The not belonging effect on mental health in immigrants

There is a saying that I learned during my counselling training which I came to understand later on in my practice, “you get clients that you need”.  

After living in the UK for 17 years and having integrated myself proudly and happily in the way of living in this country, I still feel a sense of not belonging. I go back home (Brazil) once, sometime twice a year to see my family and be surrounded by what I believed is my culture, and yet I feel that I don’t belong there anymore. I have for some time been exploring the depths of the mental and emotional impact of feeling afloat, struggles that can manifest as some of my foreign clients described, extreme loneliness, a hole, inner criticism, anxiety and depression.  
  
Migration has historically had a great participation in the creation and strengthening of economy in the developed countries and it comes with a price for those living their birth home and their beloved ones behind. We leave some parts of us behind and learn new ones, parts that were in us but buried by social norms and expectations and some that we learn from a new environment. Nevertheless, this dance between the old and the new can cause great confusion in one's perceptions of themselves and how we experience the world around us, impacting on important aspects of well-being such as self-esteem, relationships, self-identity and self-acceptance.  

A study called Migration, cultural bereavement and cultural identity, (Dinesh Bhugra and Matthew A Becker, 2005), explores the cultural identity loss and lacking sense of longing that immigrants go through and how little attention and support is given to the fragility of mental health of this minority group. Also, those searching for safety and/or better life quality, fleeing discrimination, poverty and war zone are not less subject to the stress of finding themselves in a new light.   
 
As concluded in the study above, there is a need for mental health practitioners to be culturally curious towards the cultural background and how it impacts the client in the here-and-now self-experience. In Gestalt therapy methodology, we explore all aspects and parts of one`s being by applying the Field Theory. Also, to be more inquisitive to the deeper layers (bereavement of culture and self-identity, community, family estrangement and so on) that lies beneath presenting psychological symptoms.    
 
Some psychological symptoms can be caused by deculturation presented in my practice:

• The loss of a religious community can cause depression and isolation.  
• People fleeing homophobic communities can struggle with internalized homophobia in a freer society.  
• Moving abroad for better socio-economic opportunities can evoke shame and guilt in leaving family in their home countries.  
• A sense of deep loneliness and disconnectedness is detrimental to having relationships, groups and support.  

Some ways to support clients with those present issues:  

• As mentioned before, being inquisitive about one`s background (nationality, sexual orientation, race, language, religion and so on) and bringing all these elements to the therapeutic room, raises the client's self-awareness.  
• Assisting the clients to explore those cultural layers and helping them on the self-agency and rediscovery journey to accept what is theirs (authentic self) or something learned from their environment that they wish to let go.
• With the most complicated cases, I found it helpful to apply the Gestalt, Paradoxical Theory of Change. The client is supported in bringing to awareness the aspects of their upbringing that they had to endure and accept how that impacted their being today. Make peace with it and just then change can happen.

As a practitioner, I have also learned from my clients how complicated relationships within families that immigrated as adults and had their children in a culture different from theirs can be. Young adult and adult clients have been seeking psychological support to deal with their sense of identity incongruency resulting from living between two cultures (their parents and the country where they were born); consequently, living torn between their parent's expectations and demands based on what they feel is the religious and societal norm; and the clients cultural lived experience of the new country.

The pressure to oblige, the guilt, shame and sense of fragmented self, can drive people, under those circumstances, to look for escapism in alcohol, drugs, betting and many other forms of disassociation and in more severe cases even suicide. It becomes even more complicated to the process of identity construction in an ethnic discriminating society, which can further hinder one`s sense of safety to explore their sense of who they are and where they feel belonged, therefore full expression of themselves.   
 
In conclusion, the psychological impact of living at the crossroads of cultural worlds is real and very present in immigrants' lives and it needs to be explored in the therapy room. A study on The Case for Cultural Competency in Psychotherapeutic Interventions by the university (Sue et al. 2014), emphasises the importance of mental health practitioners being aware of their own cultural biases as well as being multiculturally informed in order to facilitate a stronger therapeutic alliance with the client.

Going back to what I mentioned at the beginning of this article, we can learn from our clients more what we need to learn about us and develop a broader understanding of how multilayered the client presenting issues are.