efficaciousness of those services are presented below to conclude this chapter. Since mental health care in countries of origin is mainly offered at the secondary and tertiary care level, it is important to promote or advocate for policies and procedures that grant to all migrants access to primary, secondary, and tertiary health services and not only to primary one.
As migration and integration can create major stressors and most mental disorders in migrants are correlated with social problems in the integration phase, mental health and mobility considerations should be mainstreamed in all the concerned systems: the educational, the social care, the health care, the religious, the security and law enforcement, and the community services ones. This can take the form of capacity building of different professionals and of integrated models of service. There is no doubt that migration is a feature of today’s citizenship, and since the psychopathology of migrants does not differ substantially from the psychopathology of nonmigrant populations, segregated mental health-care services for migrants are not to be advocated, while the existing services need to be potentiated for all and be made migrant friendly.
Often migrants have problems in accessing existing services due to a number of reasons including a lack of information and understanding of mental distress, using different idioms of distress, and stigma; it is important that outreach to different migrant communities should be envisaged in forms that are linguistically and culturally appropriate and efficacious. This can include the creation of capacity among volunteers from the various migrant and host communities.
Since talking therapies dominate western therapeutic models, language barrier creates an obstacle in providing psychotherapy to migrants. Mental health services should always consider interpretation and training for interpreters among their core functions, especially those services in high migration areas. Moreover, mental health has to do with what is acceptable or unacceptable behavior in a culture and a community, and as such the understanding of cultural differences is essential to achieve good therapeutic results and avoid misdiagnoses when therapists and clients come from different cultures. In this respect, the formation of cultural or mental health mediators coming from migrant communities and capacitated in absolving this function has proved efficacious in many countries. In contrast, since migrant communities are multiple, the cultural mediator model may become unsustainable in many cultures. In addition, due to multiple subcultures in a culture, cultural mediation can at times in itself lead to stigmatizing. The management of cultural diversity in the help and therapeutic relation should in any case be made part of the training curricula for psychiatrists, clinical psychologists, clinical social workers, and nurses, especially in countries of high immigration.
In this respect, research should switch from a purely and generic focus on prevalence, to the “systematic enquiry into (…) culturally appropriate indicators of social, vocational and family functioning, which will allow clinicians to recognize problems in adaptation and undertake mental health promotion, prevention or treatment interventions in a timely fashion” (Kirmayer et al. 2011) and in research that help defining different understanding of psychosocial functioning in different cultures ad contexts to tailor appropriate responses.
All this could help operationalizing migrants’ right to mental health care, avoiding coincidentally, that migrant’s mental health needs are used to “objectify” them in terms of risk and to concur to their progressive objectification.
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