Migration,Identity,and Threatened Mental Health: Examples from Contemporary Fiction

Abstract

In 2015, the world saw 244 million international migrants. Migration has been shown to be both a protective and a risk factor for mental health, depending on circumstances. Furthermore, culture has an impact on perceptions and constructions of mental illness and identity, both of which can be challenged through migration. Using a qualitative research approach, we analysed five internationally acclaimed and influential novels and one theatre play that focus on aspects of identity, migration, and threatened mental health. As a mirror of society, fiction can help to understand perceptions of identity and mental suffering on an intrapsychic and societal level, while at the same time society itself can be influenced by works of fiction. Fiction is also increasingly used for didactic purposes in medical education. We found that the works of fiction discussed embrace a multifaceted biopsychosocial concept of mental illness. Constructs such as unstable premigration identity, visible minority status (in the host country) and identity confusion in second-generation migrants are conceptualised as risk factors for mental illness. Factors portrayed as protective comprised a stable premigration identity, being safe with a family member or good friend, (romantic) love, therapeutic writing, art, and the concept of time having an element of simultaneousness. This literature challenges the idiocentric model of identity. Analysing fictional texts on migration experiences can be a promising hypothesis-generating approach for further research.

Keywords

fiction identity medical education migration novels

“Well let’s see,” he said, slumping back in his seat and counting off the countries on his fingers. “I’ve lived in Russia, Scotland which was maybe cool but I don’t remember it, Australia, Poland, New Zealand, Texas for two months, Alaska, New Guinea, Canada, Saudi Arabia, Sweden, Ukraine—”

“Jesus Christ.”

(Donna Tartt, The Goldfinch, p. 264)

The number of international migrants is rapidly growing and reached 244 million in 2015 (United Nations, 2016). At the same time, populist political movements radically opposing everything perceived as strange or foreign in the Western World have been gaining force (Clark, Chrisafis, White, Toynbee, & Behr, 2015). Depending on the circumstances, migration has been shown to be both a protective and a risk factor for major mental disorders. Without adverse experiences, especially in the first postmigration years, migration appears to be protective – the “healthy migrant effect” – although this effect is often lost over time (Saraga, Gholam-Rezaee, & Preisig, 2013; De Maio, 2010). However, when associated with experiences of adversity, migration increases the risk for major depressive disorder, and premigration trauma and migration/postmigration stress are linked to post-traumatic stress disorder; a common problem in the migrant/refugee population (Steel, Dunlavy, Harding, & Theorell, 2017). Migration from Mexico to the U.S. seems to increase the risk for substance use disorders up to the third generation (Borges et al., 2016). The incidence of schizophrenia and other psychotic disorders is consistently reported to be higher in minority and migrant populations (e.g., Hollander et al., 2016). The reasons for this higher incidence of psychotic disorders are not completely understood, but associations have been found with minority group position, especially in areas of low ethnic density, with perceived discrimination, and finally with experiences of childhood separation, which are higher in some migrant populations (van Os, Kenis, & Rutten, 2010; Morgan, Charalambides, Hutchinson, & Murray, 2010).

Complex problems in psychiatry cannot be tackled by standardized manuals and questionnaires alone (Andreasen, 2007; Nordgaard & Parnas, 2013). Literature as a profoundly subjective, idiosyncratic and complex artistic output offers a promising approach for qualitative (hermeneutic) research (Wigand, Rüsch, & Becker, 2016). Patients long for therapists to value their personal narratives and explanations of phenomena of mental illness (James, Carpenter, Peltzer, & Weaver, 2014) and novels can help health professionals and medical students to gain a profound and compassionate understanding of major themes of human life and suffering (Goldberg, 2001). Consequently, it has been suggested that the humanities should play a greater role in medical education (Beveridge, 2003).

The emergence of a number of high selling, award winning novels from different cultural backgrounds that deal with migration, (threatened) identity, and mental illness can be seen as evidence that we are dealing with an important, global theme in psychiatry. Works of fiction have the advantage that they can simultaneously enlighten our understanding on an individual level, by giving insight into the characters’ intrapsychic processes, and on a sociological one, because fiction can simulate social experience (Mar & Oatley, 2008) and deliver knowledge (Green, 2010). Most importantly, relationships between fiction and society are bidirectional, meaning that (a) novels of a certain era are influenced by societal trends and (b) society can be influenced by works of art and cultural themes, e.g. the situation in mental institutions in the U.S. was influenced by Ken Kesey’s (1963) novel One Flew Over the Cuckoo’s Nest (Zimmermann, 2012). In this research, we were mostly concerned with understanding (as contrasted with explanation) according to Karl Jaspers, i.e., with how mental phenomena emerge from other mental phenomena (Jäger, Lang, & Becker, 2015). In the context of migration, a model of understanding should encompass sociological models of identity (Beck, 2000; Bhugra, 2004; Kang & Bodenhausen, 2015), which will be discussed.

The aims of this study were: (i) to give some examples of how the interplay between migration, identity and threatened mental health is depicted in a small sample of contemporary fiction; (ii) to analyse whether and how mental illness, psychiatry, and psychiatrists are depicted in these texts; (iii) to analyse which protective factors and problem solving strategies that may help to prevent mental illness can be found in the texts; and (iv) to discuss how the texts chosen for this research can be used in transcultural medical education on migration experiences.

Selection and analysis of texts

Works of fiction depicting migration experience were chosen to reflect geographic diversity, public influence and recent publication (last ten years). All texts were written by award winning authors, reviewed in major newspapers, and had been translated into foreign languages. Five novels and one play were chosen, covering markedly different cultural backgrounds and migration trajectories, including: Latin America to the U.S. (The Brief Wondrous Life of Oscar Wao; Díaz, 2007), Congo to France and China to France (Mélo; Ciriez, 2015), Nigeria to the U.S. (Open City; Cole, 2012), and to the U.S. and UK (Americanah; Adichie, 2014), and Eastern Europe to the U.S., with stops in the South Western Pacific region, Western Europe, and the Arabian Peninsula (Boris in The Goldfinch; Tartt, 2014). The play, I Call my Brothers (Khemiri, 2015), depicts a young man from Tunisia walking the streets of Stockholm the day after a terrorist attack. The texts describe different aspects of migration, but must be understood as literary reflections on some characteristics of migration (and migration experience) and of the societal discourse on migration.

The texts were analysed by a semi-standardised inductive/deductive approach (Wigand et al., 2016) and scanned deductively for anything pertaining to three topoi: migration, identity, and mental health/psychiatry. Issues of importance, subjects common to more than one of the books or issues that were treated controversially in the texts, were taken note of inductively. Categories were built in a first step by M. E. W. and then critically reflected on in discussions among all authors. This process allowed modifications to be made and ultimately a consensual validation to be found.

We followed a narrative inquiry approach, which involves “a systematic exploration of a series of stories with a specific focus or set of foci [spinning around] the central, three-pronged axis of the importance of the story, the storyteller and the listener [reader]” (Taylor & Francis, 2013). Here, the reader’s (i.e., researcher’s) position becomes part of the research and has to be critically reflected. All therapists portrayed in the texts were categorised according to Meehan (1964), i.e., as villains, noble characters, magicians, spiritual guides, unfeeling scientists, useless nonentities, or complex individuals.

Themes

The plots and major themes are summarized in Boxes 1-6 (See online supplemental material, https://journals-sagepub-com.web.bisu.edu.cn/doi/full/10.1177/1363461518794252). Below is an overview of how the texts depict the main topics.

Migration

Several motives for migration are given in the texts. Although mostly migration across borders is presented, there are also incidences where migration within one country and across social class borders appears to be the key stressor. The Goldfinch is a novel of Dickensian scope (Kakutani, 2013) that includes a myriad of immigrants. One of the most prominent characters is Boris, a mere teenager when the reader first meets him, who has already lived in several different countries under varying conditions as he followed his father, who works in mining and exploring. Theo, the first-person narrator, is impressed by Boris’ biography:

In New York, I had grown up around a lot of worldly kids […]. But Boris—like an old sea captain—put them all to shame. He had ridden a camel; he had eaten witchetty grubs, played cricket, caught malaria, lived on the street in Ukraine (“but for two weeks only”), set off a stick of dynamite by himself, swum in Australian rivers infested with crocodiles. […] He had endured midwinter darkness in Russia where the temperature dropped to forty below: endless blizzards, snow and black ice […]. The Goldfinch, p. 273

Unlike Boris’ involuntary migration as a minor, Ifemelu and Obinze in Americanah choose migration as adults “to escape from the oppressive lethargy of choicelessness” (p. 276) in Nigeria. Julius in Open City leaves Nigeria at age 17, not only to get an education, but also to flee from conflict with his mother, while the “Parfait de Paris” in Mélo leaves poverty in Congo to come to Paris illegally to become someone in the centre of an elegant world. Immigrant aspirations play a role in most texts. Barbara, the second-generation Chinese immigrant in Mélo, dreams of entrepreneurship and becoming rich, while two boys in Americanah sit on a sofa “buttoned-up and stiff, caged in the airlessness of their parents’ immigrant aspirations” (p. 215). Beli in The Brief Wondrous Life of Oscar Wao has to flee the Trujillo regime in the Dominican Republic, traumatized, after being beaten almost to death by the secret police because she had an affair with the husband of Trujillo’s sister.

International migration as depicted in the texts appears to be hardest on those who are visibly foreign or who have minority status through their skin colour. Ifemelu in Americanah leaves a mostly black country, but only starts feeling black in the U.S. Amor, looking foreign in Stockholm, is told by one of the voices talking to him to “Apologize for existing.” (I Call My Brothers, p. 43). Another recurring stressor for immigrants in the books is the state of living and working in a country illegally: “[…] you know he only got his papers two years ago and so for so long he was living in fear, working under other people’s names. That thing can do wonders to your head, eziokwu. It has not been easy at all for him.” (Americanah, p. 240). But characters also feel displaced in their own country. Theo in The Goldfinch learns that the rules he learned as a child in New York do not apply in Las Vegas and the union worker who commits suicide at the beginning of Mélo, being of Celtic origin, never feels at home in Paris.

Identity

Many of the graver identity problems depicted are not connected to migration at all. Those that are related to migration are mostly portrayed as aggravations of pre-existing identity problems. “How can I be myself? What does that even mean?” (p.68) asks Ifemelu in Americanah long before her emigration, while Obinze, her boyfriend, is described very differently: “[His mother] had taught her son the ability to be, even in the middle of a crowd, somehow comfortably inside himself.” (pp. 69-70). Once Ifemelu arrives in the U.S., cultural misunderstandings enhance her insecurity: “Her autumn of half blindness had begun, the autumn of puzzlements, of experiences she had knowing there were slippery layers of meaning that eluded her.” (p. 131) and it is Obinze’s voice over the telephone which calms her. Ifemelu tries an American accent (which she later discards) and adopts many ways of her two very different American boyfriends, while Obinze, who in the long run has much more adverse experiences in England, does not seem to encounter grave identity problems. His stable premigration personality and ability to look at his situation with a sense of humour constitute protective factors. It is only after Obinze’s return to Nigeria and his unexpected wealth that he starts to question the life he leads, although not his identity, which is firmly grounded.

Several episodes depict the need of immigrants to actually take on a different identity (name and social security number) to be able to work: “She [Ifemelu] repeated ‘I’m Ngozi Okonkwo’ in front of the mirror before her next interview” (p. 131). This possibility goes along with an unusual realization: “All of us look alike to white people” (p. 124). On the other hand, being able to switch identities, if one can choose to do so, can also be a protective factor: for the garbage man in Mélo, life only becomes bearable because at night he becomes the Parfait de Paris, dressed up and sitting in a rented Rolls Royce.

Several texts depict the second generation of immigrants as having identity problems. Ifemelu’s cousin Dike who, as a child, seems to represent a caricature of Americanism (“a first grader with a seamless American accent and a hyper-happiness about him”, Americanah, p. 105) is increasingly troubled by his minority status as a black immigrant. Tensions rise and his mother threatens in Igbo (one of the native languages of Nigeria, which she only adopts when angry with him) to send him back to Nigeria. When Dike states in an essay at school that he does not know what he is, is conflicted and finds his name difficult, his mother blames it on the concept that America has of identity, mental illness and responsibility:

“I think he wrote that because that is the kind of thing they teach them here. Everybody is conflicted, identity this, identity that. Somebody will commit murder and say it is because his mother did not hug him when he was three years old. Or they will do something wicked and say it is a disease that they are struggling with.” Americanah, p. 217

Interestingly, Dike’s mother is the one who, after his suicide attempt, adopts the concept of a depression as a “clinical disease” (p. 380) that comes overnight and denies that it has anything to do with his identity problems.

Amor in I Call My Brothers grew up and went to school in Stockholm, but is of Tunisian origin. Already, as a child, he is described as having identity problems. He is very unsettled by the events of a car bombing and on the verge of identity diffusion and losing his mind. His friend Shavi, a homely family man with a stable identity, is the one who in the end proves to be his most reliable friend and saves Amor.

Interestingly, Boris in The Goldfinch, who has arguably the most exotic migration history in all analysed texts, seems to have a very stable identity, despite his alcohol addiction and drug abuse.

We looked at each other. And it occurred to me that despite his faults, which were numerous and spectacular, the reason I’d liked Boris and felt happy around him from almost the moment I’d met him was that he was never afraid. You didn’t meet many people who moved freely through the world with such a vigorous contempt for it and at the same time such oddball and unthwartable faith in what, in childhood, he had liked to call “the Planet of Earth.” p. 836

Boris himself describes his identity in two very short sentences: “What can I say. I am thief.” (p. 631).

Concepts of mental illness

The texts show aspects of a biopsychosocial concept of mental illness with cultural and spiritual components (see Table 1 in online supplemental material). Díaz (2007) includes spiritual components such as a curse or fukú and a mongoose that serves as a good spirit, which is in keeping with the tradition of magic realism in Latin American fiction. Of great interest for transcultural research are scenes in which cultural context has an influence on disease concepts.

[…] Ginika said, “I think you’re suffering from depression.” Ifemelu shook her head […]. Depression was what happened to Americans, with their self-absorbing need to turn everything into an illness. She was not suffering from depression; she was merely a little tired and a little slow. “I don’t have depression,” she said. Years later, she would blog about this: “On the Subject of Non-American Blacks Suffering from Illnesses Whose Names They Refuse to Know.” A Congolese woman wrote a long comment in response: […] even though she checked “yes” to all the symptoms on the card the doctor gave her, she refused to accept the diagnosis of panic attacks because panic attacks happened only to Americans. Nobody in Kinshasa had panic attacks. It was not even that it was called another name, it was simply not called at all. Did things begin to exist only when they were named? Americanah, pp. 157-158 Later, Ranyinudo told her, “I don’t know how a fine boy like Dike would want to kill himself. A boy living in America with everything. How can? That is very foreign behaviour.” “Foreign behaviour? What the fuck are you talking about? Foreign behaviour? Have you read Things Fall Apart?” Ifemelu asked, wishing she had not told Ranyinudo about Dike. She was angrier with Ranyinudo than she had ever been, yet she knew that Ranyinudo meant well, and had said what many other Nigerians would say, which was why she had not told anyone else about Dike’s suicide attempt, since she came back. Americanah, p. 425

In these passages from different parts of the novel, we see how Ifemelu’s concept of mental illness changes along with her different phases of migration. Early on, Ifemelu totally rejects the concept of mental illness. Later, when she is settled in America, she appears to question her own position. When her cousin Dike attempts suicide, she refuses her aunt’s (guilt-ridden) concept of depression as a medical disease that comes out of nowhere, but because she sees his social experience as an important contributing factor and not because she refuses the concept of depression as a whole (Table 1, online supplemental material). After returning to Nigeria, she knows about the stigma of suicide, but at the same time fights this stigma in her conversation with Ranyinudo, referring to a Nigerian novel in which the main character commits suicide to make the point that the problem does exist in Nigeria, but is usually repressed.

Depiction of psychiatry

Several psychiatrists are portrayed in the texts. “Dave the shrink” who treats Theo in The Goldfinch can be said to belong to the useless nonentity group (Meehan, 1964): he seems nice enough and eager to help, but fails to win Theo’s trust and his therapy sessions are depicted as boring, ineffective, awkward and embarrassing. Several psychiatrists appear in Open City, foremost Julius, the first-person narrator, who belongs to the group of complex individuals. His first head of department belongs to the unfeeling scientist group, a brilliant scholar who is cold in personal contact and is said to have made derogatory remarks about Asian patients. His female successor is a noble character, both a renowned researcher and someone who cares for patients, a director who positively changes the atmosphere of the department. In Americanah, Dike sees a therapist, but we do not obtain enough information to fit him into one of the categories. Russian psychiatry is mentioned in Mélo as a place where artists are locked away.

True to Julius’ depiction as a complex individual, the depiction of psychiatry in Open City is complex. While Julius is an idealist and critical of the modern approach in psychiatry, he is also someone who (mis)uses psychiatry to tell a funny story, does not pick up on the mood of his neighbour in mourning and is depicted as an aggressor who has repressed his deed and avoids talking about it. Biological, psychological and sociological disease models are mentioned (Table 1, online supplemental material).

[…] one of the lessons I learned most swiftly as a medical student was that the larger picture was sacrificed, more out of habit than out of necessity, to the small detail. We were taught to distrust philosophy; our teachers favored the potent neurotransmitter, the analytical trick, the surgical intervention. Holism was looked down by many professors, and in this the best students followed their lead. Open City, pp. 205–206 And it was especially satisfying to me, with my stubbornly held and somewhat naïve vision, as I approached the end of my training, of what psychiatry really ought to be about: provisional, hesitant, and as kind as possible. Open City, pp. 207–208 But he sees through you anyway, you, the psychiatrist, the know-it-all. I know you think he’s a buffoon. But he’s a better man than you. He is wiser, he understands life better than you ever will. That is why, without me having to tell him anything, he knows what a malign influence you have been on my life. Open City, p. 245

Protective factors

It is not literature’s task to find answers to our problems. Yet, readers have always turned to literature to identify with the characters and possibly to learn a deeper truth about life and crisis. When analysing the six texts, several possible protective factors could be delineated.

The feeling of safety through relationships

Amor, on the verge of losing his mind in I Call My Brothers, is saved by his good friend Shavi; Theo in The Goldfinch retains a good inner representation of his loving mother after her death and finds, in Hobie, a person he can trust unconditionally: “[…] this place is good, this person is safe, I can trust him, nobody will hurt me here” (p. 176); and Beli in The Brief Wondrous Life of Oscar Wao is saved as a child by La Inca, a distant relative who cares for her and provides what is described as a “sanctuary” (p. 259). On the contrary, the union worker in Mélo who lacks close relationships commits suicide. Also, Open City, featuring Julius as an intellectual loner, ends on a downbeat note with Julius on a boat with other people yet lonely and contemplating the thousandfold death of birds on collision with the Statue of Liberty, probably a metaphor for all the suffering of migrants and minority groups described throughout the novel. Romantic love can be seen as a special form of a very close relationship and is depicted throughout the texts. Where it works (Americanah, in the end), it is a strong protective factor, sometimes even when partially unanswered (Theo’s love for Pippa in The Goldfinch).

Therapeutic writing

Literary output is depicted as a strong protective factor in several texts. Theo’s self-therapeutic efforts after his childhood traumas involve continuous writing, begun after a well-meaning teacher gives him a notebook (The Goldfinch), and in The Brief Wondrous Life of Oscar Wao writing is also depicted as a stabilizing factor. Ifemelu’s blogs about her various experiences, and especially the exchange with her readers, serve as a strong protective factor.

Engagement with art

Art is ubiquitous in the texts: an old painting and old furniture in The Goldfinch, paintings, music, statues, architecture, literature in Open City, the art of fashion and masquerade in Mélo, novels, bookstores and libraries as safe havens in Americanah. Yet, in some instances of feeling lonely art does not seem to help. Julius, after his grandfatherly friend Professor Saito dies and his ex-girlfriend cuts off contact, tries to console himself with classical music but realizes that it cannot reach him emotionally in that moment.

Temporality as simultaneity

For many of the migrants in these books, it sometimes seems unbearable that the past is gone. This feeling can be counteracted by the idea that time loses the quality of only flowing in one direction from past to future:

[…] where all was stillness and clarity, and at the same time, as in a backward-run movie, you could also imagine spilled milk leaping back into the pitcher, a jumping cat flying backward to land silently upon a table, a waystation where time didn’t exist or, more accurately, existed all at once in every direction, all histories and movements occurring simultaneously. The Goldfinch, p. 811

A similar concept is put forth in Teju Cole’s Open City: “Each one of those past moments was present now as a trace” (p. 54).

Discussion

Five contemporary novels and one theatre play, all of which won awards and/or reached a large audience, were analysed with respect to migration, identity and mental health. They represent a small sample of diverse literary depictions of possible migration experiences and – while literature might contain some deeper truths about the conditio humana – these texts should not be mistaken for actual individual migration narratives. Major themes in the texts will be discussed in the light of relevant findings from psychiatry and sociology.

Migration and Identity

It has been suggested that migration leads to an identity transformation and that leaving one’s country of origin will initiate a process of mourning (Akhtar, 1999) that can pathologically turn into a process of unresolved mourning (Kogan, 2010). In the analysed texts, those characters who (i) show a visible minority status, (ii) already had identity problems or traumatization in the premigration phase, or (iii) are second-generation immigrants who seem to face more problems in adapting to the host culture. Nazroo and Iley (2011) point out that there are ethnic inequalities in the risk of mental illness, complicated by experiences of racial harassment. Yet, they point out that ethnicity should not be seen in an essentialist way and that the risks can be overcome, e.g., by a higher socioeconomic status. This was the experience of Ifemelu (Americanah), who encountered racism but whose mental health improved with rising social status. Her cousin Dike is caught as a teenager between his mother’s American ambitions and her clinging to Nigerian cultural norms; he experiences being black in a mostly white community, which his mother refuses to talk about, and suffers identity confusion, which is suggested to contribute to his suicide attempt. Oscar in The Brief Wondrous Life of Oscar Wao has similar experiences concerning race, culture of origin and identity. Immigrant adolescents usually show great flexibility in adopting social categories according to context but some phenotypically defined categories such as ‘race’ are hard to overcome (Fuligni & Tsai, 2015). Findings that second-generation immigrants tend to believe that others view their group in a less favourable light and are less likely to believe that they can advance their social position through hard work may explain why second-generation immigrants might face more problems than their ‘healthy migrant’ parents (Wiley, Deaux, & Hagelskamp, 2012).

Bhugra, Wojcik and Gupta (2013) propose “models of vulnerability” (p. 146) for the different phases of migration that can be applied our analysis. Ifemelu (Americanah) starts out with personality factors that lead to a certain vulnerability (premigration) and perceives much acculturative stress (migration), but in the end copes with the situation and overcomes symptoms of depression (postmigration). Further into her stay, she develops feelings of loss and longing for her country of origin and moves back to Nigeria. Boris (The Goldfinch) sets out with a stable identity, despite his alcohol and drug use. He reduces acculturative stress by picking what is best for him from a new culture and keeping a critical distance from the rest. This goes along with successful coping and is reminiscent of Beck’s (2000) cosmopolitan perspective. It is noteworthy that Boris is an ambiguous character, both a good friend and a criminal, someone with strong character and a drug addict, and thereby exemplifies identity ambiguity or multiplicity. The concept of multiple identities (Kang & Bodenhausen, 2015), with all its positive and negative implications, can be applied to all six texts. Characters flexibly choose identities according to context. But the perception of different identities that, according to stereotypes, do not ‘make one whole’ may have negative effects, e.g. in Americanah when Ifemelu, working as a babysitter for a white family in a mansion, opens the door for the carpet cleaner, is mistaken for the homeowner and met with hostility. She observes that in the U.S. public discourse, blacks and poor whites are usually mentioned together, leading her to conclude that race and class belong together. As Kang & Bodenhausen (2015) remark: “In the United States, because race acts as a reliable cue to ecology, these two categories often function interchangeably. However, ecology stereotypes can override race stereotypes in situations where targets exhibit ecology cues that are incompatible with their race.” (p. 551). In this episode, the carpet cleaner is led to link two distinct categories: black and hopeful ecology.

Migration and mental illness

Berry (1997) described four possible acculturation strategies: integration, assimilation, separation/segregation, and marginalization. In a recent study, Behrens and colleagues (2015) linked the severity of depressive symptoms in a sample of immigrants to Germany to acculturation style. They found that people who favour the assimilation style show more severe depressive symptoms than those who favour either the integration or the segregation style. This finding can be directly linked to the experience of Ifemelu (Americanah), who overcomes her depression when she finds a balance between her culture of origin and host culture. In a population-based study Hollander and colleagues (2016) found considerably more psychotic disorders among migrants than among the Swedish-born population. I Call My Brothers, set in Stockholm, may offer one possible psychosocial explanation for this phenomenon and is one fictional example of how migration is a dialogical process involving the individual and the receiving society, which can also be found in scientific literature (for review, see Kirmayer et al., 2011). The texts give examples of how the migrating individual perceives the receiving society. Racism, difficulties in accessing the labour market, and the feeling of being eyed suspiciously play a role. In Americanah, this issue is even more difficult because the country of origin also becomes a receiving society for those who return. This leads to mixed feelings of coming home and feeling estranged at the same time.

Idiocentrism

Cultures have been categorized as individualistic or collectivistic, a concept that goes back to Hofstede (Bhugra, 2004). Individualistic societies emphasize that every individual has to look after him/herself, success is something personal, and ties between individuals are loose; such individuals are called idiocentric individuals. Collectivistic cultures on the other hand emphasize allocentrism, meaning common good and social harmony (Bhugra, 2004). Most stories analysed in this research feature highly idiocentric individuals as characters, although the stories emerged from different cultural backgrounds. Several of the texts see the idiocentric individual’s striving for success as a problem. In I Call My Brothers Amor keeps very much to himself and is on the verge of losing his mind. Americanah depicts how bonds between friends and even family members can be lost after migration. Barbara, in Mélo, is from a collectivist social background (her parents are Chinese immigrants) and practises a hypercapitalism that is depicted as highly problematic. Chinese society is currently in a transition phase with coexisting collectivistic and individualistic views (Kolstad & Gjesvik, 2014). Some characters defy idiocentrism despite living in individualistic societies. As a teenager, Boris, in The Goldfinch, does not understand the concept of personal property and shares everything he has with Theo, giving and taking as he pleases. Also Hobie, in the same novel, seems to be much more interested in the wellbeing of others than in personal success or achievement. Overall, a criticism of individualistic societies seems inherent to a different degree in all texts.

Disease concepts and depiction of psychiatrists

The works of fiction analysed cover a wide range of disease concepts (Table 1, online supplemental material) that mirror modern psychiatric understanding. Fiction can mirror society, and knowledge of biological disease concepts is increasing over time in the general population (including authors) (Pescosolido et al., 2010; Schomerus et al., 2012). Still, the disease concepts put forth are predominately psychological and social, which follows the logic that novels and theatre plays often display both the intrapsychic conflicts of individuals and their interactions with society. Interestingly, two novelists use the word anomie (Cole, 2012; Tartt, 2014), which was coined by sociologist Émile Durkheim and stands for a sociological concept of a “cultural insufficiency—the inability of a culture to provide individuals within it with consistent guidance” (Greenfeld, 2013; p. 5); this concept is adopted by sociologists such as Liah Greenfeld to explain mental illness. In addition to the biopsychosocial disease concept in psychiatry, (trans)cultural and spiritual factors are increasingly viewed as being important, especially concerning patients’ subjective theories about their mental illness (Conrad et al., 2007; James et al., 2014). This is highlighted in Americanah in the culturally different concepts of depression between Nigeria and the U.S. Reading fictional accounts of mental illness can be instructive for psychiatrists and medical students because fiction can exemplify how nonprofessionals (in this case authors/playwrights) understand and explain scientific concepts (to their readers/audience).

In an article on “the demonisation” of psychiatrists in fiction, Hopson (2014) writes: “Novels, both popular and literary, frequently depict psychiatrists as evil. Fictional psychiatrists are commonly rapists, murderers and sexual abusers of the vulnerable […].” (p. 177). On the contrary, in our small, idiosyncratic sample of novels, we found a range of psychiatrists depicted, none of them truly evil or abusive. In earlier research (Wigand et al., 2016) on a wider range of novels from different cultural backgrounds, we also found a wide range of psychiatrists as characters and cannot agree with Hopson’s overly pessimistic view.

What can be done: Protective factors

We identified four major themes that emerged from the texts as protective factors. Stable, non-intrusive and appreciating relationships, either from the premigration period or acquired in the new country, were depicted as helpful for mental health. Moussaoui and Agoub (2013) point out the relevance of social support in the postmigration stage, stating that the social network should include other migrants, but also people from the host society, which helps the integration process. This, in essence, mirrors Ifemelu’s experience in the U.S. (Americanah). At first, support from Nigerian family and friends in the U.S. and also the camaraderie at the African Students Association stabilize Ifemelu. Later on, relationships with Americans become more important.

Art was depicted as an important factor in several novels. We have to keep in mind a possible bias because the novelists, being novelists, are artists themselves and thus might more naturally turn to pieces of art as consolation than nonartists. But also in psychiatry there are arguments to include aesthetics into psychiatric practice to further mental health and wellbeing (Musalek, 2010, 2013). Closely related to art is the idea of therapeutic writing. We now have evidence that great authors of world literature, such as Johann Wolfgang von Goethe, have used writing also in a self-therapeutic manner (Holm-Hadulla, 2013) and there exists a tradition of therapeutic writing in medicine, especially in the realm of overcoming trauma (Peterkin, 2009).

An interesting idea put forth in two novels is taking a different perspective on time. While we are used to experiencing time as moving forward, inevitably leaving the past behind and out of our reach, alternatively we could look at temporalities as having elements of simultaneousness. This perspective makes it easier to cope with feelings of loss (persons who died, the country one has left behind). Overcoming time can be said to be the essence of writing, as expressed in the following excerpt from Shakespeare’s sonnet 18:

But thy eternal summer shall not fade Nor lose possession of that fair thou owest; Nor shall Death brag thou wander'st in his shade, When in eternal lines to time thou growest; So long as men can breathe or eyes can see, So long lives this, and this gives life to thee. (Sonnet 18, n.d., lines 9–14)

Conclusion

The fictional texts analysed here provide a multifaceted perspective on migration, identity, and mental health. They represent a small sample of contemporary literary accounts of migration experiences and are by no means exhaustive or representative of all migration experiences. Moreover, these are literary accounts of migration experiences, not personal narratives or systematic descriptions. However, fiction can be seen as a mirror of society, and the reading of texts such as those presented here might provide a good starting point for training efforts—to convey some aspects of migrant experience and societal responses and to foster empathy (Mar & Oatley, 2008). For psychiatric research, analysing fictional texts may serve as a hypothesis-generating method.

As in modern psychiatry, biological, psychological, sociological, and cultural concepts in the texts stand side by side. Characters overcome difficulties in ways that usually lie outside the psychiatric realm yet overlap with psychiatric concepts. Multiple facets of an ‘outside perspective’ on psychiatry are presented and throughout these books there is a moderate level of interest in and sensitivity towards an ‘inside perspective’ of mental health care (i.e., about work in the profession, how it is organized, to what knowledge and evidence it refers and how it is practised). However, the mental health discourse in these texts tends to be ‘psychological’ and ‘idiocentric’ (as opposed to ‘allocentric’) (Bhugra, 2004), narrating individuals’ ‘journeys’ in search in relation to their ‘inner selves’ and an external world that is in a constant process of change. This goes along with the cosmopolitan or postmodern situation of ‘multiple identities’, in which simple categorizations of identity in terms of race, gender, etc., give way to the perception and experience of more complex identities (Kang & Bodenhausen, 2015).

Beveridge (2003) sees “a growing acknowledgement of the value of the humanities in medical education” and proposes that “books about illness and suffering help doctors better understand the inner experience of their patients and, as a consequence, develop greater empathy” (p. 386). We suggest that by reading novels such as those analysed in this paper, therapists can further their empathic and transcultural understanding of emotional suffering in patients with a history of migration.

Supplemental Material

Supplemental material for Migration, Identity, and Threatened Mental Health: Examples from Contemporary Fiction

Supplemental material for Migration, Identity, and Threatened Mental Health: Examples from Contemporary Fiction by Moritz E. Wigand, Hauke F. Wiegand, Ertan Altintas, Markus Jäger and Thomas Becker in Transcultural Psychiatry

Footnotes

Acknowledgments

The authors would like to thank Jacquie Klesing, Board-certified Editor in the Life Sciences (ELS), for her assistance in editing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Moritz E. Wigand, MD, studied medicine at the Charité in Berlin, Germany, with practical training at the Johns Hopkins Hospital, U.S., and in Reims, France. He works as a psychiatrist at the Department of Psychiatry II at Ulm University, Germany. His research interests are psychopathology and medical humanities.

Hauke F. Wiegand, MD, studied medicine at the Charité in Berlin, Germany, and the Université René Descartes in Paris, France. He works as a psychiatrist and psychotherapist at the Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz. His research interests are mental health services research, philosophy of psychiatry, and psychiatric anthropology.

Ertan Altintas, MD, studied medicine at Ulm University, Germany and completed his residency at the Department of Psychiatry II at Ulm University. He is currently working at the psychiatric department of LVR-Klinik Mönchengladbach, Germany. His clinical interests are early detection of psychosis and transcultural psychiatry, he initiated an outpatient clinic for Turkish immigrants.

Markus Jäger, MD, studied medicine and did his psychiatric training at the LMU in Munich, Germany. Currently, he is professor at Ulm University, Germany and heads the Department of Psychiatry, Psychosomatics and Psychotherapy at BKH Kempten, Germany. His research interests are psychopathology, and psychiatric nosology.

Thomas Becker, MD, has been working in psychiatry (inpatient care and research) on an international basis since 1982. He is currently chair of psychiatry and heads the Department of Psychiatry II at Ulm University (since 2002). He has led multicenter randomized controlled trials and focuses on mental health services research and social psychiatry.

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