Transcultural Psychiatry

Over the last two decades, the reinforcement of security-related migration policies has resulted in the perception of the foreigner, and especially the irregular migrant, as a category outside the circle of legality. The rights of foreigners in host countries have deteriorated due to the connection made between immigration and criminality. Restrictions imposed upon irregular migrants' basic political and civil rights have been accompanied by major obstacles to their access to economic and social rights, including the right to health. The events of 9/11 further contributed to this trend, which contradicts the basic premises of the human rights paradigm. Recent policy developments and ongoing international cooperation implementing systematic interception and interdiction mechanisms have led to the securitization of migration. The preventive and deterrent measures reinforce the security paradigm. By contrast, various national and international actors have been successful in defending irregular migrants' rights. At the domestic level, the involvement of the judiciary and civil society enhances the rights-based approach to foreigners. The role of judges is vital in holding policy-makers accountable for respecting the high national standards of human rights protection. This article elaborates on the dichotomy between the state's legitimate interest to ensure national security, and its domestic and international obligations to protect human rights for all, including irregular migrants. It focuses on the changing relationship between migration and security, on the one hand, and between state and individual, on the other hand. It affirms the necessity to recognize the pre-eminence of fundamental rights upon security concerns.

Human trafficking is an international challenge that increasingly affects industrialized countries. It represents a gross violation of a person's right to liberty and freedom of movement, and is often accompanied by violence and degrading treatment which can have detrimental effects on health. In this article, we review the definition and extent of human trafficking, and focus on the human rights abuses and determinants of trafficking in women. Mental health and other health outcomes are reviewed, and differences between countries in organized activities for victim assistance and protection are assessed. Finally, we discuss the roles of mental health and other healthcare providers in identifying and helping trafficked women, and recommend a tailored multidisciplinary approach for victim assistance.

The final decades of the twentieth century were accompanied by an upsurge in the number of persons fleeing persecution and regional wars. To stem the flow of asylum seekers, several countries in the west introduced policies of deterrence, including detention. Although many countries detain asylum seekers, Australia has been unique in establishing a policy of mandatory, indefinite detention. The impact of prolonged detention on the mental health of asylum seekers drew commentary from mental health professionals soon after the policy was introduced, but administrators and politicians disputed the assertion that detention was a factor in causing or exacerbating mental disorder. This overview examines the impact of mandatory, indefinite detention on the mental health of asylum seekers by drawing on evidence gathered during Commissions of Inquiry, from observations of health and mental health professionals who have worked in detention centres, and from the small body of systematic research undertaken among immigration detainees. The data from all sources converge in demonstrating that prolonged detention has adverse mental health and psychosocial impacts on adults, families and children. Recent studies suggest that the mental health effects may be prolonged, extending well beyond the point of release into the community. The Australian experience offers general lessons to health professionals worldwide about the importance of remaining vigilant in protecting the rights of vulnerable groups, and more specifically, to ensure that the traumas that cause mental suffering in refugees are not compounded as a consequence of immigration policy decisions in recipient countries. Documentation and research can be vital in achieving policy change in these settings.

In recent years the treatment of those seeking asylum in industrialized countries has been a matter of increasing international concern. Human rights organizations have documented instances of ill treatment and the summary expulsion of those trying to cross borders in the hope of a more secure existence. This article focuses on the treatment of asylum seekers and undocumented migrants at Europe's borders, presenting examples from Europe's southern border, Belgium and the UK. The idea of a moral economy of care is invoked which provides an overarching context in which legitimate and illegitimate asylum seekers and refugees are identified. The implications of a moral economy of care are explored in relation to the provision of mental health and social care services to refugees.

Early research on refugee mental health and adaptation has largely proceeded from a life-events/biomedical framework. That approach has helped elucidate the relationship between life events and psychiatric symptoms, but has been criticized as reductionistic or exclusionary. This article argues that the complexity of the social domain of refugee experience and the causal interactions among biological, psychological and social domains make individual effects difficult to study in isolation. A biopsychosocial approach could complement the more focal research to move the field forward. Evidence in support of this position is marshaled from new analyses conducted on a meta-analytic data set of five decades of the worldwide empirical literature on refugee mental health, reflecting data derived from 67,294 primary study participants (Porter & Haslam, 2005). Results demonstrate the importance of higher-order interactions between distal and proximal social variables, as well as associations among biological, psychological and community-level social functioning in refugees. Interdisciplinary research and novel analytic methods can complement more focal research. The presumed benefits of returning refugees to their country of origin are questioned in light of the important effects of social variables on refugee adaptation.

Refugee children may encounter barriers to accessing mental health services. We conducted a case—control study based on a systematic review of clinic records to compare psychopathology and service utilization in refugee and Norwegian children referred to a child psychiatry department in a county in southern Norway. Sixty-one refugee children were compared with 61 Norwegian-born children matched for gender, age and time of referral to the clinic. There was no significant difference in rates of referral or level of service utilization, which were proportional to the population. Compared with Norwegian children, refugee children were diagnosed more frequently with post-traumatic stress disorder and other affective and emotional disorders, and less often with pervasive developmental disorders and attention deficit hyperactivity disorder. The results are discussed in terms of referral pathways and the need for culturally competent care for refugee children.

This article describes the distinct challenges associated with conducting ethical research with refugees. A case example of an ongoing study of stigma and access to mental health treatment among Somali refugee adolescents resettled in the USA is presented. In developing the study, standard research paradigms were critically examined in order to take account of the unique aspects of Somali culture and experience. Community participatory methods were adopted to uphold both ethical and methodological rigor in the research. A participatory approach for developing ethical protocols within different refugee communities is recommended.

Based on a case study of anthropological fieldwork at a small program located in the north-eastern USA, this article critically examines the development of culturally sensitive psychosocial models of care for survivors of torture and refugee trauma in western countries of resettlement. Fieldwork identified several unresolved tensions in the bicultural model of counseling, psychosocial models of care, and the field of refugee mental health. Despite efforts to develop an innovative treatment model, the culturalization of care and the emphasis placed on meeting social needs in interventions resulted in maintaining conventional relations of power within the mental health professions.