Multiculturalism and Mental Illness:
Views of Mental Health Professionals on Mentally Ill Economic
Department of Social Work, School of Health and Care Sciences, Technological and Educational Institute of Patras, Greece
Multiculturalism is an established doctrine embracing multiple cultures. Interculturalism, the outcome of multiculturalism, aims at the peaceful co-existence of multiple cultural groups and minorities or ethnic groups within a society with simultaneous recognition of the rights of one group by the other group and especially the minority by the majority. The dynamics of multiculturalism forces our societies to evolve, proceeding from the majority society stage to that of the society of cultures and cultural groups (Vernikos and Daskalopoulou 2000).
The phenomenon of migration has always been a
very significant parameter in the history of the Greek population, while
developments in recent years have led to the country changing from one of migrant
outflow to one of migrant influx. This transformation emerges gently in the
second half of the 1970s, continues during the 1980s and intensifies in the
last decade of the 20th Century (Bagavos 2003). Special emphasis is
placed on the migration flows during the 1990s due to their size, the
variations observed in the characteristics of migrants and the fact that the
evolution of migration was for the first time associated with the effort of establishing
a migration policy based on the fact that
According to Robolis (2007), the 1990s was
undoubtedly characterized by the expansion of the role of migration in the
demographic changes that took place, in terms of the population size and age
structure. More specifically, the influx of migrants and their stay in
Greece, being a recipient country for a large number of migrants, has now become a European multicultural country since migrants account for more than 7% of the total population and more than 8% of its workforce.
Migrants, who number from 900,000 to 1,200,000, tend to reverse the composition of local societies, since in certain regions they constitute as much as 25% of the inhabitants (Riga 2007). The great majority of migrants are uninsured, do not receive any social security benefits or unemployment and sickness benefits, are low paid and employed in unhealthy jobs, while most of them are lodged in unacceptable conditions. They are tyrannized by the difficulties they face with regard to family reunification, while the education they receive is insufficient since their mother tongue and culture are absent (Riga 2007).
Social inclusion of migrant populations is subject to the diptych: i) the legalization of their residence in our country, ii) their integration into the official labour market (Kassimati 2003).
With regard to the migration issue in Greece, mainly during the last few years the following major issues have emerged: i) the legality of migrant residence and employment, ii) the benefit or not of their presence for the economy, iii) public safety and the crime rate and iv) the protection of human and social rights of migrants (Tsitselikis 2007).
The migrants, arriving in the recipient country, face the following: i) difficulties and restrictions in exercising their rights (e.g. family reunification), ii) the undue and uncontrollable administrative deportation procedure, iii) the scornful treatment of by the police, and by the public administration in general, iv) the acquisition of Greek nationality, which is granted through particularly restrictive conditions on the basis of ‘law of blood’, v) poor protection of employment rights and vi) the absence of dialogue and participation of aliens in decision making that concerns them (Psimenos 2004).
The susceptibility (or resistance) of the migrant towards psychiatric disorders may be related to the following factors: i) his ethnic origin, which concerns the frequency of psychiatric disorders in the ethnic group from which he comes, ii) the socio-demographic characteristics of the migrant (e.g. sex, age, social class), iii) the difference between the natural environment and culture in the place of origin and those in the place of migration, iv) the attitude of the native population towards migrants and vice-versa, v) the difference between the social status of a migrant in their place of origin and that in the place of destination and vi) the expectations of a migrant (Kontaxakis et al. 1994).
Madianos (2000) distinguished two psychological stages following arrival: i) The first stage, which lasts for about 2 months and is characterized by a subjective sense of ‘all being well’, with increased psycho-mobility, as a primitive manner of eliminating the stress and anxiety resulting from the migration and ii) The second stage, during which the migrant gradually perceives their social status and worries about communication difficulty with the natives and the differences in customs and values. The greater the difficulties, the greater the tendency of the migrant to flee the present through recollections of the past (nostalgia). During the second period, mental reactions become apparent and reach their peak approximately 6 months after the migrant’s arrival. The main symptoms during this period are as follows: i) suspiciousness and paranoid trends, ii) anxiety and depression, and iii) physical complaints, such as feeling of weakness, joint and muscle pains, insomnia, anorexia, nausea, dread, peptic ulcer disease, ulcerative colitis, asthma, and a tendency to conversion disorder.
The significant factors that affect the mental state of individuals who belong to ethnic-racial minorities during the acculturation process are as follows: i) the duration of the acculturation process. The rapid acculturation of a social group, in combination with the violent dissociation from the familiar social and cultural environment, results in social disorganization and is a cause of stress, which often leads to the manifestation of a mental disorder, ii) the existence or not of strong bonds with people of the same cultural origin, iii) the existence of a cohesive family system that constitutes an additional psychoprotective factor, iv) the stereotypes and prejudices towards minorities. Stereotype thinking leads to stereotype racist behavior, thus resulting in marginalization, which in turn affects mental health, v) the non-supportive social policy, which does not protect special social groups, such as the minority-ethnic groups, who are financially underprivileged and vulnerable to morbidity, and which excludes them from having access to mental health services and vi) the classification of minority groups as belonging to lower socio-economic classes, a fact that causes the manifestation of mental disorders through the known relationship between the lowest social class and high psychiatric morbidity (Madianos 2005).
According to Patiniotis (1989), the marginalization of migrants leads to conflicts over social rules and social roles, insecurity over social status, and disorientation as well as isolation, consequences that contribute to the manifestation of psychosomatic diseases. Being uprooted from the society and culture of the homeland causes serious intrapsychic conflicts as a result of the confusion caused by their new social role and psycho-social disorientation and the overt or covert disparagement of migrants.
The research hypotheses upon which this study was based are: i) there is a phenomenon of multiculturalism in our country, as the number of migrants has quintupled over the last fifteen (15) years and migrants constitute seven per cent (7%) of the total population residing in Greece (Riga 2007), ii) the Greek state is unable to adopt a social policy that will extenuate the phenomenon of social exclusion and social stigmatization of economic migrants, a fact that makes it more likely for them not to receive the treatment they need or to be offered services of lower quality, and not according to their needs (Megalooikonomou 2007), iii) there is prejudice towards mentally-ill economic migrants, which results from the lack of cultural sensitization and updating in mental health professionals themselves (Madianos 2000) and iv) the mental health services do not implement actions, and consequently mentally ill economic migrants are not informed of how and why they could approach such a service (Bilanakis 2006).
The study sample consisted of one hundred and sixty (160) mental health professionals, who worked in mental health services and health structures where psychiatric observation services were also provided. The selection of the sample was made on the basis of systematic sampling. In particular, sixteen (16) structures were selected from the two (2) Prefectures (Achaia,
With regard to the sample characteristics, 120
(74.5%) were women and 40 (25.5%) were men. Their ages ranged from eighteen
(18) to fifty-six (56) years old and over. 90 (56.3%) people were residents of
urban centres, while 42 (26.3%) and 28 (17.5) people resided in rural and
semi-urban areas respectively. 87 people (54%) were public sector employees, 34
people (21.1%) were employees with a fixed-term employment contract, 30 people
(18.6%) were employees with an indefinite duration employment contract, 7
people (4.3%) were under a works contract and the remaining 3 people (1.9%)
were hourly-paid employees. The specializations of the mental health
professionals were as follows: five (5) psychiatrists, twenty two (22)
psychologists, forty (4) social workers, ten (10) occupational therapists,
forty three (43) Nurses, graduates of Technological Educational Institutes,
thirty one (31) Nurses with two years of studies in Secondary Education and ten
(10) health visitors. The majority of the employees (54) had work experience of
10 years and over, while approximately half of them (25) had work experience of
20 years and over. Of the remainder, 42 employees had worked from to 3 years, 25 employees had worked from to 6 years and 19 employees had worked from to 10 years. Finally, only 12 employees had specialized
(postgraduate studies), 2 of whom had obtained a PhD and 10 of whom had
obtained a Master’s degree. Their specialization studies were not in the discipline
of multiculturalism and interculturalism.
Presentation of Statistical Research Results
According to the results of this study it was
ascertained that mental health professionals consider
Moreover, the majority of mental health
professionals (86.8%) believe that migration is an aggravating factor in the
development of mental disorders, while 12.7% do not agree with this (Fig.2).
(Figure 2 )
70% of mental health professionals believe that economic migrants constitute a significant part of the clinical population of mental health structures, while 30% responded negatively (Fig.3).
The majority of migrants (31.5%) who approach mental health services range from 31 to 40 years old (middle adulthood), 22.5% from 19 to 30 years old (young adulthood) and 19.5% from to 18 years old. Migrants in the age range from 41 to 60 years old (7.6%), from 60 years old and over (2%), from 7 to 11 years old (9.6%) and from 2 to 7 years old (7.2%) are much less likely to approach mental health services (Fig. 5).
The reasons why migrants approach a mental health service are mainly for the treatment of a psychiatric disorder (40%), to be granted some kind of benefit (19%), to seek employment (8%), to solve general health problems (6%), to be granted a health certificate (2%) and much less likely for the purposes of solving problems regarding their children (1%), being granted a residence permit (1%), receiving psychological support and counseling (1%) or finding and securing accommodation and food (1%) (Fig. 6).
According to the responses of the mental health professionals, the disorders for which economic migrants approach Mental Health Services are as follows: Anxiety Disorders (22.1%), Mood Disorders (17.6%), Personality Disorders (14.1%), Substance use (12.5%), Sleep Disorders (12.2%), Schizophrenia and Psychotic Disorders (11.2%), Sexual Disorders (4.3%), Somatoform Disorders (3.2%), Senility (1.6%), Delinquent Behaviour (0.3%) and all the above (0.5%) (Fig. 7).
84.7% of mental health professionals maintain that they themselves treat migrants equally (as they would treat Greeks) whenever they approach mental health services to seek help, while 12.5% of them give priority to Greeks and only 2.5% of them give priority to migrants (Fig. 8).
Moreover, when mental health professionals are called on to help a mentally ill migrant who does not possess the necessary legal documents, 92% of them maintain that they offer their help regardless of the existing legal problem, and 8% maintain that in such cases they refer them to Police Authorities (Fig. 9).
83.9% of mental health professionals believe that intercultural teaching is essential in undergraduate studies. 38.8% of them maintain that there should be actions and activities at undergraduate level to inform and sensitize potential future mental health professionals so that they might develop a more positive attitude towards migrants.
31.3% maintain that there should be undergraduate courses to facilitate learning about the different cultures and civilizations of other ethnic groups, and 4.4% believe that there should be courses in more foreign languages. Finally, 23.8% maintain that all the above should apply in the undergraduate studies of mental health professionals (Fig. 12).
With regard to the acceptance of economic migrants by the community in which the mental health professionals worked, 38% answered positively, while 62% responded that economic migrants are not accepted by the community.
In accordance with the views of mental health professionals, the reasons for non-acceptance of economic migrants are: the inability of the Greek state to offer services that could ensure a better quality of life for migrants (41.9%), the xenophobia that prevails in Greek society (14%), the inefficiency and indifference of social services (10.1%), insufficient diffusion of information about the problems of economic migrants (7%), and the inadequate development of integrated intervention programmes to deal with the Social Exclusion of economic migrants (0.8%); finally, 25.6% responded that all the afore-mentioned reasons are significant reasons. (Fig. 13).
According to the views of mental health professionals, economic migrants encounter social racism because of the following reasons: the inadequate social policy of the Greek state with regard to the smooth integration of migrants into Greek society (61.1%), the negative stereotype and fear of the ‘stranger’ and that which is ‘different’ (22.2%), economic migrants cause serious problems while enjoying the hospitality of our country (5.6%), the cultures of migrants are inferior to that of the Greeks (1.5%) and 7.6% of responses included all the above (Fig. 14). At the same time, mental health professionals believe that it is the Greeks (63%) and not the migrants themselves (37%) who are responsible for the social stigmatization of economic migrants.
( Figure 13)
With regard to the provision of qualitative services for care and treatment of migrant mental illness by mental health services, only 16% of them responded positively, while 84% of professionals answered that no services are provided in order to meet the needs of mentally ill migrants (Fig. 15).
Of those professionals who do not believe that mental health services are satisfactory and qualitative, 41% maintain that the main reason why mental health services cannot meet the needs of mentally ill migrants is because they are not organized to provide support to migrants.
24.2% of professionals believe that the services have no such intention, namely also to meet the needs of migrants suffering from a mental disease, while 15.5% of them maintain that the staff in these services does not have enough time available to inform migrants through information programmes so that they can approach mental health services. 11.2% of them believe that the community is not ready in general to comprehend the significance of the existence and development of mental health services, while 0.6% of them refer to reasons such as the non-satisfactory number of personnel who staff the services, the large size of the clinical population and the unequal allocation of financial resources, respectively. Finally, 6.2% of professionals believe that all the above-mentioned constitute reasons why qualitative mental health services are not offered to mentally ill migrants (Fig.16).
The ways in which qualitative mental health services to migrants could be facilitated are: the employment of staff specialized in community mental health and the existence of wider and qualitative networking of mental health services, through substantial action (21.2% each), the employment of translators (15.2%), the employment of mental health professionals from the same countries of origin as the migrants (9.2%), the spatial expansion of the existing workplace of professionals (λείπει ποσοστό), while 26.3% of respondents included all the above. Finally, 0.5% of respondents included measures such as: informing professionals of the legal issues related to migrants, the development of more social services, the legalization of migrants, the increase in financial resources by the State and the flexible working timetable of mental health professionals, respectively (Fig. 17).
To the question regarding the effectiveness of the Greek social policy in terms of the elimination of discrimination and the social integration of migrants in our country, 57.1% of mental health professionals responded that they believe that Greek social policy is insufficient, 32.9% maintain that Greek social policy does not include an organized plan for the migrants, while only 9.9% of them believe that Greek social policy is satisfactory with regard to the social integration of migrants in our country (Fig. 18).
Finally, with regard to the support that migrants should ideally [προτείνουμε να μπει η λέξη ideally] have in Greece, 32.6% of mental health professionals maintain that there should be special centres for the rehabilitation of mentally ill migrants, staffed by specialized personnel, 31.7% maintain that there should be cooperation between the Greek mental health services and the corresponding mental health organizations from the countries of origin of the migrants, through the delegation of specialized staff to cooperate with Greek mental health professionals, 18.1% believe that temporary hostels should be established, aiming at the return of migrants to their countries, 9.7% believe that Greece should follow the EU social policy for migrants, while 1.3% believe that migrants should be deported. It is worthwhile noting here that, in response to the same question, just 0.4% of mental health professionals believe that migrants should have the same legal rights and equal opportunities as Greek citizens, and 6.2% believe that all the above could apply in order for migrants to be supported by the Greek state (Fig. 19).
According to the results of this research, migration is a significant triggering factor in the manifestation of a mental disease. As Kontaxakis et al. (1994) maintain, the susceptibility of a migrant towards psychiatric disorders may be related to the following factors: i) their ethnic origin, which concerns the frequency of psychiatric disorders in the ethnic group from which they come, ii) the possibility of ‘selecting’ individuals susceptible (or not) to psychiatric disorders within the group of migrants, iii) the socio-demographic characteristics of the migrant (e.g. sex, age, social class), iv) the difference between the natural environment and culture in the place of origin and those in the place of migration, v) the attitude of the native population towards migrants and vice-versa, vi) the difference between the social status of a migrant in their place of origin and that in the place of destination and vii) the expectations of the migrant.
Madianos (2000) points out that the ethnic origin variable is closely associated with the phenomenon of migration. From other research studies implemented among groups of migrants, different figures regarding the prevalence of mental disorders among these groups have been ascertained, and their social status (less or more disadvantageous) certainly plays a significant role in the development of mental morbidity. The migrant’s traditional culture and the degree to which they are assimilated [μήπως εννοείτε αφομοίωση;] by the foreign culture also play a role in the development of mental mechanisms leading to the manifestation of a mental disorder (acculturative stress). At the same time, as Madianos (2000) reports, the initial period following the arrival of a migrant has been judged crucial to the development of psychopathological conditions, since at this time they face a flood of cultural influences.
The arrival of the migrant is characterized as a period of personality crisis, and stress may cause a weakening of the migrant’s Ego. According to Madianos (2000), the main symptoms during this period are suspiciousness and paranoid trends, anxiety and depression, physical complaints such as feeling of weakness, insomnia, anorexia, nausea, dread, and a tendency to conversion disorder. Siampos (2003) also adds to this list the intense feelings of separation and being distanced from their place of birth, parents, relatives and friends. If migrants have a family, this is crippling and migrants are loaded with two unbearable financial burdens because they have two households (one in the country of origin and one in the recipient country), increased travelling expenses, long-distance calls, visits back home, etc. If migrants bring their family or various relatives with them, they ‘do not feel as if they were an uprooted tree, but rather a tree replanted in a flowerpot’, as the sociologist Tsaousis characteristically remarks in his analysis of migration. Thus, emotional deprivation coexists with financial difficulties and the migrant’s inner world is irreparably damaged.
The overwhelming majority of migrants who
usually approach mental health services are of Albanian and Afghan descent,
while the most frequent disorders they develop are mainly Anxiety Disorders,
Mood Disorders and Personality Disorders. Kasimati (2003) reports that the
overwhelming majority of migrants in
According to this study, mental health professionals feel uncomfortable and embarrassed whenever they are called on to help and support the mentally ill migrant due to their inability to communicate in the same language. Megalooikonomou et al. (2007) point out that one of the most frequent problems to arise when migrants contact a mental health service is extreme difficulty in communicating and/or complete communication failure, because neither the user nor the service officer speak each other’s language and translators are not usually available.
According to this study, mental health professionals believe that intercultural teaching is essential in their undergraduate education, especially in terms of their being informed and sensitized in order to develop more positive attitudes towards economic migrants, but also in terms of their learning the culture and civilization of these nations. Megalooikonomou et al. (2007) maintain that if mental health professionals show an interest in becoming familiar with the culture of the ‘foreigner’ and his/her personal [μήπως εννοείτε προσωπική γιατί δεν έχει νόημα το προσωρινή] experience, it is possible that they may comprehend many things which otherwise would seem inexplicable and irrational.
The confidence of mental health professionals in the belief that ensuring a better quality of life for mentally ill migrants and meeting their needs would both be accomplished through the provision of support at special alternative structures of psychiatric care addressed only to migrants, would appear to indicate a prejudice. This prejudice seems to be characterized by two (2) prejudicial aspects: i) the first concerns the individuality of economic migrants that characterizes them as ‘foreigners’ and ‘inferiors’ in relation to the ethnic majority and Greek cultural identity (Riga, 2007) and ii) the second concerns the ‘distorted image’ associated with a patient with mental illness, who is believed to be violent and dangerous, unpredictable, lazy and incapable of working or making decisions about his life (Lykouras and Soldatos, 2006).
According to Anthopoulos (2000), xenophobia is mainly provoked by the Mass Media through the use of negative national stereotypes against migrants, thus creating a climate of moral panic in which racial trends and racist behaviour or practices are developed or strengthened.
With regard to the feelings of mental health professionals whenever they are called to help a mentally ill economic migrant at their service, it was ascertained that they feel uncomfortable as their cooperation with the migrants is dysfunctional and problematic.
According to this study, mental health professionals maintain that they would offer their help to migrants exactly as they would do with their fellow citizens, in accordance with their principles and professional ethics. However, they would not actively participate in migrants’ attempts to secure their rights. As Zaimakis (2002) reports, the commitment of professionals to the values of racial, ethnic and cultural diversity demonstrates evidence of their ethical and professional conduct. Within the framework of a society which is inhabited and characterized by the coexistence of population groups with discrete collective identities, what is being sought is the formation of a multicultural environment, a structure that enhances interaction between different populations, mutual recognition, mutual acceptance and social incorporation of various cultural realities.
According to the views of mental health
professionals with regard to the sufficiency of mental health services offered
Megalooikonomou et al. (2007) point out that,
although migrants and refugees constitute 10% of the population in the
Bagavos and Papadopoulou (2006) maintain that
the process of legalization of migrants in
According to Tsitselikis (2007), under pressure
from the concerned bodies, Law 3386/2005 was passed, according to which the
third phase for legalization of migrants was set. At the same time, the Greek
Nationality Code was cleaned up, especially on a technical level, without,
however, spectacular improvements in its content, and migration policy in
With regard to the migration issue in Greece, mainly during the last few years the following major issues have emerged: i) the legality of migrants’ residence and employment and the benefit or not of their presence for the economy, ii) public safety and the crime rate and iii) the protection of human and social rights of migrants (Tsitselikis 2007).
health professionals maintain that migration is an aggravating factor in the
development of mental illness,
as a large number of economic migrants approach Mental Health Services to deal
with and solve their psychological or psychiatric problems, even though actions and programmes to
inform migrants of the objectives of the Greek Mental Health Services are
neither organized nor implemented. A possible explanation that may justify
this contradictory situation is the implementation and organization of actions
to inform migrants by mainly voluntary
medical and social organizations in
The reasons why economic migrants approach a mental health service are mainly for the treatment of a mental illness and to be granted some kind of benefit, but only of course when economic migrants have managed to obtain the documents for their legalization.
The disorders from which migrants suffer and consequently cause them to approach the relevant services are mainly Anxiety Disorders, Mood Disorders, Personality Disorders, Substance Use Disorders and Sleep Disorders.
The predominant feeling of mental health professionals in their communication with the migrants is one of embarrassment. The main reason for this is their inability to communicate with the migrants and therefore communication becomes dysfunctional as the necessary means and ways are not available to facilitate the provision of their therapeutic work.
Mental health professionals maintain that Mental Health Services do not offer quality services to migrants for the following reasons:
The initial aim of the establishment of these Services was to meet the
psychiatric needs of beneficiaries of Greek descent. The sheltering and
continued arrival of economic migrants in our country found the
ii) The inability of Greek society to comprehend the significance of the existence of Community Mental Health Services, since it continues to ‘stigmatize’ the mentally ill and even more so the mentally ill economic migrant.
iii) The difficulty that professionals encounter in finding and dedicating more time within the framework of their work timetable to implement actions that could be beneficial for migrants in terms of informing them of issues related to the prevention and treatment of mental illness.
Despite all the afore-mentioned impediments, mental health professionals maintain that they endeavour to offer their services to migrants without discrimination, even when migrants do not possess legal documentation for residence and shelter in
With regard to this allegation, a probable prejudice towards the ‘stranger’ and that which is ‘different’ is revealed, arising from the wider value system of mental health professionals which has its roots in the very community in which these professionals live and work. Besides, mental health professionals constitute part of the community and hold the views and values of the community for which they are called to offer their services.
According to mental health professionals, migrants are not accepted by the Greek society mainly for three (3) reasons which are divided into three (3) levels: i) the Greek State, ii) the Mental Health and Social Care Services and iii) the community. Consequently, on the one hand, we have the inability of the Greek State to develop or expand actions or services aiming at the social integration of migrants into Greek society, the inability or indifference of Mental Health Services to develop actions related to the social integration of migrants and the negative stereotype within the community towards the ‘stranger’ and that which is ‘different’.
The suggestions made by the mental health professionals with regard to the provision of qualitative mental health services to migrants, which could also contribute to their social integration, are:
i) the existence of more professionals engaged in the provision of social care to citizens, and also offering supplementary services to those of the Mental Health Services, such as the direct issuing of legal documentation for residence in our country, the granting of benefits, the direct finding of accommodation, etc.
ii) the cooperation between the Greek Mental Health Services and the mental health professionals from the corresponding countries of origin of the migrants, also helping with translation during communication with the migrants
iii) the wider networking and mutual supplementation of Mental Health Services
iv) the development of special rehabilitation centres, the services of which are to address only migrants
v) the cooperation with the Mental Health Services of the corresponding countries of origin of the migrants
vi) the development of more shelters for migrants and their return to their homelands.
The granting of equal civil, employment and
democratic rights to both
natives and migrants.
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