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The relevance of immigration in the psychodynamic formulation of psychotherapy with immigrants

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Abstract

The main goal of this article is to highlight the relevance of the immigration process in psychodynamic psychotherapy with immigrants. Conceived of as a general phenomenon, immigration challenges the stability of the individual's psychic structure and family organization and it has significant transgenerational implications. Its psychodynamics includes interrelated processes of mourning, discontinuity of identity and imbalance of self-esteem. Clinically, in the psychodynamic formulation of the adult immigrant's unique experiences, behaviors and symptoms, immigration operates as a complex precipitating factor, and its three interrelated processes need to be contextualized in the patient's history, organization of identifications and defenses, central conflicts and system of beliefs and ideals. In order to capture the intersection of personal, familial and cultural meanings, the conceptual framework for the psychodynamic formulation of psychotherapy cases includes intrapsychic, interpersonal and cultural dimensions of psychic reality. The theoretical foundation of this article draws on the integration of relational psychoanalysis and social cognition. The outcome of the psychological process of immigration is considered to depend not only on the restructuring of dynamic aspects but also on non-dynamic factors such as the immigrant's age, socioeconomic background, linguistic and cultural differences, forced or voluntary migration, and the possibility of revisiting the country of origin. Two psychotherapy case presentations illustrate the three interacting processes of the psychodynamics of immigration formulated in the context of each immigrant's history and personality from a psychodynamic framework that includes intrapsychic, interpersonal and cultural perspectives. Copyright © 2004 Whurr Publishers Ltd.
The Relevance of Immigration in
the Psychodynamic Formulation of
Psychotherapy with Immigrants
SIL
VIA HALPERIN
ABSTRACT
The main goal of this article is to highlight the relevance of the immigration process
in psychodynamic psychotherapy with immigrants. Conceived of as a general
phenomenon, immigration challenges the stability of the individual’s psychic
structure and family organization and it has significant transgenerational implica-
tions. Its psychodynamics includes interrelated processes of mourning, discontinuity
of identity and imbalance of self-esteem. Clinically, in the psychodynamic formu-
lation of the adult immigrant’s unique experiences, behaviors and symptoms,
immigration operates as a complex precipitating factor, and its three interrelated
processes need to be contextualized in the patient’s history, organization of identifi-
cations and defenses, central conflicts and system of beliefs and ideals. In order to
capture the intersection of personal, familial and cultural meanings, the conceptual
framework for the psychodynamic formulation of psychotherapy cases includes
intrapsychic, interpersonal and cultural dimensions of psychic reality. The
theoretical foundation of this article draws on the integration of relational psycho-
analysis and social cognition. The outcome of the psychological process of
immigration is considered to depend not only on the restructuring of dynamic aspects
but also on non-dynamic factors such as the immigrant’s age, socioeconomic
background, linguistic and cultural differences, forced or voluntary migration, and
the possibility of revisiting the country of origin. Two psychotherapy case presenta-
tions illustrate the three interacting processes of the psychodynamics of immigration
formulated in the context of each immigrant’s history and personality from a psycho-
dynamic framework that includes intrapsychic, interpersonal and cultural
perspectives.
Key words: immigrants, psychodynamic formulation, psychotherapy
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INTRODUCTION
Psychodynamic clinical work with immigrants is a particularly useful arena for
investigating the multiple intersections of personal, familial and cultural
meanings. On the one hand, it involves linking the clinical study of individual
meanings to the cultural study of shared meanings because only the study of
shared meanings provides a normative framework to understand the culturally
specific significance of individual differences. On the other hand, it implies
thinking psychodynamically about the impact of the cultural and social order on
individual subjectivity, and about the psychological processes that contribute to
the recreation of the cultural and social order (Altman, 1995). In addition,
psychodynamic psychotherapy with immigrants makes it clear that cross-cultural
moves precipitate experiences, behaviors and symptoms, which emerge from the
dynamic shifts that parallel the geographic changes, and that the form and
content of the patient’s symptomatology depend on the individual’s history and
personality.
The main goal of this article is to highlight the relevance of the immigration
process in psychodynamic psychotherapy with immigrants. The psychodynamics
of immigration is conceived of as involving interrelated processes of mourning,
imbalance between the change and continuity components of identity, and
dysregulation of self-esteem. In the psychodynamic formulation of psychotherapy
(Horowitz, 1997; McWilliams, 1999; Perry et al., 1987; Westen, 1998) with
adults, immigration is conceptualized as a complex precipitating factor, and its
three interrelated processes are contextualized in the patient’s history and person-
ality. In order to account for the complexity of the immigrant patient’s psychic
reality, the conceptual framework for the psychodynamic formulation needs to
include intrapsychic, interpersonal and cultural dimensions of psychic reality.
The article includes four sections. The first characterizes the theoretical
foundation and main tools and operations of the clinical framework as well as
fundamental considerations and impasses of the therapeutic process. Part two
conceptualizes three essential interrelated processes of the psychodynamics of
immigration that adopt specific forms according to each immigrant’s history,
personality structure, developmental stage and circumstances of immigration. In
part three, two psychotherapy cases illustrate how the psychodynamic formu-
lation process integrates the intrapsychic, interpersonal and cultural dimensions
of psychic reality, and conceptualizes immigration as a complex precipitant in the
context of the person’s history. Part four includes the discussion and conclusions.
I. THEORETICAL ASSUMPTIONS AND CLINICAL
CONSIDERATIONS
The main ideas presented in this article were developed from a dialectic
relationship between theoretical assumptions and questions and conclusions
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derived from clinical practice with immigrants from different countries of
origin, diverse socioeconomic backgrounds and varying levels of
psychopathology. It is assumed that the external world profoundly forms the
internal world, and that the internal world mediates the biological and
environmental determinants of illness. Thus, biological traits, race, ethnicity,
gender, socioeconomic background and cultural values shape and color the
individual’s representations and affects and are in turn socially and psychologi-
cally represented.
In order to integrate the intrapsychic, relational and cultural perspectives in
the psychodynamic formulation of the patient’s unique experience, behavior
and symptoms, the theoretical foundation of this article draws on relational
psychoanalytic and social cognitive models of the mind (Beebe and Lachman,
1998; Freud, 1957/1914, 1957/1917, 1961/1923; Greenberg and Mitchell, 1983;
Horowitz, 1988; Kohut, 1977; Kohut and Wolf, 1978; Lyons-Ruth, 1999;
Skolnick and Warshaw, 1992; Stern, 1998; Stolorow, 1991; Wachtel, 1977;
Westen, 1992). The individual’s psychic reality is conceived of as structured by
relationships and culture through internalization, identification (Freud,
1957/1917; Halperin and Shakow, 1989), interactive regulation and social
learning processes (Curtis, 1991), and is formulated in terms of unconscious
conflictual and defensive motives, and derived compromise formations. In the
relational context of human development, human beings invest emotionally in
their significant others and in the goals invested by them, and their significant
others emotionally invest (Aulagnier, 1975) and cognitively define the
subject’s psychic reality. The family is the active agent that mediates the
relationship between the individual and the broader context of culture. The
relational configurations that constitute the intrapsychic experience reflect the
specific cultural meanings of the community in which the interaction between
parent and child takes place (Harwood et al., 1995). Thus, cultural categories
inform the individual’s representational, emotional and motivational processes:
meanings, values, ideals, constructions of reality, affects, regulatory strategies,
conflicts and defense mechanisms. Because it is a basic assumption of this
article that the mental health significance of ontogenetic adaptations must be
assessed in the context of their specific cultural relevance (Kleinman, 1988),
the developmental and psychopathological models used in clinical work are
interactive and contextualized.
The psychology of immigration highlights the convergence of universal and
culturally contextualized motives. This article questions the assumption that
primary drives are the only universal motives of human behavior and supports
an affective theory of psychological motivation (Karush, 1989; Sandler, 1989;
Westen, 1997). In this theory, affects play a dynamic role in the selection and
activation of behavioral and mental processes – including coping strategies and
defense mechanisms – and are at the same time shaped by cultural and familial
contexts (Westen, 1992, 1994).
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The therapeutic framework relies on psychodynamic theories of personality,
psychopathology and psychological change using constructs from a broad
spectrum of psychoanalytic orientations. However, it is compatible with the
implementation of techniques from different approaches if the conceptual
formulation identifies specific targets of intervention that would benefit from
complementary clinical strategies. (See first case presentation for implemen-
tation of cognitive behavioral techniques in a psychodynamically oriented
psychotherapy.)
The psychodynamic therapeutic process focuses on the subjective
experience and treasures the subjects’ internal world of thoughts, fantasies and
dreams, wishes and fears, hopes and disappointments, as well as representations of
self, others and relationships. In addition, it seeks to elucidate the cultural
resonance of personal experiences by referring them to the patterns of the
individual’s parallel or successive cultural meanings. In this manner, psycho-
therapy can reveal the diverse ways in which the patient experiences conflicting
cultural models (Alvarez, 1995) during different stages of immigration and
treatment.
Patient and therapist co-reconstruct the immigrant’s personal and familial
meanings – and the symbolic ways in which they are expressed – both from the
patient’s history and from their transference/countertransference exchanges. The
meanings of the transference and countertransference interactions need to be
contextualized in the differing cultural worlds of the patient and the therapist.
The therapeutic exploration of the immigrant’s culturally mediated construc-
tions of reality, patterns of attachment, affect regulation, emotional expression
and conflict resolution constitutes an indispensable step in the collaborative
efforts to identify and differentiate the cultural, interpersonal and intrapsychic
dimensions of conflicts embedded in transferential/countertransferential
impasses.
The multifaceted conflicts of identity and loyalty, the “guilt at success in the
new country” (Akhtar, 1995) and the “separation guilt” (Modell, 1965) are
crucial facets of the treatment of immigrants. For example, in some cases the
therapist spends many years struggling with the deadly loyalties of patients who
want to return to their countries despite knowing they could be killed (see first
case presentation). These patients’ intrapsychic conflicts are, for the most part,
conflicts between survival needs and superego ideals: loyalty to significant
others left behind, solidarity with those who were unable to leave a violent
regime or abusive family, commitment to the ideals that sustained the activities
that forced them to leave their homeland.
II. THE PSYCHODYNAMICS OF THE IMMIGRATION PROCESS
Immigration is a highly complex phenomenon that challenges the stability of
the individual’s psychic structure and family organization and has significant
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transgenerational implications. Specific clusters of clinical manifestations and
concomitant dynamic constellations result from the interaction of each
individual’s history and personality structure (especially strategies to cope with
loss, conflict and ambiguity) with the severity of immigration as a stressor.
Non-dynamic factors – the immigrant’s age, and his or her socioeconomic and
cultural background; linguistic and cultural differences; migration conditions
such as temporary or permanent, forced or voluntary; reasons for leaving and
the possibility of revisiting the country of origin – play a crucial role in the
development and outcome of the psychological process of immigration.
As Akhtar states in his groundbreaking article “A Third Individuation:
Immigration, Identity, and the Psychoanalytic Process,” “no two immigrations
are the same” and “at the same time, a core migratory process resembling
separation individuation does seem to unfold in most adult immigrants”
(Akhtar, 1995). This section of the article will focus on the psychodynamics of
this “core migratory process.”
Analysis of the relevant literature, and of the immigrant’s unique experi-
ences, behaviors and symptoms, led me to conclude that three interrelated
processes fulfill a crucial role in the psychodynamics of migration:
(1) Amourning process precipitated by the immigrant’s loss of love objects,
original environment, native language, and culturally shaped values, ideals
and identificatory references (Akhtar, 1995, 1999; Freud, 1957/1917;
Garza-Guerrero, 1974; Grinberg and Grinberg, 1989). The depth and
possible complication of the immigrant’s mourning process can be best
understood if we think that not only are representations and affects, and
attachment and affect regulation strategies culturally shaped, but that so
too are mourning patterns. Thus, whereas in many cultures grieving is a
private intrapsychic process, in others the mourner needs to share the
memories of and the affects for the lost object with significant others. This
means that, in certain cases, the loss itself has to be mourned through
“foreign” grieving patterns.
(2) An imbalance between the two poles of identity – change and continuity
precipitated by the disturbance of the immigrant’s psychic equilibrium that
results from the “culture shock” phenomenon (Garza-Guerrero, 1974;
Ticho, 1971). Identity is dynamically constructed in relation to a social
environment (Erikson, 1956) and has two components: change and conti-
nuity. Continuity is achieved through a process of synthesis that includes
corroboration of the individual’s identification systems, organizing roles,
beliefs, and scripts of expression and action by cultural patterns of social
recognition (Akhtar, 1984). In the first stages of immigration, the person’s
internal models are not confirmed in the everyday interactions with the
environment. This has particular impact on the feeling of self-sameness
and continuity of identity and on the self-esteem balance, and thus can
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complicate the mourning for the abandoned culture. The “culture shock”
phenomenon (Garza-Guerrero, 1974) is the result of an alarming disparity
between the immigrant’s representational world and the new external
reality. The mismatch between the external demands and the internal
configurations of object, self and relational representations precipitates
feelings of anxiety, confusion, sadness, depression and anger.
(3) An imbalance between the immigrant’s internal and external sources of
self-esteem regulation precipitated by the lack of social recognition in the
new culture of the culturally shaped ideal self-representations that were
internalized in the original family and culture. The self-esteem regulation
process has internal and external sources of sustenance. The individual, in
his/her development, ideally shifts from external sources of regulation to
an increasingly autonomous self-esteem regulation process guided by an
internalized system of values and ideals (Kohut, 1971, 1977; Kohut and
Wolf, 1978). The lack of social recognition in the new culture of the values
and ideals that the immigrant internalized in her/his culture of origin
creates a significant imbalance between the internal and external poles of
self-esteem regulation. Whereas the immigrant’s ideal self-representations
continue to be emotionally invested intrapsychically, they do not continue
to be validated in the cultural discourse or emotionally invested in the
interpersonal interactions in the new community. As a result, self-esteem
can become dysregulated and give rise to various symptoms.
The psychodynamic formulation of the immigrant’s unique experiences,
behaviors and symptoms includes situating the three described interrelated
processes in the context of her/his personal and familial history, developmental
stage, personality structure, psychological resources, belief systems and socio-
cultural circumstances in the different stages of immigration and treatment. By
virtue of its dynamic interaction with these factors, the experience of
immigration can be formulated as a unique blend of unraveling and rebuilding
of the self. Migration can function as a precipitant of disturbing affects,
conflicts and symptoms and as an opportunity to restructure the individual’s
internal and external world.
Successfully working through the immigrant patient’s specific conflicts,
compromise formations, anxieties, affects and mourning process precipitated by
immigration leads to a reorganization of representational configurations and
identity and makes possible different interactions with the external world. This
reorganization has been designated “a third individuation” (Akhtar, 1995) and
has been conceived of as an “identity transformation” (Akhtar, 1999) or
“transcultural identity” (Meaders, 1997) that represents an ideal outcome of
the psychological process of immigration and that implies “a fecund growth of
the self” (Garza-Guerrero, 1974). Unfortunately, the increasing number of
immigrants in the world, their difficult circumstances of immigration and their
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vulnerability to psychopathology preclude the successful completion of this
process in many cases. Instead, what predominate in our clinics are psycho-
logical and somatic symptoms, identity conflicts, mood and self-esteem
destabilization, splitting between idealized and devalued self and object repre-
sentations and cultures, dissociation and trauma. It is these remains of the
patients’ migration experiences that we continue to work through, integrate
and negotiate, with hope and persistence, in the unique, multicultural, transfer-
ential/countertransferential space of our psychodynamic psychotherapy with
immigrants.
The following two psychotherapy case presentations of immigrant patients
will illustrate the formulation of the unique experiences, behaviors and
symptoms from a psychodynamic framework that situates the three interrelated
processes in the context of each patient’s history and personality.
III. CASE PRESENTATIONS
First Case
Carlos was a 38-year-old divorced and remarried man who immigrated to the
US four years before he sought treatment. When treatment began, Carlos was
living with his second wife and their two-year-old daughter. He had two
adolescent children from his first marriage who lived in his country of origin
with their mother. Carlos had completed three years of college education in his
homeland and had limited command of the English language. He worked two
jobs, one in an electric company, the other at a supermarket, to send money to
his older children.
In the initial visit, Carlos reported that two years ago, while he was cutting
meat in the kitchen of his home, he was struck by a mental image of himself
cutting his then six-month-old daughter into pieces with that same knife.
According to him, after that episode, the idea of cutting his daughter became
an obsessive thought. He requested psychological help at another setting but
stopped treatment after two sessions. A few weeks before he called for an
appointment with our program, Carlos had a recurrence of intrusive thoughts of
hurting his daughter, who was by then two. These thoughts were precipitated
by seeing his wife cutting meat with a big knife.
I conducted a mental status exam to make a differential diagnosis. Carlos
was polite, engaging and cooperative. He was insightful and showed adequate
judgment. His speech was pressured but clear and goal-oriented. His thought
content was “obsessively” focused on his symptoms. He reported that he was
experiencing increased anxiety, sadness and depression about his thoughts of
harming his little daughter, whom he adored. He also described generalized fear
as well as an oppressive pain in his chest and heart. He spoke of his anxiety of
being separated from his older children and expressed fears of not regaining
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their trust and love. The patient presented no significant history of acting out
aggressive impulses and, over the course of the evaluation process, he burst into
tears each time he mentioned his disturbing thoughts. He stated that he was
unable to control these thoughts, and expressed feelings of self-recrimination,
self-devaluation and shame as well as fears of “hospitalization and reclusion in a
mental institution.” There was no suicidal ideation and no evidence of
psychotic features. It was clear that the patient’s symptom was ego-dystonic.
Carlos was the second of seven siblings born to a low-income family. He
described his father as tyrannical and unpredictably violent. His father would
inflict severe physical punishments in a “random” way; that is, when the
children did something wrong, the father threatened them but did not neces-
sarily hit them. Rather, when the children least expected it, the father would
strike out. From the patient’s description, it was evident that he and his siblings
had grown up in an atmosphere of imminent danger that resulted in chronic
anticipatory anxiety and fear. This was the same affective climate that the
patient was experiencing at the time of the assessment. Carlos portrayed his
mother as loving, caring and protective of the children. She also feared the
father’s temper outbursts; the father was verbally abusive and occasionally
physically abusive toward her. Culturally contextualized in the ideal of male
dominance and female submission in a society without the benefits of an
agency like the Department of Social Services (DSS), this mother had done all
that she could to protect her children from their father.
Throughout the psychotherapy process, it was evident that his unresolved
conflicts with his father had played a significant role in Carlos’ first marriage.
The patient and his first girlfriend made the decision to get married after the
second time she became pregnant. The relationship was very conflictual and
the patient had “tried to be an understanding, loving husband, all the opposite
that my father was.” Carlos had been very involved in his children’s upbringing,
and was affectionate and caring. After 10 years of marital conflicts, his wife left
their home with their children. In the beginning, she did not allow him to stay
in touch with the children, which precipitated a serious personal and financial
crisis for Carlos. However, the patient persevered in his attempts and finally,
before emigrating, he had re-established a regular and satisfying communi-
cation with his children.
After regaining emotional balance following the separation from his older
children, Carlos assumed a political position in his homeland, a country
characterized by political violence. He was the victim of several threats to and
actual attempts on his life. He was traumatized by an experience in which
someone aimed a gun at him and fired. The shot that was intended to kill him
actually hit one of his friends, who died immediately. Carlos himself was
seriously wounded. He continued to receive further death threats and finally
decided to leave his country.
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Carlos described his second marriage as very good and different from his first
marriage. He felt that his wife was understanding and supportive but that his
obsessive thoughts were now interfering with their good relationship. He felt
uncomfortable making excuses to avoid babysitting for their little daughter
because of his fears of being alone with her, losing control and acting out his
thoughts of hurting her. He also did not inform his current wife about how
much he missed his older children and his increasing fears of losing them. He
was concerned that if he told her, she would think he was being disloyal to her
and their little daughter. Over the course of treatment, he stated repeatedly
that he kept busy as a way to forget his problems.
Psychodynamic Formulation of the Treatment
After placing the patient’s chief complaint in the context of his current life
situation, developmental history, cultural beliefs system, ideals and conflicts,
the patient’s unresolved conflicts with his father emerged as the central
conflictual theme having a repetitive effect on his behavior. A long history of
traumatic interaction with his father in childhood had led to the internal-
ization of father–child relational representations in which aggression, anger,
fear and vulnerability had unconsciously organized the patient’s interpersonal
experience. These aggressive self–other configurations had been reactivated by
the patient’s traumatic experience of political violence and consolidated by the
three interrelated immigration processes, and they were the core organizers
underlying the patient’s chief complaint. They were interfering with his identi-
fication with the ideal image of the “good father,” as it was constructed in his
culture of origin. It is important to mention that the patient’s father did not
represent the cultural ideal of the paternal image in the patient’s original
culture. Even by the standards of his culture, his father was violent, domineer-
ing and tyrannical. His punishments were not viewed as “educational” but as
sadistic in nature, in the sense that the father took pleasure in surprising and
punishing. It is also important to mention that the configurations derived from
his interaction with his father were not the only relational representations that
the patient had internalized. Through the interaction with his mother, he had
been able to internalize representations of a loving and caring parent, which
were in agreement with his original culture’s ethical standards. For this reason,
his symptom was ego-dystonic.
In the process of conceptualizing the role played by the patient’s experience
of migration in the psychodynamic formulation of the case it became clear that
– in relation to past history and present situation, and cultural and personal
constructions – migration and resettlement had multiple conscious and uncon-
scious meanings. When he left his country, Carlos was avoiding
re-traumatization. He was avoiding the unsafe place that in his adulthood
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recreated the experience of his traumatic childhood. In his country, he had
been resourceful enough to cope with adversity. In the US, the stress of invol-
untary migration was compounded by a language barrier and mounting
financial difficulty. Carlos was ill-equipped to cope with loss and the vicissi-
tudes of identity and self-esteem characteristic of the first stages of the
migration-resettlement process.
The psychodynamic interaction of constellations derived from personal
history and original culture enacted by the highly stressful experience of
immigration contributed to produce a complicated mourning process. Tw o
temporal associations of dynamic value during psychotherapy led to the identi-
fication of the factors that precipitated the onset and the reactivation of the
patient’s presenting symptom: his obsessive ideas of harming his little daughter.
First, the patient’s father had died a few months before the onset of the chief
complaint, two years before my initial assessment. The second event was that,
shortly before the exacerbation of obsessive thoughts, the patient had learned
that his adolescent children, whose arrival he believed was imminent, would
not be coming to the US from their homeland. These two important losses
activated the configurations of the patient’s father–child conflicts, in the first
case with the patient as child and, in the second, with the patient as father. In
both cases, intense feelings of loss, responsibility and guilt played an important
role in the reenactment of his primary conflict.
When the patient saw himself cutting meat with a big knife, he was already
struggling with a complicated mourning process over the death of his father,
precipitated by the fear, anger and resentment associated with the father–son
representations. The knife as a symbol of aggression operated as the external
stimulus that revealed the patient’s hostility toward his father. This activated a
discrepancy between his actual self-representation of a bad, angry and
vulnerable son and the ideal self-representation of a loving son, the internal-
ization of the cultural ideal of the good child who loves his father. The
psychoanalytic notion of compromise formation was a useful tool in the
conceptualization of the over-determination of Carlos’ presenting symptom.
Through the content of his obsessive ideas, the patient was expressing his
identification with an aggressive, sadistic father, whose recent death had
revealed the patient’s ongoing unresolved conflictual relationship. Carlos’
identification with the aggressor, as evidenced in his thoughts about injuring
his daughter, was also determined by guilt feelings and resultant wishes for self-
punishment. For this loving father, who had been forced to separate from his
older children, there was no worse punishment than losing his children.
Learning that his adolescent children would not be coming to the US
reinforced the fear of losing them. Through his symptom, the patient uncon-
sciously was condemning himself to be an unpredictably violent father and lose
his children’s love as his father had lost his and his siblings’ love. In his
everyday life in the US he was compelled to avoid being alone with the only
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child that he had not lost because he was afraid of acting out his horrendous
thoughts. Furthermore, he experienced a sense of loss around the major battle
of his life, that of struggling with his identification with his father.
In addition, when his father died, the patient made a choice that had
personal, familial and cultural meanings that contributed to the determination
of his presenting problem: he refused to go to his father’s funeral. Consciously,
he had valid and legitimate reasons to refuse to go, because his life was literally
in danger in his country. Unconsciously, however, his refusal to go represented
an angry attempt to rebel against his tyrannical father and it expressed the
anger that he had not been able to express throughout his father’s life, due to
the internalization of his original culture’s ideal of unconditional submission to
paternal figures. Also, by not going to his father’s funeral, the patient went
against his culture’s mandate regarding bereavement rituals for one’s parents,
which include the expectation of obligatorily attending such events regardless
of the personal circumstances and risks. He received numerous cards from
relatives and friends, encouraging him to forgive his father and come to the
funeral, because this would be his last opportunity to say goodbye. This reflects
the cultural norms and meanings both in the discourse and in the social inter-
actions of his original community, and represents a clear example of culturally
informed affect regulation strategy that attempts to maintain relational
closeness through the induction of guilt feelings. His relatives’ advice and
warnings reinforced interpersonally what the patient believed unconsciously:
that he was avoiding his father’s funeral, not because he could be the target of
political violence but because of his “oppositionalism and defiance” toward his
father. The discrepancy between his culture’s mandate of attending his father’s
funeral and his decision not to go activated the experience of fear and vulnera-
bility common to his traumatic history in childhood and adulthood. His
separation from his older children was experienced as a painful loss. It precipi-
tated loyalty conflicts between his two families and activated his fear of being a
“bad father” – like his father – with the consequent guilt feelings.
Culturally shaped ideal representations of relationships between family
members internalized by the patient reinforced his loyalty conflicts and guilt
feelings and contributed to consolidate a complicated immigration mourning
process. In relation to the optimal balance of autonomy and relatedness, in
contrast to the emphasis on the ideal of self-sufficiency and self-resourcefulness
predominant in the US, Carlos’ culture placed a greater emphasis on emotional
interdependence on family members. In addition, the interplay between the
cultural ideal of emotional interdependence and self-representations of
helplessness, derived from the patient’s traumatic history, increased his
separation anxiety from his family. The combination of the complicated
mourning over the loss of his father, separation anxiety, fear of loss of his older
children and guilt feelings complicated the immigration mourning process. The
complicated immigration mourning process in turn interfered with the ability
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to master the functions that contribute to the assimilation to the new culture,
having a negative impact on the continuity of identity and regulation of self-
esteem.
Seeing himself working at the supermarket inflicted a daily blow to Carlos’
professional dreams. His social interactions in this environment did not sustain
the reciprocal identity/environment corroboration that his interactions in a
work environment had provided in his country, before he was exposed to
terrorism. This affected his identity feeling of self-sameness and continuity over
time and represented a self-esteem injury that permeated the different spheres
of the patient’s life. His financial difficulties in the US interfered with the
possibility of sending the amount of money that his children needed. This in
turn collided with his culture’s masculine gender ideal of supporting one’s own
children financially, which affected his self-esteem in the specific areas of
gender and father self-representations.
In the earliest stage of treatment, working through the dynamic relationship
between his longstanding history of terror, anger and resentment towards his
father and his fear of identification with his aggression remarkably decreased
the patient’s level of anxiety and guilt feelings related to his obsessive symptom.
This strengthened a positive maternal transference toward me that played an
essential role in the progress made in treatment. However, Carlos’ guilt feelings
resurfaced when the main focus of therapy was the mourning over the death of
his father. Subsequently, the diagnosis shifted to a panic disorder. The father
had died of a heart attack and the patient replicated in his panic symptoms his
father’s chest pain and showed his terror of dying in the same way his father had
died. Multiple checkups confirmed there was no cardiac pathology. Insight-
oriented work established the meaningful connections between the
psychodynamic constellations underlying the obsessive symptoms and the
panic disorder symptoms. The patient gained increasing insight into how his
traumatic histories in childhood and adulthood (including his migration
experience) had interacted to produce a pervasive fear of violence, fear of his
own anger and of retaliation, and successive identifications with his abusive
and his terminally ill father. Then, addressing in psychotherapy Carlos’ loyalty
conflicts, as well as the function fulfilled by the values internalized in his
culture of origin and the interactions with his family members in maintaining
the symptoms and guilt feelings, led to the disappearance of the obsessive fear
of having sadistic impulses. The most important behavioral change of this stage
of psychotherapy was the patient’s capability to enjoy his relationship with his
little daughter.
The following information regarding transference-countertransference
aspects needs to be provided. Despite not sharing the same cultural
background, Carlos and I are both immigrants and did speak our maternal
language in psychotherapy. Psychodynamically, the experience of success of
verbal communication in being understood in his maternal language by a
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therapist who herself had had migration experience increased the feelings of
safety, trust and hope and reinforced the positive cooperative transference. This
transferential trend contributed to decrease the terror derived from Carlos’
unconscious belief of having no other choice than repeating physically
aggressive interpersonal interactions, which resulted from the traumatic history
that had given place to the psychodynamic constellations underlying his chief
complaint. The same positive transferential trend, however, was not as
successful in decreasing the patient’s “guilt at success in the new country” or the
deadly loyalties that increased his impulse to return to his homeland, both of
which were reinforced by culturally informed communications with his signif-
icant others. In addition, non-dynamic factors like complicated circumstances
and age at migration as well as limited English skills played an important role in
the outcome of the psychological process of immigration. As a consequence,
Carlos remained mostly referred to the meanings and relationships of his
culture of origin, which interfered with the possibility of internalizing values,
ideals, and relational and behavioral patterns informed by the host culture.
To conclude, I will add certain remarks about the compatibility of this
conceptual framework with the implementation of non-dynamic techniques. A
psychodynamic case formulation can lead to the conclusion that psychody-
namic treatment is not the best option for a particular patient or period of
psychotherapy. It can also suggest that a non-dynamic treatment modality is
the most appropriate intervention to use in parallel with, or throughout all or
part of, a psychodynamic psychotherapy. Thus, in the stage of Carlos’ panic
disorder, short-term cognitive behavioral and psychopharmacological treat-
ments were used in combination with psychodynamic psychotherapy to
achieve relief of the panic symptoms.
Second Case
Maria was a 28-year-old married woman who had immigrated to the US one
year before she sought treatment. When treatment began, Maria was living
with her husband at a university campus. She was unemployed and had no
command of the English language. Maria had completed graduate education in
her homeland and was satisfactorily working in her field when her husband
received the letter of acceptance to a doctoral studies program at one of the
best universities in the US.
In the initial evaluation interview, Maria reported as her chief complaint
that since learning that she would emigrate, she started having increasing
feelings of anxiety and sadness that culminated in a severe depression, a few
months after arriving in the US. She also stated that she had sleep, attention
and concentration disturbances, and that she viewed herself as absolutely
incapable of learning English and working in this country. With tears in her
eyes, she explained that the most remarkable experience connected to her
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depression was her feeling of loss of her professional identity since migrating
had implied interrupting a promising professional career. She had completed
her graduate studies two years before her departure, and she was just about to be
promoted when they left their country. In the last minutes of the interview, she
told the interviewer that, despite her own resistance, she had finally decided to
seek treatment because she had lost all those she usually relied on in times of
difficulty: “family,” “friends” and “colleagues.”
Maria was the oldest of three siblings. She had two younger brothers and
had grown up on the outskirts of a big city in a middle-class patriarchal
Catholic family with a very rigid system of beliefs and values. She portrayed her
parents as loving and caring, and at the same time rigid-minded and restrictive
of their children’s freedom. According to her, as was characteristic of the
culture of her parents’ generation, her father was the indisputable authority,
whereas her mother was in charge of transmitting to her children the principles
of Catholic education. Because Maria was the only girl in the family, her
mother had spent a significant amount of her development ensuring that she
was not having “improper relationships” with males. In other words, her
mother had embodied the cultural emphasis on sexual repression that was
especially targeted towards women. Maria reported that her father had an
“unbearable character,” that sometimes he acted as “the boss of the family,” and
that she – “her father’s favorite child” – was “as bossy and stubborn as he was.”
She believed that her brothers had had an easier position in the family because,
on the one hand, they had not been the focus of their “mother’s overwhelming
overprotection.” On the other hand, they had not suffered, as she had, from a
terrible split in her father’s regard. He crowned her as the favorite object of his
love while he simultaneously denied her intellectual respect because she was
not male.
Psychodynamic Formulation of the Treatment
In our first session Maria shared with me “a secret” that she “would never share
with any other person in this world.” She told me that this was an important
part of her chief complaint that she had not dared to report in the initial visit.
One month before she and her husband had emigrated from their country, she
had fallen in love with a supervisor at work and they had initiated a love affair
that they continued to maintain currently. She told me that she was “absolutely
sure” that her feelings towards her supervisor and her “compulsive relationship”
with him were connected with her “husband’s imposition to leave her country.”
She summarized her internal struggle by saying: “A terrible dilemma is
constantly present in my mind in the form of an obsessive doubt: Do I love my
husband or him?”
The psychodynamic formulation of psychotherapy is a continuing dialectic
process that progresses from the initial conceptualization of the case which
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guides the first clinical interventions, through further immersion in the
patient’s dynamics, to the reformulations of the original conceptualization.
Maria’s chief complaint was placed in the context of her life situation
(including stage and vicissitudes of the immigration process), her develop-
mental history, her organization of identifications, her central conflicts, her
ideals and cultural beliefs and the transference/countertransference manifesta-
tions. The patient’s association between her infatuation with her supervisor and
the anxieties and feelings precipitated by the migration process (including
anticipatory anxiety) led me to think that her “compulsive relationship” with
her supervisor as well as her “obsessive doubt” were part of a dynamic constel-
lation that needed to be formulated in psychotherapy.
In our sessions, Maria informed me that she was the first female who went to
college and the first professional woman in her family. Her mother had been a
housewife, a position that Maria admired and respected because she understood
it as the “pillar” of the cohesiveness of the family. At the same time, she feared
getting trapped at home, like her mother, and burying forever the efforts of so
many years of learning. In trying to understand Maria’s comment about her
“husband’s imposition to leave the country,” and knowing that she had “a bossy,
authoritarian father,” I asked her whether she had considered the possibility of
remaining in her country for a short while, after her husband’s departure, to
complete a cycle at work and be able to enjoy her expected promotion. For few
minutes, she made deep eye contact with me and yelled: “Husband and wife live
together and travel together! That would not have been wife-like behavior!”
This comment showed me that Maria had learned well her parents’ lessons.
Having internalized their rigidity of values, she did not grant herself the right to
examine different options in order to decrease the suffering and sacrifice
produced by her emigration.
From the point of view of her interaction with me, since the revelation of
her secret, Maria had remained for four sessions seated in one corner of the
office, looking down, unable to make eye contact with me, with evident fear
and shame. She seemed to feel “cornered” in the room. Given the combination
of verbal and body messages, I thought that our therapy work should focus on
the transference-countertransference dynamics in order to shift the relationship
from the polarization between a condemnatory, parental figure and a guilty,
embarrassed child. Thus, I highlighted the multiple forms in which the
repressive and restrictive meanings of certain parental messages operated
intrapsychically and were played out interpersonally in Maria’s transference
towards me in psychotherapy. Over the course of the following sessions, Maria
told me that she traveled and continued to have secret encounters with her
lover in different parts of the world. She also told me that, as she continued to
have this relationship with him, it became clearer to her that it would not
work. “However,” she added firmly and defiantly, “I think that a woman should
marry the person she is in love with.” “And so do I,” I responded, attempting
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with this intervention to differentiate myself from the repressive object of a
maternal transferential trend projected onto me. The patient made a sequence
of movements on her chair that seemed to dispel her fear and shame from the
office, and adopted a new, relaxed posture. Then she confessed that her
mother’s repressive behavior had awakened in her a pleasure for the forbidden.
“And perhaps this is my problem,” she reflected, “that my husband is too
available.”
Maria’s severe depression as well as her feeling of loss of professional identity
can be easily conceptualized by reference to the three interrelated processes of
the psychodynamics of immigration. She was experiencing a mourning process
precipitated by her separation from love objects and original environment, as
well as by the need to speak a different language. Her interpersonal interactions
in the US were not validating and valuing the configurations of self-representa-
tions that had been culturally and socially recognized in her culture of origin.
This affected her feeling of self-sameness and continuity of identity and
produced a self-esteem imbalance with a particular impact on the sphere of
professional identity and professional self-esteem. Maria’s mourning process was
complicated by the predominance of angry feelings derived from her conviction
that her migration was a result of her “husband’s imposition.” Her anger also
played a crucial role in her resistance to develop the skills required for
adjustment to the new environment, including learning English, which repre-
sents an indispensable tool for the job search.
As we summarize the information that we have collected, we begin to
formulate Maria’s case within a framework that integrates intrapsychic,
relational and cultural perspectives in the psychodynamic formulation, and
conceptualizes the role fulfilled by the immigration process in the context of
the patient’s history. Maria had grown up in a patriarchal middle-class Catholic
family with a very rigid value system. In relation to her sexuality, the ideal self-
representations invested by her mother were not very different from the
Victorian ideals well characterized by Freud. In relation to her intellect, Maria’s
father had not invested in her intellectual ideal representations in the same
way that he had invested in her brothers’, because she was female. In fact, her
father was very ambivalent about his daughter’s professional development: he
had not idealized and mirrored her professional self-representations. Maria
presented an intrapsychic conflict between the ideal of the devoted wife and
mother and the ideal of the professional woman who “necessarily sacrifices her
family.” She had internalized this conflict from her interactions with her
parents in the formative years of the personality. Her parents, in turn, were the
carriers of a culture of transition in relation to female ideals. The conflict that
was represented in Maria’s intrapsychic world was also represented in her
original sociocultural world. When her husband had announced that he could
fulfill his vocational dreams by emigrating, Maria felt that she had to abandon
her own professional career.
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In working through her experience of “husband’s imposition,” Maria arrived
at the conclusion that she had projected onto her husband her images of an
authoritarian father who was very ambivalent about his favorite child’s profes-
sional career because she was a female. She also thought that she had projected
onto her husband images of an over-controlling mother. With sadness and
anger, she one day concluded that having an affair had been the “first personal
decision” that she had made in her entire life. She finally remembered that, in
fact, her husband had suggested multiple options, including resigning from his
doctoral studies so that they both could remain in their native country. It was
she who had resigned her ideal of freedom and re-enacted internalized relations
between a submissive/inhibited self and a domineering/repressive authority.
How do we formulate in this meaningful context Maria’s “compulsive
relationship” with her supervisor and the “obsessive doubt” that did not allow
her to overcome the paralysis in either her internal or her external world?
Which are the multiple confluent psychological trends that overdetermine this
psychodynamic constellation? We know that Maria had projected onto her
husband the object representation of a bossy, authoritarian father. Once she
had made that projection, she experienced her migration as an imposition, to
which she reacted with increasing anger leading to a rebellion against her
husband/father. She was also rebelling against her over-controlling mother who
had exercised the function of sexual repression throughout so many years of
development. The rebellion against her husband manifested in the sphere of
sexuality, which was an arena of control and prohibition as well as one of
inhibition and temptation. In fact, the patient discovered the pleasure of
sexuality in her relationship with a “prohibited object,” and this relationship
was the “first personal decision” that she had made in her battle against
imposition, repression and inhibition. And so, Maria’s “object choice” (Freud,
1957/1914) was her supervisor: the person who had invested and idealized – as
her father had not – her professional self-representations.
Working through the patient’s conscious and unconscious meanings of her
migration revealed that it reactivated constellations of conflictual self, object
and relational representations with associated affects. Migration as a stressor is
not a simple but is rather a complex precipitant that includes interrelated
processes that in turn interact with and are expressed according to the previous
history of the individual. Having to interrupt her professional career devel-
opment triggered in Maria a fear of being incapable of succeeding in an
unknown environment and losing forever her professional skills. This fear
started with her anticipation of a self-esteem imbalance in the new culture and
was confirmed by her personal experiences throughout the first stages of
immigration. The re-enactment of relational representations that included her
father’s underestimation of women’s intellectual abilities as well as fears
of identification with a non-professional mother played a significant role
in Maria’s imbalance of her professional self-esteem. The internalization of
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interactions with a domineering, authoritarian father and with an over-
controlling, repressive mother played an important role in her experience of
migration as an imposition. These constellations of representations and affects
operating in the context of the patient’s history and the process of immigration
as a complex precipitant were expressed in a compromise formation that
accounted for different psychic trends. The patient’s experience of migration as
an imposition, her derived need to act out her rebellious anger towards her
husband/parents, as well as her need to rebalance her decompensated self-
esteem, were manifested in the selection of her supervisor as an object of
idealization and sexual attraction. This object fulfilled the function of a
compensatory strategy of self-esteem regulation: a “narcissistic object choice” in
Freud’s terms. Working through in psychotherapy the underlying constellations
of the patient’s “infatuation/symptom” led to overcoming the obsessive doubt
between loving her husband or her supervisor. Maria’s identification with her
sexually repressive mother had produced a split between the object of
tenderness and the object of sexual arousal that became very evident in the
patient’s first stages of her extramarital relationship. Once and again, with
evident pain, she commented that she loved her husband but could not fall in
love with him.
Working through the intertwining between the intrapsychic, interpersonal
and cultural aspects of the patient’s specific conflicts, affects and transference-
countertransference dynamics in a long-term therapy process led to a
reorganization of Maria’s representational world, identity and self-esteem. This
in turn allowed her to make significant progress in her English lessons and job
search in the US. Once she started working, her identifications with her
“bossy” father played an important role in her quick promotions to leadership
positions. Her achievements in the professional world contributed to consol-
idate the stability of her identity and the balance of her self-esteem. And last,
but not least, working through her relationship with her parental figures, her
projections onto her present objects, including her transferential trends towards
her therapist, and the affects of fear, anger and shame led to an important
change in her relationship with her husband. To her own surprise, she one day
discovered that she was falling in love with him. From the point of view of our
transference-countertransference interactions, after working through the
repressive and restrictive forms of her maternal and paternal transference in
psychotherapy, Maria made significant progress toward the integration of
idealized and devalued self-representations of the cultural, personal and profes-
sional aspects of her identity. In this transferential stage, her focus on her
representations of me as an immigrant played a significant role in her possibility
to envision being a wife, a mother and a professional in a new cultural
environment. The essential aspect of my interventions in the transference-
countertransference dynamics seemed to have been my consistent respect for
her personal belief (which in fact I share) that an individual “should marry the
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person she is in love with.” This allowed the patient to unfold her multiple and
conflictual wishes, representations, affects, defenses, values and ideals with a
degree of freedom that she had not been able to experience in the interaction
with her original objects. It also allowed me to follow the therapeutic investi-
gation without assuming psychological positions that would have reinforced
the patient’s resistance and interfered with the process of discovering her own
underlying meanings.
IV
. DISCUSSION AND CONCLUSIONS
This article conceptualizes psychotherapy with immigrants within a psychody-
namic framework that includes intrapsychic, interpersonal and cultural
perspectives of psychic reality and formulates immigration as a complex precip-
itating factor that involves mourning processes, and affects the stability of
identity and the regulation of self-esteem. To illustrate how the psychodynamic
formulation guides the psychotherapy process, I have discussed two cases whose
gender identities, countries of origin, socioeconomic and educational
backgrounds, levels of psychopathology and outcome of the psychological
immigration process differ.
After placing each patient’s chief complaint in the context of his/her devel-
opmental history, organization of identifications, cultural beliefs and ideals and
transference manifestations, their central conflicts were formulated as a reacti-
vation of constellations of conflictual self, object and relational representations
with associated affects precipitated by the three interrelated processes of the
psychodynamics of immigration. Working through the role fulfilled by the
interaction of processes of mourning, discontinuity of identity and decompen-
sation of self-esteem as well as of intrapsychic, interpersonal and cultural
dimensions in precipitating and maintaining symptoms and affects led to the
resolution of the presenting problem in both patients. At the same time, it is
evident that each individual’s particular combination of non-dynamic and
dynamic factors explains the different outcomes of their immigration processes.
In the case of Carlos, the underlying conflicts were worked through and the
symptoms that led him to seek help were resolved in psychotherapy. However,
his history of trauma in both childhood and adulthood as well as the compli-
cated circumstances of his migration interfered with the completion of a
successful process of resettlement. Carlos’ “guilt at success in the new country”
(Akhtar, 1995) provides a good example of an affect regulation strategy that is
intrapsychically structured, shaped by ideals of his culture of origin, and inter-
personally reinforced by his relatives and friends. This patient maintained the
splitting between idealized and devalued self-representations and cultures and
did not attain the stage of “hyphenated identity” (Akhtar, 1995). His
intrapsychic conflicts, feelings and anxieties interfered with the mastering of
functions necessary for the adjustment and assimilation to the new culture. In
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the case of Maria, working through the central conflicts, identity and self-
esteem instability that were re-enacted by the psychodynamics of migration
and expressed in her symptoms and transference allowed the patient to discover
that she could recover her professional identity in a different sociocultural
context. Although migration precipitated disturbing symptoms and affects, it
also offered an opportunity for her to mourn the significant losses, and
reorganize her identification systems, identity and self-esteem. This reorgani-
zation facilitated a different interaction with the external world as well as the
development of the skills that led to a successful completion of her resettlement
process.
ACKNOWLEDGEMENT
I am very grateful to George Fishman, MD, and to Carol Shakow, LICW, for
the critical reading of the manuscript. I am very much in debt to my patients
and colleagues for making this work possible.
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Silvia Halperin
Department of Psychiatry, The Cambridge Hospital, Harvard Medical School,
Boston, MA, USA.
sylvia_halperin@hms.harvard.edu
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... Conroy (2008) for example claims that people who had early psychological disturbances and pre-migration trauma have greater difficulties, while those with basic capacities to mourn, form healthy relationships, and endure difficult feelings have a greater chance of success. On the other hand, relationally and interpersonally focused authors (e.g., Halperin, 2006) highlight age, socio-economic background, and cultural-linguistic differences as the most important factors in determining the outcome of successful adaptation. ...
... Relationally focused authors argue that the psychological outcome of immigration is not solely determined by intrapsychic factors or childhood experiences, but by tangible external variables. These include the level of cultural difference between societies (Searle & Ward, 1990; Ward & Kennedy, 1992), age, reasons for relocation, and reception by the host country (Garza-Guererro, 1974; Halperin, 2006; Mishne, 2002; O " Hare, 2004; Sengun, 2001). The ability to frequently visit one " s home country to " emotionally refuel " is also thought to lead to better results (Akhtar, 1995; Denford, 1981, Sengun, 2001). ...
... A number of authors agree that a comprehensive assessment should be undertaken including a history of familial, educational, work, social and cultural background (Elovitz & Khan, 1997) and include intrapsychic, interpersonal and cultural dimensions (Halperin, 2006). It is also suggested that traumatic experiences, acculturation level and language competency should be evaluated (Tseng & Streltzer, 2001). ...
Article
This dissertation explores psychoanalytic and psychodynamic perspectives regarding immigration and how the experience influences a person's psychological processes and identity. Additionally, this research considers how such theoretical understandings could inform cross-cultural therapeutic practice. The research method consists of a modified systematic literature review (SLR) and critical evaluation of articles, many of which incorporate clinical case studies. Relevant theoretical concepts drawn on by authors are explained, and themes within the literature are organised by utilising an adapted data analysis process. Both personal and social variables influencing immigration outcome are summarised, while common psychological defence mechanisms are examined alongside cultural transference dynamics, issues of culture shock, grief and loss, and narcissistic injury. Considerations for assessment and diagnosis, and suggested treatment adaptations are also summarised. Psychodynamic literature suggests that although immigration experiences vary, common themes include object loss, separation-individuation processes, mourning work, identity reformation, and narcissistic wounding alongside social variables such as language difficulties, prejudice and isolation. Positive factors and opportunities for personal growth as part of the immigration process are also noted. By understanding these complex psychosocial processes, acknowledging the multiplicity of human experience, and reflecting on their own culturally constructed theoretical frameworks therapists may be better able to work with immigrant clients. It is however suggested that a shift from a primarily intrapsychic treatment focus to one emphasising interpersonal connectedness and contextual cultural factors may be essential for addressing immigrant identity issues within Aotearoa New Zealand. In doing so therapists may be able to assist clients in the process of mourning for losses and developing a stable sense of self in order to embrace their new community and live fully, while also maintaining links to their "motherland" and retaining their own special ethnicity, culture, and language.
... 21 There is a widespread belief amongst psychoanalysts, rooted in Freud's classic paper, Mourning and Melancholia (1917), that an individual's ability to mourn -or her resistance to mourning -the losses of place, identity and people (Volkan, 1993;Akhtar, 1995;Lijtmaer, 2001) determines "the degree to which an adjustment is made to the new life" (Volkan, 1993:65). Indeed, we can see in Zainab's account of her move from London to Pakistan, the three inter-related processes identified by Halperin (2004) as characteristic of the psychodynamics of migration: a process of mourning of lost people and places; a discontinuity of identity -"an imbalance between change and continuity" Page-241 9780230320543_12_cha11 PROOF Sasha Roseneil 241 (2004:100) -as internal models of self are disturbed and not reinforced by everyday interactions, and "culture shock" (Garza-Guerrero, 1974) is experienced as the "result of an alarming disparity between the immigrant's representational world and the new external reality" (2004:104); and the disregulation of self-esteem, because of the lack of social recognition in the new setting. ...
... More recently, however, a literature has developed amongst clinicians working with migrants, refugees and exiles, some of whom also reflect on their own experiences of migration -e.g. Garza-Guerrero (1974), Denford (1981), Grinberg and Grinberg (1989), Akhtar (1995Akhtar ( , 1999, Lijtmaer (2001) and Halperin (2004). 20. ...
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