Migration, the mass movement of groups of people, may contribute to a unique set of clinical challenges that mental health practitioners around the globe must be able to recognize and treat if they serve migrant populations. The Oxford Textbook of Migrant Psychiatry, one of the most comprehensive textbooks of its kind, does an excellent job of not only contextualizing the cultural, political, and socioeconomic factors driving migration but offering culturally tailored therapies that all mental health providers, especially those based in western countries, ought to become familiar with. The textbook spans 75 chapters, divided into six sections explaining migratory as well as pre and postmigration phenomena associated with mental health. It is authored by over 100 contributors from around the world, all leading experts in their field. It is edited by psychiatrist Dr. Dinesh Bhugra, Emeritus Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London and former President of the World Psychiatric Association, Royal College of Psychiatrists, and British Medical Association (to name a few among a long list of honors and accolades).
Section One, “Background,” begins with the concept of identity formation in migrants. The authors then turn to a macroview of migration, focusing on cultural relativism and the moral obligation of richer countries to provide aid to ensure global welfare. They further explain the role of modern western politics in the flow of emigration from global south to north. Entire chapters within this section are dedicated to the discrimination of minority groups and its association with mental illness. Special focus is given to gender differences in mental illness, victims and survivors of human trafficking (including child exploitation in Europe), as well as lesbian, gay, bisexual, transgender (LGBT) forced migration. Theoretical and clinical frameworks for assessing and treating trauma disorders are highlighted alongside a call for clinicians to further their own cultural competence when working with marginalized populations. Authors also discuss the psychological impact of globalization, noting the effects of rapid technological changes on migration. They urge large cities, a pull for many migrants, to prioritize investment in mental health, citing potential economic gains in return.
Section Two, “Premigration,” begins with an explanation of the unique problems faced by migrant children. The authors also describe case studies and solutions for clinical rapport building. The authors then discuss various transcultural therapeutic approaches in shaping child and adolescent migrants’ complex cultural identities. Gender differences in migration are reiterated, this time elaborating on the psychopathology of migration in women. Other topics include the involuntary resettlement of elderly refugees and forced migration of families. Special focus is given to populations left behind in the home country following migration, specifically children and their caregivers. Research has shown that the effect of out migration possibly contributes to generalized mistrust and loss of social capital in these groups. The section concludes with an explanation of understudied phenomena, such as in migration (movement within a country) and the challenges experienced by disabled asylum seekers.
In Section Three, “Migration,” authors parse and juxtapose the many boundaries migrants may encounter and eventually cross: borders of time and space, deserts of health care access, and labyrinths of bureaucracy that often strand the stateless, even those who are highly skilled. This section also challenges longstanding tropes, namely that of the “unhealthy, infectious, and traumatized” migrant. To the contrary, most migrants are healthy at baseline and, except for refugees and asylum seekers in some populations, do not experience post-traumatic stress disorder (PTSD) at rates greater than that of other mental illnesses. Several authors reiterate the importance of developing sturdier tools to assess how the physical act of migration affects migrant wellbeing and delineate protective factors in this population.
Section Four explores the postmigration stage; nearly a third of the text is dedicated to this topic alone, and rightly so. The authors describe how new migrants must navigate the unfamiliar terrain of cultural, religious, and social mores of their host country. How psychiatry can best support migrants throughout the acculturative process is often the question at hand. Several authors warn against the pitfalls of pathologizing every migrant’s distress; at the same time, special consideration is afforded to those populations for which trauma is unfortunately quite prevalent (i.e., asylum seekers, refugees or exiles, victims of torture). This section reminds readers that newly arrived migrants must relocate themselves both in relation to their old and new cultural frameworks; a sense of loss and the motions of bereavement are not uncommon. Simultaneously, mental health providers are encouraged to develop culturally competent screening tools, offer intervention appropriate to the individual, and address medical problems via a sensible health system that does not actively disenfranchise those who are already vulnerable.
Section Five is a concise survey of psychotherapy modalities that can be offered to migrants. Authors address the discordant perspectives of clinicians and patients regarding therapy. Rather than highlight any potential cultural clashes, they frame the interaction as a dance of compromise and curiosity. They also leave room for adjunctive interventions like psychoanalysis, eye movement desensitization and reprocessing (EMDR), and religious counseling. In any case, this section establishes that whatever the psychotherapeutic approach, it must be tailored to the migrant’s own individual experience to allow for maximal cultural continuity.
Closing the text, Section Six addresses areas of a migrant’s life beyond the act of migration itself, such as encounters with racial animus and discriminatory institutional policies. This section also persistently advocates for a more robust delivery of psychiatric and medical services, ideally offered in the context of an integrated, accessible, and culturally competent system. Once more, readers are asked to consider the concept of distress versus disorder as well as the consequences of pathologizing all suffering. Telepsychiatry is discussed at length, including the idea of asynchronous telemedicine as a means of ameliorating access problems and linguistic barriers. Finally, the section broaches the subject of return migration, whereupon the migratory process can simultaneously undo and repeat itself, in some cases causing a similar level of psychiatric burden. Dr. Bhugra then concludes the text with an impassioned call to continue this work.
Oxford Textbook of Migrant Psychiatry does a wonderful job of explaining key cultural, political, psychosocial, and economic problems in the burgeoning field of migrant psychiatry. This text is an essential tool for the modern day behavioral clinician.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
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