We decide to summarize an interesting paper made by the World Health Organization that talks about the cultural contexts of health. The study is focused on the use of narrative research in the health sector, and the part that we choose to show to our readers highlight the mental health of refugees and asylum seekers.
Most health-related research focuses on demographic trends and quantitative measures of health status and needs. Narrative research can provide an important complement to deterministic, variables-centred research and the bureaucratic need for standardized categories.
A number of factors may affect mental health in migrants, including the effect of forced migration and disruption, trauma and psychological stress, issues of acculturation, and interaction with the asylum system and the health care system. Ruiz and Bhugra proposed a taxonomy of variables that impact either positively or negatively on the acculturation process for migrants, including sociodemographic variables, societal variables, migrant group variables, sociological and psychological variables and behavioural variables. They comment:
These variables, as well as the final mode of resolution of the acculturation process, will determine the final degree of positive or negative outcomes when resolving the impact of the acculturative stress.
A major factor that can lead to mental health issues for migrants is trauma related either to events in their home country that precipitated their migration or to the journey itself. In 2011, the European Observatory on Health Systems and Policies described and quantified patterns of voluntary and forced migration into and within the countries of Europe and their effect on health. One section of that book highlighted the higher prevalence of both nonspecific psychological stress and psychopathology in forced migrants than in the general population or voluntary migrants. The preferred explanation is the life-course violence model: traumatic events taking place before and during migration may have latent effects, leading to vulnerability to illness that can be triggered at later times, and particularly when exposed to adverse circumstances following migration.
Partly because of the difficulty in obtaining authentic, first-person narratives in this field of enquiry, some authors have used a more radical, semi-fictional approach to conveying sufferers’ experiences. Dr Joseph Achotegui, Professor of Psychopathology at the University of Barcelona, has described a new syndrome, Ulysses syndrome, which he defines as a combination of both physical symptoms and psychological ones experienced by migrants facing multiple stressors. This is not an accepted mental health disorder under the WHO “Classification of mental and behavioural disorders”, as post-traumatic stress disorder is, for example. Rather, Achotegui suggests that it is an extreme form of migratory mourning, a holistic disorder of well-being generated by the extremes of context and hence is better studied with reference to myth and meta-narrative than to medicine’s manuals of diseases. It is named after Homer’s Greek hero Odysseus (known as Ulysses in Roman myths) who spent 10 years through a long and exceptionally harrowing sea journey to return to his home after the fall of Troy; far from his loved ones, he spent days “sitting on the rocks, at the edge of the sea, setting eyes on the barren sea, crying inconsolably“. The syndrome has been described in the following way: The Ulysses Syndrome takes place at the extreme level of stressors. The complex migration context may include factors causing high levels of stress such as: forced separation, dangers of the migratory journey, social isolation, absence of opportunities, sense of failure of the migratory goals, drop in social status, extreme struggle for survival, and discriminatory attitudes in the receiving country. Rather than explaining the symptoms of Ulysses syndrome in terms of combinations of variables Achotegui instead draws parallels with the intercultural story of Ulysses, whose identity is so profoundly damaged from his ordeal that he says, “You ask me my name. I shall tell you. My name is nobody and nobody is what everyone calls me“. Achotegui draws extensively on numerical data to describe the problem of forced migration but he also provides detailed case narratives of individual migrants and makes explicit and rhetorical use of metaphor. For example, he acknowledged that most immigrants do not arrive by raft but viewed the raft (precarious, makeshift, risky) as the perfect metaphor for the migration journey. He quoted his patients’ use of metaphor (one said, of his sense of confusion, “it is as if I had a centrifuge in my head, working all day“). He used his own metaphors and imagery to illustrate the near-unbearable tension between hope and despair experienced by many forced migrants.
Achotegui emphasizes the fact that most forced migration journeys today are undertaken alone rather than as a three-generation family as described by John Steinbeck in “The grapes of wrath”; his fictional Joad family were forced to migrate by severe economic hardship but did so as a supportive unit. The rhetorical devices of association and dissociation combine to make a powerful narrative point about existential isolation.
One area in which narratives of forced migrants have been researched successfully is in the study of experiences of the health care system. Two studies asked about such experiences, one through narrative interviews with 20 Somali refugees in Sweden and one with focus groups with 34 Somali refugees in the United Kingdom. Findings were similar: a high regard for the health care system in the host country (and high expectations of it), but difficulty accessing services (particularly when moving between temporary housing) plus perceptions of discrimination from health care staff. Participants felt that their problems and culture were not well understood by health professionals, who (allegedly) did not take them seriously. In the United Kingdom study, high use of accident and emergency departments was attributed by Somali refugees to being refused care (or their concerns being dismissed) by general practitioners. These studies have direct and important lessons for the redesign of services and the education of staff.