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Abstract

Recent years have seen an increase in the immigrant population in Norway, and within this population, a considerable rise in substance use disorders (SUDs) and elevated odds of developing mental health disorders (MHDs). Immigrants are thus regarded as an at-risk group for both situations. No studies have been conducted on the subjective understanding of co-occurring SUDs and MHDs among this immigrant population; thus, there is limited knowledge of the field. This qualitative study aims to explore the lived experiences of being an immigrant and living with co-occurring SUDs and MHDs. Indi- vidual interviews with 10 persons of immigrant background with co-occurring SUDs and MHDs, and treatment experience in Norway, were conducted. Data were analyzed using a phenomenological approach and systematic text condensation. Analysis yielded three categories, each with two subcategories, of the immigrants’ experiences of living with co- occurring SUDs and MHDs. The overarching theme was how they coped and negotiated a sense of self within the self, within the surrounding culture, and within the structures of society. Subcategories revealed their experiences that necessitated coping and negotiating sense of self within each level. Participants experienced “living a double life” and a “culture clash” along with a sense of belonging to a marginalized group, thus, lacking a sense of belonging in mainstream society. This study provides enhanced understanding of how immigrants with co-occurring SUDs and MHDs experience being an immigrant and having the concurrent disorders.
Coping and Negotiating a Sense of Self
Immigrant Mens Experiences of Living with Co- Occurring
Substance Use and Mental Health Disorders in Norway
 ,  ,  ,
 ,   
ABSTRACT
Recent years have seen an increase in the immigrant population in Norway, and within
this population, a considerable rise in substance use disorders (SUDs) and elevated
odds of developing mental health disorders (MHDs). Immigrants are thus regarded as
an at- risk group for both situations. No studies have been conducted on the subjective
understanding of co- occurring SUDs and MHDs among this immigrant population; thus,
there is limited knowledge of the  eld.  is qualitative study aims to explore the lived
experiences of being an immigrant and living with co- occurring SUDs and MHDs. Indi-
vidual interviews with  persons of immigrant background with co- occurring SUDs and
MHDs, and treatment experience in Norway, were conducted. Data were analyzed using
a phenomenological approach and systematic text condensation. Analysis yielded three
categories, each with two subcategories, of the immigrants’ experiences of living with co-
occurring SUDs and MHDs.  e overarching theme was how they coped and negotiated
a sense of self within the self, within the surrounding culture, and within the structures of
society. Subcategories revealed their experiences that necessitated coping and negotiat-
ing sense of self within each level. Participants experienced “living a double life” and a
“culture clash” along with a sense of belonging to a marginalized group, thus, lacking a
sense of belonging in mainstream society.  is study provides enhanced understanding of
how immigrants with co- occurring SUDs and MHDs experience being an immigrant and
having the concurrent disorders.
KEYWORDS
co- occurring disorders, substance use disorder, mental health disorder, immigrants, lived
experiences
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019
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Introduction
Immigrants constitute . of Norway’s population, . of whom
are from low- and middle- income countries (SSB, ). Immigrants
are vulnerable due to their di erent cultural and ethnic backgrounds,
and those diagnosed with co- occurring substance use disorder (SUD)
and mental health disorder (MHD) are o en referred to as “di cult
to help” and “complex” due to a variety of factors and lack of tailored
services (Davidson et al., ).  is becomes even more di cult when
native populations have negative a itudes toward immigrants, creating
challenging situations and integration barriers.  e negative a itudes
are o en associated with racism and discriminatory practices that
prevent immigrants from accessing help and social inclusion (Constant
et al., ). Further, preexisting ethnic a itudes in the institutional
arrangements, including law and organizational policies or practices,
may make opportunities for immigrants unequal (Reitz, ). Brekke
and colleagues recently wrote that the practice of residence- permit or
citizenship revocation in Norway has led to disintegrating e ects among
immigrants, including social exclusion, stigmatization, social withdrawal,
and lack of a sense of belonging (Brekke et al., ). Also, recent studies
have revealed underutilization of mental health services (Abebe et al.,
) and less frequent hospitalizations among immigrants, despite a
prevalence of mental problems three times higher than in the general
population (Spilker et al., ). In addition, immigrants’ mental health
is a ected by acculturative pressure that causes stressors while they
balance between two cultures and adapt to the dominant culture of the
society (e.g., identity crisis, discrimination, and trauma faced by their
parents during di erent phases of migration), which increases their risk of
developing SUDs and MHDs (Lien et al., ).
A Swedish survey among adolescents reported that immigrants were
more likely to use illicit drugs than the native population (Svensson
& Hagquist, ). Another cross- sectional study that explored the
relationship between immigrant status and the history of compulsory
treatment for SUD showed that second- generation immigrants were 
more likely than the general population to have had compulsory treatment,
making them an at- risk group (Lundgren et al., ). A longitudinal
study (Sagatun et al., ) and a review study (Abebe et al., ) from
Norway also found that the immigrant population experienced more
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
MHD than native Norwegians.  e immigrants in Abebe et al.’s study had
a high risk of developing acculturative stress, su ered from poor social
support, socioeconomic deprivation, multiple negative life events, and
experiences of discrimination and traumatic premigration experiences.
A qualitative study (Biong & Ravndal, ) among young immigrant
men in Scandinavia suggested that immigration and SUDs put them at
greater risk of suicide due to a sense of being marginalized in an unknown
environment.  is study also indicated that immigrants with SUDs are a
vulnerable group with multiple treatment needs.
Understanding the processes of coping and sense of self in persons
with prolonged MHDs can provide a basis for them to manage, compen-
sate for, and help them to recover from their disorders. Coping is under-
stood as the process in which individuals take actions to handle stressful
situations (Bartle , ). We regard migration, SUD, and MHD as stress-
ful events in one’s life. Lazarus () argued that stressful situations are
associated with harm, loss, threat, or challenge, and that if these situations
are signi cant for the person, then the person will engage in coping to deal
with the perceived harm, loss, threat, or challenge. Sense of self is under-
stood as the organized, consistent set of perceptions and beliefs about
oneself (Rogers, ), and it appears to be a major component in the ev-
eryday experience of MHDs, o en described as a core factor in illness and
change (Davidson & Strauss, ). Furthermore, in a novel framework
for sense of self, Prebble and colleagues described the phenomenological
experience of sel ood as a subjective sense of self, which provides a cru-
cial precondition for phenomenological continuity in episodic memory
(Prebble et al., ), and we argue that it may also provide insights into
the experiences of persons living with SUDs and/or MHDs.
Increased immigration to Norway in the last  years has led to
greater ethnic diversity among the population (Abebe et al., ).  is
relocation of large groups of persons has transformed Norway from a
perceived homogeneous and monocultural society to a heterogeneous
and multicultural society (Oppedal et al., ). Research has shown that
poor integration has led to higher rates of MHDs in immigrant groups
(Roberts et al., ; Virta & Westin, ).  is makes it important to
study both cross- cultural and within- culture perspectives in multicultural
society (Oppedal et al., ). Culture must be understood as mental
representation of the meaning of systems, symbols, and practices
through which persons interpret experiences, and culture and individual
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019
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psychological functioning are mutually constitutive (Mistry & Saraswathi,
). We therefore need more knowledge about cultural perceptions,
possible ethnic di erences, and risk factors for lifestyle behaviors.  is
knowledge is important for generally reducing social inequality in health
(Abebe et al., ).
e aim of this study is to explore the lived experiences of being an
immigrant and living with co- occurring substance use and mental health
disorders in Norway.
Method
Design and Collaborative Research
e study design is qualitative and exploratory, with a phenomenological
approach to data analysis.
Collaborative research is invaluable in bringing a fresh perspective
to the research process, is highly relevant to clinical practice, and helps
to improve the evidence base used to inform how services are provided
(Beresford, ).  erefore, a competency group of three persons was
established to work with the research team in all stages of the study. Two
members were previous users of psychiatric treatment with lived experi-
ences of co- occurring MHD and SUD, and one was a relative of one user.
All three members had immigrant backgrounds and understanding of
their local community as well as the greater Norwegian community.
Recruitment
A purposive, criterion- based sampling method (Pa on, ) was
used to recruit the participants from two large Norwegian cities, Oslo
and Drammen. To achieve information- rich data, the study included a
diverse sample of immigrants from low- and middle- income countries
with experience of living with co- occurring disorders and of treatment
in Norwegian health care. Immigrants in this project are understood as
persons who were born or whose parents were born in low- and middle-
income countries. In addition, we included immigrants (persons born
abroad of two foreign- born parents and four foreign- born grandparents)
and persons who were Norwegian born to immigrant parents (persons
born in Norway of two parents born abroad who also have four
grandparents born abroad) in our study (SSB, ). Note also that
immigrants is not a homogeneous category; they di er in multiple ways,
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
including culture, ethnicity, the reason for migration, and historical
migration pa erns. So this study considers them heterogeneous versus
homogeneous.
We initiated contact by emailing and calling the leaders of various
treatment and rehabilitation centers in these two cities who had access
to participants with the inclusion criteria.  ese leaders received detailed
information about the research project. Recruitment of participants was
extremely challenging. We do not know exactly how many persons the
team leaders asked to participate, but most of them refused to take part in
the study. Only one participant was recruited through these leaders.  is
participant was contacted by telephone by the  rst author and informed
about the study. Subsequently, by snowballing, this participant helped to
recruit three more participants with whom he had contact.  e compe-
tency group played a key role in recruiting further participants: Six par-
ticipants were recruited with the help of this group, whose members had
contacts in their local community. Potential participants were able to show
interest by contacting the  rst author by telephone or text.
Participants
Ten participants who met the inclusion criteria were included in this study
(Appendix A, Table- ). All were males, with an age range of  to  years.
ey had been diagnosed with co- occurring SUDs and MHDs and had
experience of treatment in the Norwegian health care system. All of them
were polysubstance users and the most common substances used were
cannabis, alcohol, and heroin. Five persons reported not using substances
at the time of interview, while the other  ve were using substances.  e
participants also reported having experienced MHDs, most commonly
a ective disorder, pos raumatic stress disorder, personality disorder, and
anxiety. Eight participants reported having experienced suicidal thoughts
and a empting suicide.  e objective diagnosis was not considered, but
rather how the participants understood their own mental health condition.
Five participants were from Iran, and the remainder were from Sierra
Leone, Eritrea, India, and Pakistan. Two participants were born in Norway,
and most others migrated at a very early age, while two had arrived at ages
 and  years. Eight participants started using substances at a young age
a er arriving in Norway, while the two adult migrants started at a young
age in their countries of origin.
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019
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Data Collection
Ten semistructured, in- depth individual interviews (Kvale & Brinkmann,
) were conducted between June  and March . A er  inter-
views, the research team considered the data to be su ciently saturated
to ful ll the aim of the study.  e interviews lasted between  and 
minutes and all were audio recorded. Nine of the interviews were con-
ducted in Norwegian with the  rst author and an interpreter, while one
interview was carried out in English and Punjabi only with the  rst author,
and transcribed in English. An interview guide, consisting of open- ended
questions about what it means to live in Norway as a person with immi-
grant background living with co- occurring SUD and MHD, was created
and agreed upon by all authors and the competency group.
Data Analysis
Interviews conducted in Norwegian were transcribed by the interpreter,
and the one conducted in English and Punjabi was transcribed by the  rst
author.  e transcripts were analyzed using systematic text condensation
(Malterud, ), which is a pragmatic phenomenological approach in-
spired by Giorgi ().  is is an exploratory and descriptive method
aimed at thematic cross- case analysis, which enables a process of re ex-
ivity, feasibility, and intersubjectivity, while maintaining methodological
rigor. Systematic text condensation is a stepwise procedure that involves
the identi cation of recurring initial codes and themes relevant to the pur-
pose of the study. In the  rst step, a total impression was gained by read-
ing all the transcripts, which resulted in initial themes. In the second step,
meaning units were identi ed and sorted into code groups by systemati-
cally reviewing the transcripts. In the third step, the code groups with the
meaning units were classi ed into subgroups.  e fourth step involved the
formation of arti cial quotations by reducing the meaning units under
each subgroup.  e arti cial quotation containing the participants’ orig-
inal terminology was identi ed for each subgroup.  e  nal step was to
develop the analytic text and descriptions from the arti cial quotations.
e analytic text was reconceptualized by returning to the complete tran-
scripts and re ecting on whether each illustrative quotation still re ected
the original context.  is process validated the analytic texts. At the end,
the supporting quotes were added to the analytic texts, which are present-
ed in the Results section. In each step, the research team was consulted,
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
and in the  nal step, the competency group was consulted to provide an
understanding of the results within the local context they represented.
Ethical Considerations
is study was approved by the Norwegian Centre for Research Data
(Project No. ).  e participants signed the informed consent form
and received an information le er and debrie ng about the project prior
to the interviews. All con dential details were deleted from the data to
preserve participant anonymity.  e interpreter and the members of the
competency group signed a con dentiality declaration.  e contact de-
tails of the  rst author were made available to the participants in case they
had any postinterview concerns or questions.
Results
e analysis yielded three categories, each containing two subcategories,
of the immigrants’ experiences of living with co- occurring substance use
and mental health disorders.  e main theme overarching these categories
and subcategories was coping and negotiating a sense of self.  e analysis
conceptualized how participants coped and negotiated their sense of self
(a) within the self, (b) within the surrounding culture, and (c) within the
structures of society (Appendix B, Figure ).
Coping and Negotiating a Sense of Self Within the Self
Inner con ict. A “culture clash” between their own culture and Norwegian
culture emerged as one of the major inner con icts of the participants.
e cultural di erences and understanding of Norwegian culture were
described as a big problem, and ultimately, the participants did not know
how to  t into both cultures.  is led to the con ict of recognizing oneself
in both cultures and losing one’s sense of self with no sense of belonging
(participant ID numbers follow each interview excerpt):
.. . culture clash between Iran and Norway. It was a big clash and I
didn’t know who I was.... I started seeing both sides and lost myself
completely. I became a person with a completely blocked mind and I
did not know where I belonged. (P- )
A majority of the participants described the inner con ict of struggling
to trust anyone.  eir immigrant background, living in a context quite un-
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019
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like their country of origin and having experienced war and bullying, had
ruined their ability to trust anyone, and resulted in their carrying a bag-
gage of doubts and suspicions, which they found tiresome and exhausting.
Trust, which is zero. I don’t trust anyone and nothing in this world....
We sat with many Norwegian drug abusers but I still could not see my-
self in them.  ere was more to this, I had su ered, I had another back-
ground, I had war, bullying, refugee. All of this was also baggage I was
carrying. It wasn’t just drugs and alcohol for me, I had much more. So I
struggled with trust and trusting anyone with my words. (P- )
Participants experienced guilt, shame, and hurtful thoughts.  ey de-
scribed struggling with these negative emotions due to their self- perceived
inability to  t in with the norms of society.  ey described taboos a ached
to the use of substances and having a mental health disorder, which to-
gether with their immigrant background made it di cult for them to share
their feelings about the problems they were facing.  ey described this as
keeping these negative emotions inside even though they were su ering,
which led to the inner con ict. As one participant explained, “It’s a lot of
taboo and di cult to talk about. I don’t talk much either and keep things
inside me even though I’m su ering” (P- ).
e participants described how they coped by running away when
things became di cult and using substances; this became the way to es-
cape from who they were and a medicine for all the negative emotions.
Using substances made them feel invulnerable and con dent, and reduced
their pain of not recognizing their sense of self. Some of the participants
described coping by developing selective mutism, becoming introverted
and passive- aggressive. Furthermore, they negotiated their sense of self by
being a ected by past experiences that helped to carry them forward.
Lack of family support. Participants experienced a lack of family sup-
port, which also contributed to their substance use. Having abusive family
relationships in which they were beaten by their family members led to a
feeling of being pressured over time.  ey experienced a serious lack of
communication within the family, which meant that they did not confront
their family members with their struggles. Many described the divorce of
their parents as a disruptive event and the beginning of destructive rela-
tionships between their parents and themselves.  ey also reported that
their inability to live up to their family’s expectations and demands led to
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
the fear of family rejecting them. In addition, some pointed out that their
family had broken their trust by placing them in child care.
Participants described how, in order to cope with destructive family
relationships, they found substances to be a kind of survival strategy and
defense mechanism to anesthetize themselves. Some of them described
having to negotiate their sense of self by becoming bi er, hateful, and an-
gry about their family situation. Some developed the rebellious a itude of
smoking in front of their family to cope with the lack of familial love and
support:
I smoked, I was in opposition to my family. When I was , my father
had had enough and told me to pack my things and go to hell.  e
substances helped me get through everything actually.  e pain, ev-
erything about my family, about not having seen them, having been
thrown out.... We came from a well- established family... I did not
manage to ful ll my family’s high demands and expectations. And that
led to more and more substances, in fact. (P- )
Coping and Negotiating a Sense of Self Within
the Surrounding Culture
Cultural stigma.  e participants’ experiences illustrated that having
substance use and mental health disorders was associated with stigma, es-
pecially within their communities. It was considered disgraceful by their
families, and discovery as an “addict” within their community was associ-
ated with shame and everyone around them looking down on them. Since
participants’ communities in Norway are small, they constantly faced the
fear of being detected.
To cope with the cultural stigma, participants described the experienc-
es of wearing a mask and using substances even more.  ey coped and
negotiated their sense of self by keeping their substance use secret, and
when they were seeking treatment, they were forced to lie about leaving
home and going to work outside Norway for some period of time, so that
nobody would know that they were in treatment centers.  ey described
this as “living a double life,” in which they behaved soberly in front of their
family and relatives, but continued to use substances or seek treatment
that they concealed from others:
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I know people who don’t dare to start the treatment. Or they’ve been
in treatment, and tell their mum and dad, “I’m going on a trip around
the globe for one year. And I don’t want to take my phone with me,
because I don’t want to be a part of this digital world,” when they are
going to treatment centers. And if you have to do that with your close
ones, I can imagine how many masks you must be wearing. If you can’t
manage to be this open with your family, and the people closest to you,
then how on earth are you going to get help? (P- )
Belonging. Being accepted for who they were in a group of substance
users was experienced as positive by the participants and gave them a
sense of belonging.  ey described having struggled to  nd a place where
they were not judged based on their immigrant background and their di-
agnosis of co- occurring SUD and MHD. It was therefore easier for them
to be with other substance users than with persons in general due to a feel-
ing of acceptance and belonging.  ey experienced being recognized as a
person and not as a “junkie” or “addict” or based on their ethnicity. More-
over, they did not feel victimized in these groups, as they used to feel with
their family and relatives:
It was hard for me to  nd a place anywhere, but I met a gang of people
who used drugs and they accepted me for who I was. I didn’t really feel
like I had a place before, but with that gang of people I was just me and
had the place where I belong. (P- )
Participants coped and negotiated their sense of self by using substanc-
es with others and protecting each other at all times.  ey even reported
ghting together against racial remarks.  ey also joined training activi-
ties like taekwondo and gym together and coped by supporting each other
within the group.  is also helped them to forget the pain and fear they
were facing by being substance users and immigrants.
Coping and Negotiating a Sense of Self Within the Structures of Society
Experiences of racism. Most participants reported having experienced
racism and being labeled at various institutions due to their immigrant
background, substance use history, and mental health disorder. Many stat-
ed that, even though they had lived most of their lives in Norway, they
were still considered as “black” and not Norwegian.  ey also described
being given an ethnic label if there were any crime situation. Some partic-
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
ipants described their experiences of being bullied in school due to their
di erent skin and hair color and lack of  uency in Norwegian.  ey men-
tioned being beaten and given bad grades by teachers, even though they
believed they were doing well at school.  ey had also experienced racial
remarks from persons in their community.
Several participants mentioned being looked down on and facing di -
culties in ge ing jobs.  ey felt that they were stigmatized when applying
for jobs at the Norwegian Labour and Welfare Administration (NAV) due
to their history of substance use and crime:
When I apply for something I can feel that I’m being looked down
upon by the system, because of my past with drugs and crime.  ey
push us down.... With the system and with jobs, with people at work.
at’s where I feel stigmatized... yes, that’s something I’ve noticed.
Like with NAV, or if I’m applying for a job. (P- )
ese racial experiences led participants to try to cope by using sub-
stances even more than before.  ey also coped by hating their own im-
migrant background and culture.  is hatred resulted in a lack of com-
munication with their families and relatives.  e participants negotiated
their sense of self by ge ing involved in  ghts to defend themselves from
racism.
Distrust of the system. Several participants said that they had very lit-
tle or no trust in the system.  ey reported being unable to rely on health
care services when seeking treatment. Being prescribed antidepressants
or anti- anxiety pills without anyone inquiring about the problems they
were dealing with made them reluctant to receive the treatment.  eir dis-
satisfaction with treatment added to their lack of trust in the health care
system. Some participants mentioned that they felt worse a er treatment
ended, which led to relapses and self- medication. Participants described
their experience of treatment while in Child Welfare Services (CWS) as
astonishing because their personal information, which they had shared
with their psychiatrist, was reported to the child care services.  is led
them to feel cheated and initiated their fundamental distrust in the system.
Participants also experienced fear of CWS because they could lose
their parental rights. Many stated that having a child was a ray of hope for
them in their struggle with SUD and MHD.  e fear of losing their child
to CWS was thus a threatening experience, which led them to distrust the
services:
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019

It’s a very di cult situation, I have to stay alert and cautious whenever
I’m out with my kid. I feel I’m being watched all the time. I don’t like
this thing at all. I feel constantly scared of losing my child to the child
care services. So yes, this is one thing that scares me. (P- )
Participants reported coping by seeking compulsory treatment, as
they did not want to lose their children to CWS. Some described coping
and negotiating their sense of self by being manipulative in treatment and
counseling.  ese painful early experiences led to an inability to regain
trust in the system later in life.
Discussion
is study provides new insights into the experiences of immigrant men
living with co- occurring SUDs and MHDs.  e participants described
their experiences of coping and ways in which their sense of self was nego-
tiated within their own selves, with the surrounding culture, and with soci-
ety. One signi cant  nding is participants’ experiences of “living a double
life” and a “culture clash” due to con icts between their family culture and
the culture of the host country. Another is the participants’ experiences
of racism at di erent levels and cultural stigma that leads to lack of trust
and no sense of belonging within the context they are living.  is was in
addition to  uctuating feelings of being an immigrant and living with co-
occurring disorders.
Migration is a profound, nonnormative transitional event with long-
term e ects on life.  e challenges of assimilating into the dominant
culture, and those faced when the dominant culture does not welcome
diversity, can lead to increased substance use among immigrants (Dalla
et al., ).  is hypothesis is in line with participants’ experiences of
culture clash as living at the juncture of two cultures, using substances
to cope, and  nding ways to negotiate their sense of self between two
cultures. Further, this is associated with negative consequences such as
intergenerational con icts, family con icts, and societal pressures (Torres
& Rollock, ); also, immigrants who are refugees from con ict- prone
areas are likely to be dealing with their own trauma. Culture clash can
also be understood in terms of culture con ict theory, which states that
conduct norms vary among cultures, where an action may be a violation
of norms in one culture, but not in another culture.  is poses a potential
for cultural con ict when the dominant culture sets the standards for
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
acceptable behavior and considers those who do not comply with these
norms deviant (Henderson, ), which concurs with the participants’
experiences.
Experiences of guilt, shame, negative thoughts, and di culty in trust-
ing anyone created a feeling of inner con ict for participants.  ese expe-
riences are associated with low self- esteem, which o en results in social
devaluation and rejection. Low self- esteem is also shown to be strongly re-
lated to a variety of psychological di culties and substance abuse (Leary,
), which likewise is in line with our  ndings. Furthermore, a study on
harm reduction and tensions in trust and distrust in mental health se ings
reported that distrust was more prevalent than trust in the participants’ re-
ports (Lago et al., ), consistent with the  ndings of our study in which
participants struggled to trust anyone. Dalla et al. () noted that when
such negative emotions become unbearable, using substances becomes
the coping mechanism and also a way of expressing frustration and anger.
Participants described how experiences of family con icts, including a
sense of a lack of love, support, and communication, led to substance use
and problematic behavior as early as adolescence.  is  nding is similar to
a study of immigrant Latino families (Marsiglia et al., ) that showed
how family con icts and low family cohesion predicted lifetime use of
substances.  e study found that binge drinking was problematic among
adolescent immigrants who were trying to navigate between two di erent
cultural worlds. Further, it demonstrated that when these adolescents did
not have any positive coping strategies to reduce mental distress caused by
family con icts and tensions, they resorted to substance use and problem-
atic behavior, including rejecting family values in the form of rebellion, as
experienced by the participants of the present study. Furthermore, Dalla
and colleagues () reported that assimilation into a new culture may
create family con icts due to di erent rates of acculturation between par-
ents and children.  is can lead to signi cant tensions between them in-
cluding personal distress, delinquent behavior, and substance use, which
is also in line with the  ndings of the present study.
Substance use disorders and mental health disorders consistently
rank among the most stigmatized conditions (Room, ; WHO, ).
Personal cultural beliefs have a great impact on perceptions of mental
disorders and substance use. In most places, the culture determines how
persons understand and deal with these conditions. Chen and Farruggia
() documented that persons with conservative thinking o en view
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019

these conditions as stigmatizing and avoid those living with them.  is is
similar to our  nding of cultural stigma as experienced by the participants,
who described fear of being discovered by their communities and expelled
from families that a ach stigma to MHD and SUD. Participants also
described this cultural stigma as one of the reasons for “living a double
life,” which is stressful as they constantly have to wear a mask of sobriety in
front of their families and community.
e participants had a positive view of their sense of belonging and
feeling of acceptance when in a group of substance users with a similar
diagnosis. Within these groups they found inclusion and were seen as
being of value, in line with the study by Dalla and colleagues (), who
further suggested that these groups function at the periphery of society
and adopt substance use as a method of socialization within the new
culture. Because of their lack of acceptance in the two cultures where
they lived, participants struggled with their lack of a sense of belonging
elsewhere. Further, it has been documented that it is not only a cultural
barrier, but a community- level barrier, that leads to lack of acceptance and
no sense of belonging within the community. A study done in Norway
among persons admi ed to psychiatric hospitals stated that participants
experienced a sense of loneliness, struggled for equality, and felt neglected,
and hence lacked a sense of belonging within the community (Granerud &
Severinsson, ). Such a sense of belonging is validated by one’s fellow
citizens (Ponce & Rowe, ).  is includes persons with co- occurring
disorders who are marginalized, hard to reach, and o en face di culties in
achieving inclusion within communities.
A sense of belonging is both supported by and supports a person’s rela-
tion to the citizenship framework, with the  Rs of rights, responsibilities,
roles, resources, and relationships that society o ers (Rowe, ). More-
over, the citizenship framework o ers a connection via social and public
institutions, supportive social networks, closely tied relationships, and as-
sociational life in their community (Rowe & Pelletier, ).  is in turn
would be valuable for the participants of our study, who have experienced
disruptive life events, stigma and racism, no sense of belonging, and so-
cial marginalization. Giving the participants a possibility of community
integration and inclusion by allowing them to participate in society and
valuing their participation would provide them a sense of personal own-
ership of their roles and responsibilities (Ponce et al., ). Further, to
experience a sense of belonging, it is important to value dignity, diversity,
Copyright © 2020 University of Nebraska Press
Prabhjot Kour et al. 
and di erence for all persons, which would reduce psychiatric symptoms
and substance use (Rowe, ).  is would in turn provide a sense of be-
longing and acceptance not only within a particular group of users, but
also at a societal level.
Participants described experiences of racism related to their immigrant
background and their co- occurring disorders from di erent societal struc-
tures, including school, workplace, state welfare services, and the health
care system. In a recent integrative review, it was stated that persons of
immigrant background with MHD o en face few or no opportunities
and decreased access to resources because of racism practiced by employ-
ers who tend not to give them jobs, and by landlords less inclined to rent
them houses. Such racist a itudes deprive them of the chance to fully in-
tegrate and participate in society (Abdullah & Brown, ). Immigrants
o en cope with these experiences of racism by leaving their ethnic group,
feeling embarrassed by their parents and culture (Dalla et al., ), which
is similar to our  ndings that participants described coping with racism by
hating their family and culture.
Last, this study included only men due to the challenges in recruiting
immigrant women with co- occurring disorders. We had planned to re-
cruit both men and women with the inclusion criteria.  e recruitment of
participants, however, was extremely challenging, even with men, due to
the stigma a ached to SUD and/or MHD. According to the participants,
there were many men and women with a similar diagnosis, but they did
not want to come forward owing to fear of being detected in their small
communities in Norway. We argue that this holds true, especially for im-
migrant women with SUDs and/or MHDs, because of their di erent cul-
tural norms and their perceived potential risk of greater harm if they are
detected and identi ed. Moreover, due to their more hidden nature and
fear of being discriminated against, immigrant women are less likely to re-
port their SUDs and/or MHDs and instead remain camou aged.
Limitations and Strengths
is study provides insights into immigrants’ experiences of living with
SUDs and MHDs in Norway, which to our knowledge has not been ex-
plored previously.  e results are based on these participants’ experiences
and do not allow for generalization; however, the insights may be of rele-
vance to future research. Further, our interpretation of the results should
be viewed within the scope of qualitative research and is thus not general-
Copyright © 2020 University of Nebraska Press
American Journal of Psychiatric Rehabilitation ∙ 22:1–2 ∙ 2019

izable in a statistical sense. However, even with these challenges, we argue
that our results provide insights into the experiences of a group of persons
who are considered hard to reach and o en stigmatized. Furthermore, we
enhanced the internal validity of our data by collaborating with a compe-
tency group in all stages of the study, including writing the protocol, pre-
paring the study, analyzing the data, and compiling the results. Last, this
study included only men due to the challenges in recruiting immigrant
women with co- occurring disorders.
Conclusion
Immigrant men living with substance use and mental health disorders
interpreted their experiences within themselves, within the surrounding
culture, and within the structures of society, in order to cope and nego-
tiate their sense of self. Norway and other countries would greatly ben-
e t by improving the health of immigrants. Hence, we believe that the
insights from the participants are timely and that the knowledge gained
can broaden the perspectives of practitioners and policy makers to pro-
vide more appropriate services. Further, we suggest that policies that are
immigrant-friendly, that may reduce stigma and racism, and that increase a
sense of belonging should be implemented within the Norwegian context
at a community level, thus enabling immigrants to achieve full citizenship.
Further research is suggested for comparative studies between native and
immigrant persons living with co- occurring SUDs and MHDs.
 , Norwegian National Advisory Unit on Concurrent Substance Abuse
and Mental Health Disorders (NK- ROP), Innlandet Hospital Trust and University of
South- Eastern Norway
 , Norwegian National Advisory Unit on Concurrent Substance Abuse and Men-
tal Health Disorders (NK- ROP), Innlandet Hospital Trust and Faculty of Health and So-
cial Sciences, Inland Norway University of Applied Sciences
  , Norwegian Institute of Public Health
 , University of South- Eastern Norway
  , Norwegian National Advisory Unit on Concurrent Substance
Abuse and Mental Health Disorders (NK- ROP), Innlandet Hospital Trust and Faculty of
Health and Social Sciences, Inland Norway University of Applied Sciences
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?sequence =  & isAllowed = y
Copyright © 2020 University of Nebraska Press
Appendix A
Table . Description of Participants
 Age in Years Country
of Origin
Age at
Migration
to Norway
Reason for
Migration
Age When
Starting
to Use
Substances
 Iran . years War/political
refugees

 Sierra
Leone
 years Family
reunion

 Iran  months War/political
refugees

 Eritrea  years War/political
refugees

Around
 (not
con rmed)
African
descent
(unknown
country)
 years Family
reunion

 India Born in
Norway
Family
reunion

 Pakistan Born in
Norway
Family
reunion

 Iran  years War/political
refugees

 Iran  years War/political
refugees
  Iran  years War/political
refugees

Copyright © 2020 University of Nebraska Press
Appendix B
Coping and Negotiating a
Sense of Self
Within the Self Within the Surrounding
Culture
Within the Structures of
Society
Inner
Conflict
Lack of Family
Support
Cultural
Stigma
Belonging Experiences
of Racism
Distrust of the
System
Copyright © 2020 University of Nebraska Press
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