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“So far different countries have responded quite differently to the psychosocial needs of immigrants“

“So far different countries have responded quite differently to the psychosocial needs of immigrants“

Photo: Smiling woman with dark hair asked Doctor Yesim Erim of the LVR-Clinical Center Essen/Institute of the University of Duisburg-Essen, Clinic for Psychosomatic Medicine and Psychotherapy, what culture can mean for our feelings, what studies have been conducted on the subject and what treatment options there are for immigrants. Doctor Erim, how much does culture control our emotions?

Yesim Erim: That’s a difficult question. For instance, a separation or divorce situation in the Turkish cultural milieu can be experienced as very emotionally draining – and can also lead to depression or post-traumatic stress, while a separation in another cultural area can be viewed as something, though stressful, more commonplace. That is actually a great example from our research.

For instance, we have a special treatment choice for immigrants from Turkey and in this group we examined what personal events these immigrants experience as something that’s very stressful. The result was that break-ups and divorces, respectively, are perceived as extremely stressful. In most cases this dealt with marital relationships, since in this environment there is no tradition of cohabitating before marriage or to have non-marital cohabitations. It’s primarily women who experience the break up of such a relationship as very emotionally draining. You can definitely understand this very well, since there were many people in this Turkish group who did not come to Germany until after marriage. So culture plays a big role here, but so does the immigration situation. Language is not the only barrier for psychological support, but also the immigration experience: Are there projects, both at home and abroad, to better attend to people from different cultural areas?

Erim: Of course there are. So far however, different countries have responded quite differently to the psychosocial needs of immigrants. Take the U.S.A. for instance: Here you no longer just talk about immigration, since there are many people from different cultural areas who have lived there together for quite some time. The largest group is made up of African-American people. This group has been researched over the past 30 years and it was discovered that the group doesn’t just exhibit cultural differences, but also social and disadvantages specific to society level. For this reason so-called diversity programs were created that try to include people from different ethnicities into all areas of social life as well as also into psychosocial support.

In addition so-called empowerment programs were developed. The belief here is that this group has lost some mental power due to ethnical and specific characteristics pertaining to social class. And it was also proven, that in the group of African-Americans for instance the crime rate, substance abuse and suicidal tendencies were significantly more distinctive compared to other ethnical groups, whereas at the same time education was marginally distinct. Thus the income of these people is lower which results in a higher potential for conflict. That’s why there was a lot of work on programs to be able to offer these groups specific education as a preventative measure and to perhaps alleviate fears or to hold them more socially accountable again. So the therapists were appropriately trained to be able to respond to specific cultural characteristics?

Erim: That’s correct; the therapists received a special education. There are also guidelines for psychotherapists you can gear yourself towards when you are working with certain groups. With African-Americans for instance it’s said that the family holds a lot of power – but you have to resurrect this strength again.

  Are these guidelines also defined in Germany?

Erim: In Germany a guideline was written and published for the Turkish-speaking group. This guideline from Essen, Germany, for cross-cultural psychotherapy recommends for psychotherapists to look into their own biography, their own attitudes and moral concepts. Generally this is something that’s very important when you train to become a psychotherapist. This is called self-awareness. Regardless of what kind of education you pursue, you have to present self-awareness, so you are able to sense your own judgments and prejudices when you deal with patients. And one very important requirement is that this general self-awareness does not suffice in a cross-cultural psychotherapeutic relationship. After all, a therapist needs to extensively deal with his assumptions and prejudices towards an ethnic group, if he treats patients from this group. Migration presents mental stress for many people: In what countries were studies mainly conducted and why is there barely a corresponding study in Germany?

Erim: Indeed there are no representative population studies in Germany. That is to say, even though there are studies like the ones we have conducted where smaller random samples are being examined; most studies however analyze people for example who already have issues. We call this a case study sample, meaning a sample that already appeared with issues in the system, for instance in a hospital or an outpatient clinic. In fact to get a better informational value you would need to also examine samples from people who really represent everything that exists in Germany: Age, gender, immigration experience. The fact that such studies don’t exist yet certainly has many reasons. Basically in the political sector it was also acknowledged relatively late, that immigration is an important phenomenon. Surely you are familiar with this from political debates: Is Germany an immigration country? This is a very late admission in politics.

That’s why at the moment there are only few studies. However, there is for instance a reanalysis of data that has already been collected, for example of large representative population studies done five or ten years ago. Here you check again how immigrants performed back then. One important question for example is: Are immigrants sicker more often or have an increased occurrence of mental disorders?

Those questions remain essentially open if you look at all of these studies, because the studies in most cases are not tailored toward immigrants and were not prospectively conducted. So you analyze after the event, like for instance how immigrants are doing – and through this approach there are always distortions. If I take citizenship for instance, I have to reckon that immigrants who have better resources have already accepted citizenship. That is to say, I am not capturing this specific group in the study. That’s why there also is a dispute on who actually counts as an immigrant. Currently there is an understanding that says: Immigrants are people who were either born abroad or whose parents were born in a foreign country. And this of course enlarges the group. The WHO has conducted a study in 14 countries that proved that specific symptoms can be assigned to specific cultural groups1. Could you briefly sum up the findings of this study?

Erim: This study was about so-called somatic or functional symptoms. This includes disorders that are of a physical nature but that don’t have a physical origin. That is to say, people for instance exhibit stomach pain, even though there is nothing wrong with the actual organ. Even so, they experience pain in the stomach area. In this case you say that mental disorders are physically experienced. This is a universal phenomenon that takes place in all cultures. The WHO-study confirmed this, but also discovered differences. In India for example, “burning sensations“ are more frequent, meaning for instance a burning of the scalp, whereas in Latin-American cultures for example feelings of helplessness are more frequent. In Turkish patients on the other hand there are more pain symptoms. However, you can also say this about Germans: In the case of backaches, the pain perception for instance often exceeds ”normal“ levels. That’s why today there are multi-professional outpatient clinics in almost any city. Here you often meet patients who complain about functional or functionally overlaying discomfort. Do patients notice that they are being specially treated when they come to such an outpatient clinic or does this virtually happen covertly?

Erim: No, this cannot take place in secrecy, because when you treat functional disorders, for instance as a psychosomatic doctor, at first you mostly start with psychoeducation. The patients are informed on how the pain or the pain perception for example originate. After all, pain originates in the brain and when it comes down to it therefore in our perception. Patients need to learn these things, so they can do specific exercises for example that can divert them from the pain.

The interview was conducted by Simone Ernst and translated by Elena O'Meara.



1: Gureje, O. (2004). What we can learn from a cross-national study of somatic distress? Journal of Psychosomatic Research, 56, 409-412



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