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Abstract

Immigrants are considered at risk of psychological distress and therefore involvement in substance abuse, due to a variety of pre- and post-migration factors. Further, there is lower treatment engagement, a higher dropout rate, and less frequent hospitalizations among this group compared to the general population. There are few studies on the subjective understanding of co-occurring substance use disorder (SUD) and mental health disorder (MHD) among immigrants in Norway. This qualitative study aims to explore the treatment experiences of immigrant men living with co-occurring SUD and MHD. Within a collaborative approach, individual interviews were conducted with 10 men of immigrant background, living with co-occurring SUD and MHD, who had treatment experiences from the Norwegian mental health and addiction services. Data were analyzed using a systematic text condensation. The analysis yielded 6 categories where participants described their treatment experiences in mental health and addiction services in Norway as: lack of connection, lack of individually tailored treatment, stigma and discrimination preventing access to treatment, health professionals with multi-cultural competence, care during and after treatment, and raising awareness and reducing stigma. A significant finding was the mention by participants of the value of being seen and treated as a “person” rather than their diagnosis, which may increase treatment engagement. They further mentioned aftercare as an important factor to prevent relapse. This study provides an enhanced understanding of how immigrant men living with co-occurring SUD and MHD experienced being treated in Norwegian healthcare settings. These experiences may add to the knowledge required to improve treatment engagement.
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https://doi.org/10.1177/1178221820970929
Substance Abuse: Research and Treatment
Volume 14: 1–10
© The Author(s) 2020
DOI: 10.1177/1178221820970929
Introduction
Over the past 2 decades Norway has become a multicultural
and ethnically diverse society due to a substantial increase in
migration.1 Immigrants account for 18.2% of Norway’s popula-
tion, and 10.8% are from middle- and lower-income countries.2
Previous studies show that immigrants may be at risk for devel-
oping mental health problems due to a variety of pre- and post-
migration factors.1,3 Mental health problems and substance use
often present with a high degree of co-occurrence4-6 with poor
life quality7 and those diagnosed with co-occurring substance
use disorder (SUD) and mental health disorder (MHD) are
often referred to as “complex” and “difficult to help” due to lack
of tailored services.8 SUD is understood as a term that includes
harmful use of, and dependency on, drugs and alcohol9 and
MHD as range of problems characterized by some combination
of abnormal thought, emotions, behaviors and relationships, for
example, depression, schizophrenia, intellectual disabilities,
post-traumatic stress disorder etc.10 Further, co-occurring dis-
order is understood as the co-existing of SUD and any
combination of MHD in an individual with a strong impact on
everyday life.
Further, research has documented that immigrant groups
with SUD and MHD are at a high risk of neglect even in
developed healthcare systems; possible reasons include lack of
existing healthcare policies for these groups and insufficient
funding to target specific areas of immigrants’ mental health
care.11 A recent Swedish cohort study reported increased rates
of SUDs among immigrants who migrated at an early age or
had lived for a long time in the host country12; they were fur-
ther disadvantaged by poor access to healthcare.13,14 In addi-
tion, immigrants who have connections to a closely-knit drug
scene or group may be hampered from seeking mental health
treatment. This could be due to the feeling of social solidarity
that they want to display within the group. Further, these
closely-knit scenes may provide a community for immigrants
who experience a low degree of inclusion elsewhere.15 Moreover,
it has also been documented that immigrants have lower rates
of utilization of specialist mental health care services in
Treatment Experiences with Norwegian Health Care
among Immigrant Men Living with Co-Occurring
Substance Use- and Mental Health Disorders
Prabhjot Kour1, Lars Lien2, Bernadette Kumar3, Stian Biong4
and Henning Pettersen2
1Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders
(NK-ROP), Innlandet Hospital Trust and University of South-Eastern Norway, Norway. 2Norwegian
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, Norway. 3Norwegian Institute of Public Health, Norway. 4University of South-
Eastern Norway, Kongsberg, Norway.
ABSTRACT: Immigrants are considered at risk of psychological distress and therefore involvement in substance abuse, due to a variety of pre-
and post-migration factors. Further, there is lower treatment engagement, a higher dropout rate, and less frequent hospitalizations among this
group compared to the general population. There are few studies on the subjective understanding of co-occurring substance use disorder (SUD)
and mental health disorder (MHD) among immigrants in Norway. This qualitative study aims to explore the treatment experiences of immigrant
men living with co-occurring SUD and MHD. Within a collaborative approach, individual interviews were conducted with 10 men of immigrant
background, living with co-occurring SUD and MHD, who had treatment experiences from the Norwegian mental health and addiction services.
Data were analyzed using a systematic text condensation. The analysis yielded 6 categories where participants described their treatment expe-
riences in mental health and addiction services in Norway as: lack of connection, lack of individually tailored treatment, stigma and discrimination
preventing access to treatment, health professionals with multi-cultural competence, care during and after treatment, and raising awareness
and reducing stigma. A significant finding was the mention by participants of the value of being seen and treated as a “person” rather than their
diagnosis, which may increase treatment engagement. They further mentioned aftercare as an important factor to prevent relapse. This study
provides an enhanced understanding of how immigrant men living with co-occurring SUD and MHD experienced being treated in Norwegian
healthcare settings. These experiences may add to the knowledge required to improve treatment engagement.
KEYWORDS: Co-occurring disorders, mental health disorder, substance use disorder, immigrants, qualitative methods, treatment experi-
ences, lived experiences
RECEIVED: May 20, 2020. ACCEPTED: Octo ber 6, 2020 .
TYPE: Original Research
FUNDING: The author (s) disclose d receip t of the foll owing na ncial su pport fo r the
researc h, author ship, and /o r public ation of th is arti cle: This s tudy was fun ded by Inl anndet
Hospit al Trust, Nor way
DECLARATION OF CONFLICTING INTERESTS: The aut hor(s) decla red no pote ntial
conic ts of inter est with re spect to t he resear ch, autho rship, an d/or publ icatio n of this
article.
CORRESPONDING AUTHOR: Prabhjot Kour, Nor wegian Nationa l Adviso ry Unit o n
Concur rent Subs tance A buse and Me ntal Hea lth Diso rders (NK- ROP), Innlan det Hosp ital
Trust, Kjone rud komp etanses enter, Løvst advegen 7, Otte stad, 2312, Nor way. E mail:
prabhjot.kour@usn.no
970929SAT0010.1177/1178221820970929Substance Abuse: Research and TreatmentKour et al.
research-article2020
2 Substance Abuse: Research and Treatment
Norway,16 compared to the general population. This has also
been documented among immigrants in Sweden,17 and among
non-Western immigrants in the Netherlands.18
There is strong evidence that completion of SUD treat-
ment is one of the most consistent factors associated with
favorable treatment outcome.19 Persons living with SUD and
MHD are often difficult to engage in treatment, leading to
frequent relapses and rehospitalizations.20 Lower treatment
engagement has also been documented among immigrants,21-23
resulting in challenges in providing them with targeted help.15
Engagement is understood as the process of establishing a
mutually collaborative, trusting, and respectful helping rela-
tionship.24 Integration of principles of person-centered
healthcare (PCH) in mental health and addiction services
have been shown to enhance the engagement process and lead
to improved outcomes.20 Person-centered healthcare focuses
on the unique goals and life circumstances of an individual in
MHD and SUD treatment models20 by not only managing
and overcoming the health conditions, but also rebuilding the
lives of persons living with SUD and MHD.25
Further, PCH involves valuing the individual as a “person”
with objective, absolute and intrinsic worth,26 along with the
person’s life history and relationships, both in illness and health.27
We conceptualize “person” as defined by Cassell, “as an embod-
ied, purposeful, thinking, feeling, emotional, reflective, relational,
human individual always in action, responsive to meaning and
whose life in all spheres points both outward and inward.
Virtually all of a person’s actions – volitional, habitual, instinctual
or automatic – are based on meanings”.28 Considering the fact
that “meaning” and “personhood” are mutually constituted,
understanding about persons involves understanding about val-
ues and social phenomena.29 This may imply that treatment
engagement will be improved by the development, coordination
and provision of healthcare services that respect the uniqueness
of individuals by focusing on their values, beliefs, desires and
wishes, regardless of their age, gender, social status, faith, finan-
cial situation, ethnicity, and cultural background.30 We believe
that this holds true for immigrants living with co-occurring
MHD and SUD, who often feel discriminated against, stigma-
tized, left alone, and lack a sense of belonging.31 PCH has
emerged as a cornerstone of effective SUD treatment32,33 and
has been highlighted in the Norwegian national guidelines for
SUD treatment.34 In addition, we believe that culturally tailored
healthcare services are a part of person-centered “cultures”,
which may lead to higher treatment engagement.
Various studies have shown that immigrants are less likely
to use the available mental health and addiction services,16,35,36
which may be due to lower treatment engagement and unsatis-
fied treatment needs. There have been a few quantitative stud-
ies, but no qualitative research, that has studied treatment
experiences from the perspectives of immigrants. Thus, there is
a knowledge gap concerning immigrants’ subjective experi-
ences of MHD and SUD treatment.
This descriptive and exploratory study aims to examine the
treatment experiences of immigrant men living with co-occur-
ring MHD and SUD in Norwegian mental health and addic-
tion services.
Methods
Collaborative study design
The study follows a qualitative and exploratory design with a
collaborative approach. Traditional research into mental health
and substance use disorder treatment is considered by an
increasing number of service users as disempowering, and
poorly reflective of their priorities.37,38 To remedy this, the pre-
sent study has adopted a collaborative research approach.
Collaborative research brings a different perspective to the
research process, which is highly relevant to clinical practice
and helps to improve the evidence base used to inform how
services are provided.39 Thus, a competency group of 3 persons
was established to work with the research team in all stages of
the study. Two members were previous users with lived experi-
ence of having co-occurring MHD and SUD, and one was a
relative of one of the users. All 3 members were of immigrant
background and had an understanding of both their original
local context as well as the Norwegian context.
Recruitment
A criterion-based, purposive sampling method40 followed by
snowballing was employed to recruit the participants from 2
cities in Norway. The inclusion criteria were persons with
immigrant background, from low- and middle-income coun-
tries, having experienced living with co-occurring SUD and
MHD and treatment in Norwegian healthcare. A diverse sam-
ple was included in order to obtain information-rich data for
the study. “Immigrants” in this project are understood as per-
sons who were born or whose parents were born in low- and
middle-income countries. In addition, we include as immi-
grants persons born abroad or in Norway of 2 foreign-born
parents and 4 foreign-born grandparents in our study.2 We
would also like to point out that “immigrants” are not a homog-
enous group; they differ in various ways, including culture, eth-
nicity, reason for migration, historical migration patterns, etc.
Recruitment began by phoning and sending emails to leaders
of various rehabilitation and treatment centers in these 2 cities.
The facilities chosen were those with access to potential partici-
pants with the inclusion criteria. Detailed information about the
research project was given to these leaders. The recruitment of
participants meeting the inclusion criteria was more challenging
than expected. We do not know exactly how many persons were
asked by team leaders to participate, but most of them refused to
take part in the study. A few reasons mentioned were, person’s
unwillingness to talk about their lived experiences, lack of trust
in system, including any research project, fear of being detected
in their small immigrant communities in Norway and fear of
Kour et al. 3
stigma attached to SUDs and MHDs and seeking it’s treatment.
Further, through these leaders only one participant was recruited.
This participant was contacted by telephone by the first author
and given information about the study. Subsequently, by snow-
balling, this participant helped to recruit 3 more participants
with whom he had contact. The competency group played a key
role in recruiting further participants. Six participants were
recruited with the help of the competency group, whose mem-
bers had contacts in their local community. Potential participants
were able to show interest by contacting the first author by tele-
phone or SMS.
Study participants
The study included 10 participants who met the inclusion cri-
teria (Appendix A, Table 1). All the participants were males,
aged from 25 to 53 years. All of them had been diagnosed with
co-occurring SUD and MHD and had experience of treatment
in the Norwegian mental health and addiction services. All
participants were polysubstance users and the most common
substances used were alcohol, heroin, and cannabis. Five par-
ticipants reported not using substances at the time of the inter-
view. The participants also stated having experienced MHDs,
most commonly anxiety, affective disorder, personality disorder
and post-traumatic stress disorder. Eight of 10 participants
reported having experienced suicidal thoughts and suicide
attempts. The objective diagnosis was not considered, but
rather how the participants understood their own mental
health condition. Five participants were from the Middle East,
while others were from South Asia and East and West Africa.
Two participants were born in Norway, and most others
migrated at a very early age, while 2 had arrived at age 21 and
24. All the participants started using substances at an early age:
8 after arriving in Norway, while the 2 who migrated at age 21
and 24 started at a young age in their countries of origin. All
the participants had dropped out of treatment in Norway at
least once and most had dropped out several times. All partici-
pants had the treatment seeking experience in one or the other
mental health or/and addiction services, such as generic spe-
cialist service units, special units that collaborate closely with
primary level services, residential addiction treatment based on
AA- or NA-principles and detoxification units. Further, par-
ticipants have both in-patient and out-patient treatment expe-
rience, where the length of treatment program ranged from 9
to 12 months, and some of the participants were still continu-
ing the treatment.
Data collection
Data were collected through in-depth, semi-structured indi-
vidual interviews41 between June 2018 and March 2019. The
data were considered be sufficient to fulfill the aim of the study
after the tenth interview. This was done using the concept of
“information power”, which implies that the more relevant
information the sample has, the smaller the number of partici-
pants needed.42 This could be justified in our study as the aim
of the study was narrow, and concerns a specific experience
among a population that hold specific characteristics and
which are “hard-to-get” group, which would in itself limit the
number of eligible participants (diverse immigrant background,
living with co-occurring SUDs and MHDs, with having treat-
ment experience in Norwegian mental health and addiction
services). Further, we believe that participants hold the experi-
ences that have previously not been described, has also
enhanced the information power. Also, there was strong and
clear communication between the first author and the partici-
pants, partly due to being introduced by the members of com-
petency group and partly because the first author has previous
experience with qualitative interviews. Moreover, the after the
tenth interview, assessment was made by all the authors that
these data made it possible to answer the aim of the study. All
the interviews were audio taped and lasted from 40 to 90 min-
utes. Nine of the 10 interviews were conducted in Norwegian
by the first author and an interpreter, while one interview was
carried out in Punjabi and English by the first author only. All
the interviews were transcribed in English. An interview guide,
consisting of open-ended questions about what it means to be
treated in Norwegian healthcare settings when living with co-
occurring disorders as a person of immigrant background, was
created and agreed upon by all authors and the competency
group. The main questions included were (all these questions
had the follow up and probing questions): Can you please
describe your experiences with treatment within Norwegian
mental health and addiction services as a person with immi-
grant background? Can you please tell us why according to you
persons with immigrant background do not take the complete
treatment? Can you please describe your experiences with
treatment when it comes to your needs as a person with immi-
grant background? What kind of treatment do you wish for as
a person with immigrant background in Norway?
Data analysis
The interview conducted in English and Punjabi was tran-
scribed by the first author and the remaining 9 conducted in
Norwegian were transcribed by the interpreter. These inter-
view transcripts were analyzed using systematic text condensa-
tion (STC),43 which is a descriptive and explorative method
which aims at thematic cross-case analysis, and which main-
tains methodological rigor and enables feasibility, intersubjec-
tivity, and reflexivity. STC is a stepwise procedure that includes
the identification of recurring initial codes and themes relevant
to the aim of the study. Step one involves the formulation of a
total impression gained by reading all the transcripts, leading to
initial themes. In step two, after systematically reviewing the
transcripts, meaning units were identified and sorted into code
groups. The third step involved the formation of subgroups
from code groups with meaning units. The next step was to
4 Substance Abuse: Research and Treatment
form artificial quotations by the reduction of meaning units
under each subgroup. In the final step, analytic text and descrip-
tions were developed from artificial quotations. The analytic
text was reconceptualized by returning to the complete tran-
scripts and reflecting on whether each illustrative quotation
still reflected the original content. This was done in order to
validate the analytic texts. Lastly, the analytic texts were sup-
ported by quotes, which are presented in the “Results” section.
In each step, all the co-authors were consulted and discussions
took place. In the final step, the competency group was con-
sulted to provide an understanding of the results within the
local context they represented.
Ethical aspects
The study was ethically approved by the Norwegian Centre for
Research Data (Project No. 59707). The research procedure
was designed and followed in accordance with the Declaration
of Helsinki. The participants agreed to take part in the study
voluntarily and signed the informed consent, which ensured
their confidentiality and anonymity. They received an informa-
tion letter and an oral explanation about the project prior to the
interviews. The members of the competency group and the
interpreter signed a confidentiality declaration. The partici-
pants were given the contact details of the first author in case
they had any concerns or questions after the interviews.
Results
The analysis yielded 6 categories where participants described
their treatment experiences in mental health and addiction ser-
vices in Norway as: lack of connection, lack of individually tai-
lored treatment, stigma and discrimination preventing access
to treatment, health professionals with multi-cultural compe-
tence, care during and after treatment, and raising awareness
and reducing stigma. A significant finding was the mention by
participants of the value of being seen and treated as a “person
rather than their diagnosis, which may increase treatment
engagement. They further mentioned aftercare as an important
factor to prevent relapse.
Lack of connection
A majority of participants experienced a lack of connection
between themselves and health professionals (HPs) while they
were in treatment, such as a lack of interest from HPs. The
feeling of lack of connection was interpreted as not being lis-
tened to and having unsatisfactory communication. They fur-
ther mentioned that the lack of connection was stronger when
the HP only talked about their diagnosis and said nothing
about contexts that were important for them, like their process
of migration, living as an immigrant in Norway, reasons why
they started using substances and discrimination in treatment
settings. They experienced not being seen as a person in treat-
ment settings, leading to a more pronounced feeling of lack of
connection, which discouraged them from continuing the
treatment.
They did not understand my needs. It was only written in papers, about
me, that my mother is divorced and about events of my life but there
were actually no conversations about it with me, nothing about what
it’s like to be an immigrant. . . (P-6)
The participants also stated that there was no aftercare once
they were out of the treatment centers. They had no contact
with service providers after the standard treatment was over.
They had to follow a schedule while they were in treatment
and they felt lost once they had no schedule, leading to a higher
chance of relapse.
We didn’t have any aftercare. When people are done, what happens to
them afterwards? It’s called aftercare, in the medical terminology. And
that’s the part we are bad at. The time when you are inside, you know
that 12 o’clock you go and eat, 6 o’clock the food comes on the table, 9
o’clock is dinner time. You have a routine. But when you come out,
nobody tells you to go and eat at 12 o’clock, do they? And if you’re hun-
gry, or thirsty, all that, it can have almost the same effect as the drugs,
you see?. . .But when you wake up in the morning, look around, see the
same apartment, the same place, the same things, you know? They can’t
take it. And then you go and you take drugs. . .(P-8)
Participants also described how HPs did not have any
understanding of their cultural context, which meant that their
needs were not met in treatment, further leading to a lack of
connection between them and the HP.
If you talk about immigrant background, there is actually a lack of cul-
tural identification topics in every treatment I have been to in Norway,
both in psychiatric and drug abuse treatment. They do not have this in
their protocol. I will give you an example, I know so many people from
Iceland who have addiction problems, it is a big issue with them, they
are alcoholics. I have many friends who are from Iceland and we talk
about this topic many times among ourselves and they also say they
want more culturally specific treatment, that we do not have in Nor-
way. (P-3)
Lack of individually tailored treatment
The participants described experiencing a conventional and
standard approach to treatment with no cultural sensitivity.
There were no new strategies brought up in the treatment pro-
tocol that could satisfy their needs of being culturally different
from the majority. They mentioned having few daily activities
and a monotonous routine while in treatment, which discour-
aged continuity of treatment. Further, they mentioned conven-
tional group therapy where the participants felt mismatched in
the group. This led to discomfort and lack of satisfaction in the
group therapy. Some participants also mentioned that even
though they had the same sickness and diagnosis as Norwegians,
their needs were different. They further added that even though
group therapy was important, individual therapy was equally
important, because of their different needs and levels of
Kour et al. 5
understanding, and they had not experienced that as part of the
treatment.
I felt bad, I felt like shit. The others were old, in their 40s and had been
shooting needles for years. I was only 20 so I felt very small, I felt dirty,
small, low. It wasn’t a good place to be. You just sat there and ate and
watched TV. I thought to myself “Is this the place to be for
treatment?”(P-1)
Furthermore, participants narrated their experiences of not
being understood specifically in relation to their cultural beliefs,
values and language. Only being prescribed the standard anti-
depressant and sleeping pills when they asked for help, without
the HP understanding their social and cultural context led to
their discontinuing the treatment. Some participants expressed
worries as they felt vulnerable being an addict and might be
very likely to become dependent on sleeping pills.
Stigma and discrimination preventing access to
treatment
Living with SUD and MHD, all the participants described
experiencing stigma and discrimination in one form or another.
They were aware of the fact that using substances and having
MHD was associated with stigma and discrimination, which
had restrained them from accessing help and adhering to treat-
ment. If they sought help, they felt they would become even
more stigmatized in their small communities.
I see so many Norwegians in the treatment, of course they are in the
majority here but very few immigrants. They feel that they will be stig-
matized if they take such treatments, they want to be identified beyond
their skin color, beyond their social and cultural background. That is one
of the main reasons they don’t take treatment. . .. That makes me feel
inferior, especially with such closed and cold behavior. That’s the biggest
stigma and this stigma is also incorporated in the Norwegian health
care system. (P-6)
Many participants revealed a cultural stigma in acknowl-
edging the problems of SUD and MHD, and this prevented
them from seeking treatment and help. They described that
seeking psychiatric help was associated with a stigma in their
culture where they were labeled “mad”. They also stated that
they had to drop out of treatment because of family pressure
and the stigma that the family faced, which led to relapses and
continued use of substances.
In addition, participants recounted experiences of discrimi-
nation that they faced while they were in the treatment centers,
due to their immigrant background, which also prevented them
from getting the help they needed in treatment. They men-
tioned incidents of being looked down upon by the HPs, which
led to them dropping out of treatment and further relapses.
So I went to the meeting there and there was a psychiatrist there and she
was going to talk to me and I shared a bit about my life and such, about
how I had been treated here in terms of racism. I was so vulnerable and
then she only asked me “Are you violent?”, and I thought “What. . . are
you going to start judging me?”, that’s what I thought at least. I said I
can’t work with you. You are already judging me when I am so vulner-
able and then asking me if I’m violent. I’ve had enough of that violent
thing. Every time I have been seen in the streets they asked if I was
violent. What does that have to do with anything? I also want to live
like a person in this country, I don’t want to have these labels on me all
the time. That’s what hurts, right? (P-8)
Health professionals with multi-cultural competence
Several participants experienced that having health profession-
als who had expertise in understanding different cultural back-
grounds was helpful in completing treatment. They further
mentioned that HPs who recognized the special needs of
immigrants led to a higher level of satisfaction with treatment.
In addition, participants stated that it could lead to better treat-
ment outcomes if HPs learned more about different cultures
via seminars and shared results of different studies and experi-
ences from treatment centers in Norway and abroad that have
successful rates in treating persons with different cultural back-
grounds. Moreover, participants reported receiving the most
help from HPs who had an understanding of both foreign and
Norwegian culture. Experiences of having being understood
and accepted as who they were without judgments in the treat-
ment centers were facilitators for their treatment.
He (HP with immigrant background) is quite well-known in the psy-
chologist circles, and he works as chief psychologist, here, which is the
oldest place offering treatment in Norway. It was really great. I just
met him and I felt it was positive. .. He had experience with people who
had seen war, and that helped, yes. (P-10)
Some participants also stated that having an HP with an
immigrant background was a motivating experience, as it
became easier to connect with them. They experienced a sense
of being better understood by HPs with a similar background,
which helped in building trust. Further, a few participants
mentioned that having an HP with experience of war traumas
was beneficial for them, as they could open up about their own
trauma experiences. This provided participants with motiva-
tion to complete treatment and a sense of belonging.
Member of staff or doctor with a similar background. . . That would be
perfect. . .def initely because there was one health professional from
Chile at the treatment center where I was admitted to. I could identify
with him, much better than with other health workers. . . I opened up a
little bit with health workers from different cultural backgrounds, on
the sole basis of identification, that I could identify with them. (P-2)
Care during and after treatment
Experiences of being valued as a person in treatment centers,
and not being looked down upon based on their diagnosis and
their immigrant background, were regarded as meaningful.
One participant described the feeling of being well attended to
by one of the HPs and not seen as an “addict who does not
look like most people in that treatment center, and has
6 Substance Abuse: Research and Treatment
different cultural background. The participant experienced the
positive feeling of being welcomed and thus completed treat-
ment in the same center twice. A few participants said that
conversations about their past related to migration and settling
in Norway and understanding their needs in relation to their
past in the treatment process had a positive impact on them.
Another participant also mentioned that the use of prayers in
treatment gave him the experience that life is meaningful and
worth living, which helped him to adhere to treatment.
Well, if someone would sit there alone, or looked a bit depressed, he (HP)
would try and involve the person a bit more. He would say “Come here”,
and he would walk into their rooms and bring us out and things like
that. He kind of involved us, he tried to pull us out of those thoughts,
feeling included was a good thing. (P-3)
For a few participants, the experience of being treated with
love and respect regardless of their cultural background was
encouraging and this created an open and healthy relationship
between them and the HP. Moreover, positive attitudes of HPs
with expressions of gratitude toward the participants, like
shaking hands and hugging, contributed to a higher level of
satisfaction with treatment. This further led to the building of
trust between the participants and HPs.
Luckily the people (HPs) that worked there said “Try telling us a little,
you have the same rights as us here in Norway.” And I thought “Oh, do
I? Can I also take a little space here?”, And I started thinking, oh maybe
I can. Maybe the woods outside are also for me, and not only for Norwe-
gians. Maybe it’s not just Norwegian nature for Norwegians. Maybe I
can actually enjoy the green leaves as well. That’s how I began, step by
step. (P-8)
Most of the participants mentioned the importance of
aftercare. They described being lost after they left the treat-
ment centers, they had no schedule and no one to look after
them, which ultimately led to frustration and relapses. Further,
they mentioned that aftercare was as important as in-treatment
care. This was because they did not spend a long time in treat-
ment or detoxification centers and were thus on their own most
of the time and were more likely to have relapses when they
were not followed up, especially because they had different cul-
tural background and lack the feeling of social inclusion else-
where. A few participants mentioned that aftercare from HPs
was crucial in their treatment process, as they often remained
hidden and could not ask for help in their small communities
due to fear of stigmatization.
Raising awareness and reducing stigma
Several participants stated that it would have been easier for
them to access treatment if there was less stigma attached to
SUDs and MHDs among acquaintances and in their commu-
nities. One participant mentioned that it would be his dream
treatment if he could be seen and treated beyond the wall of the
stigma in healthcare and his community. Others mentioned
that it would be better not to have stigmatizing names of treat-
ment centers, like ‘acute addiction ward’, but to have nicer
names, as they felt that such traditional names were associated
with stigma within their community and prevented their access
to the services needed for emergency treatment.
Take away some of that shame. . . To talk more about it in the media,
maybe? To remove that taboo that is there. We have to be a bit realistic
and admit that a drug/alcohol problem is seen as a taboo still, and a
moral problem, not a sickness, actually. . . That barrier can also be
removed just by seeing it as a sickness, you know what I mean. I think
that many people, me included, have way too much prejudice when it
comes to drugs and alcohol. (P-1)
Obtaining information and awareness about the conse-
quences, diagnosis and treatment strategies from the HP was
described as a positive experience by a few participants. They
described how having insight into their diagnosis and the
harmful effects of using substances motivated them to adhere
to and complete treatment. Further, some participants men-
tioned that raising awareness about the harmful effects of sub-
stances and available treatment options, and reducing stigma
via the media, would allow their co-users to access treatment.
In addition, they stated that raising early awareness in primary
and secondary schools was important, as most of them had
started using substances at that time.
and at the same time, a treatment where you get information. Informa-
tion about your sickness, what are the drugs doing to you, how are they
making you react, why do you, despite being sick the day before, go out
and buy the same stuff and become as sick as before, again. What is that
insanity? Those places where they can give you information and take
care of you, at the same time as you yourself have to create a network.
These are the places I go for. . ..(P-3)
Additionally, having a supportive network of family, peers
and role models was mentioned as particularly helpful, both
during and after treatment. A few participants mentioned that
this supportive network was key to giving them hope, motiva-
tion and a positive approach toward accessing and completing
treatment. This further gave them a feeling of inclusion which
was a driving force to get out of their “dark side of life” and
change their self.
Encouragement. Because I had psychologists that encouraged me and I
had those who think negatively themselves and it was contagious. So, it
is important, very important for the patients, to understand that it is
possible to get well. It is the most important thing. I would say that it is
to try to build trust in the patient. (P-9)
Discussion
In this study, we explored the treatment experiences of men of
immigrant background living with co-occurring SUD and
MHD in Norwegian mental health and addiction services. Six
main categories of experiences were revealed, which we classi-
fied into 2 major insights. First, negative experiences that acted
as barriers and reduced treatment engagement. These negative
Kour et al. 7
experiences posed significant challenges for the participants
prevented them from seeking treatment and encouraged drop-
out. Emphasis was placed on the connection between them and
the HPs, individually tailored treatment and stigma and dis-
crimination. Secondly, positive experiences that functioned as
facilitators and enhanced treatment engagement. HPs with
multicultural competence, being cared for well during and after
treatment, along with strategies to reduce stigma and raise
awareness for treatment completion were supportive experi-
ences for the participants’ well-being. Further, a significant
finding of being treated as a “person” in treatment settings, not
as a disease or diagnosis, was reflected in both types of experi-
ences. Being regarded as a “person” was experienced as positive
and valued, while not being seen as a “person” was perceived as
negative and led to lower treatment engagement.
Participants’ experiences of not being treated as a “person” in
the treatment setting resulted in lower treatment engagement.
They described the notion of “person as being valued and
respected for who they were, which was dependent on their
immigrant background and their life history. They had been
through a series of disruptive events (immigration, living with
SUD and MHD) which had shaped their coping and negotiat-
ing of their sense of self.31 They experienced a lack of discus-
sions around events such as their migration process, initiation
of substance use and coping with stigma and discrimination in
community and treatment settings, which were vital for them.
They felt of little worth when conversations only focused on
their diagnosis and symptoms, which made it impossible to feel
like a “person” while they were in treatment. This could be
understood in terms of Cassell’s definition of “person”, which
involves understanding an individual as a person in medicine,
based on the meanings of the person’s actions28 through an
understanding of values and beliefs of that person in a particu-
lar social context.29
Further, participants’ experiences of lack of connection with
HPs in view of negative past encounters with lack of interest
and little attention in treatment sessions resulted in lower
treatment engagement. Other studies have found that many
immigrants are reluctant to seek treatment for mental health
and substance use problems, which results in poor health out-
comes with longer duration of untreated problems.44,45 This
could be attributed to difficulty in developing trust in mental
health and addiction services due to unfamiliarity with how
these services work31,46 and previous negative experiences with
treatment.35 Moreover, participants revealed that the situation
worsened when they had to wait longer to start treatment,
leading to more substance use and relapses, which is reported
by Pinedo etal.36 as a logistical barrier to treatment.
Another barrier that overwhelmingly shaped participants’
decisions not to enter treatment or to be less engaged in treat-
ment was the lack of culturally competent services tailored
to their specific needs in relation to cultural beliefs, values
and language, which is in line with previous studies.36,45
Misunderstandings arise regarding patients’ acceptable and
typical behavior when HPs lack cultural competence.46 This
often leads to a lack of discussions on important social con-
texts, such as immigration and discrimination within treat-
ment settings, resulting in low adherence rates,36 which
concurs with the participants’ experiences. Furthermore, the
treatment program of 12-step support group therapy did not
function well with the participants as they felt the groups
were mismatched with regard to age, language and duration
of using substances. They further mentioned that they had
difficulty expressing emotions and sharing private informa-
tion within such groups and hence showed lower treatment
engagement, as in a study on Asian immigrants in the US.45
Connected to this is the lack of individually tailored services
for immigrants, which reduces their engagement to treat-
ment. This could be due to the manual-based and standard
trend of knowledge-based practice that is followed in mental
health and addiction services, which may lack individualiza-
tion and cultural sensitivity within treatment.
Further, experiences of stigma prevented participants from
accessing treatment when living in small communities in
Norway. This is in line with previous studies stating that stigma
regarding seeking treatment for SUDs and MHDs was a sig-
nificant barrier to enroll in treatment programs. These disorders
among immigrants are often viewed as a sign of weakness,
shame or a lack of willpower, which often results in ambivalence
about seeking timely help; either the person delays or does not
seek treatment at all.45,47,48 Further, in recent studies on immi-
grants, fear of being negatively perceived within their commu-
nity, especially family resistance, discouraged them from seeking
treatment even though they were willing to get help,31,36 which
concurs with the participants’ experiences in our study. In addi-
tion to stigma, our participants mentioned experiences of dis-
crimination and unfair treatment from HPs which lowered
their treatment engagement. This further resulted in a higher
risk of relapses and severe mental health disorders.47,49 These
experiences of discrimination at structural level could be under-
stood by Foucault’s biopolitics and state racism, where biopoli-
tics refers to the social control and power disseminated through
social body, such as healthcare and is regarded as the norm. This
gives rise to the state racism which becomes one of basic dimen-
sions of social normalization,50 focusing on the superiority of
dominant culture over the another who are culturally different
from majority. Such type of structural racism that prevails in
European health care, is normalized and is enacted through
invisible, subtle practices by HPs (consciously or unconsciously)
that leads to unequal access to treatment.51 This further leads to
perceived racism, as stated by participants to be treated differ-
ently from the ethnic Norwegians and is associated with lack of
trust in healthcare and refrain from seeking treatment.
Understanding barriers is critical to ensure lower drop-out
rates and facilitate adequate use of treatment.35 The participants
stated that receiving treatment from culturally competent HPs
8 Substance Abuse: Research and Treatment
facilitated their treatment process, as their needs were under-
stood during the counseling and healing process. This finding is
consistent with previous studies44,52 and a review,53 where hav-
ing HPs that were sensitive to cultural nuances was seen as more
effective. This could be correlated with an approach of intercul-
turalization of mental health services, which entails adopting
treatment according to the patient’s cultural contexts and
needs.54 Further, our participants had positive experiences with
HPs of immigrant background, in line with a study by Salami
et al.,47 especially if the HPs also had an understanding of
Norwegian culture. In addition, HPs with war trauma experi-
ences were considered as facilitators that motivated the partici-
pants to complete the treatment and gave them a sense of
belonging.
Furthermore, the positive experience of being seen as a per-
son and not as a diagnosis and of having one’s needs understood
based on one’s culture, values and beliefs were appreciated by
the participants and increased treatment engagement. This is
similar to the approach of person-centeredness and individuali-
zation of SUD treatment services,32,33 which is now part of the
national guidelines for SUD treatment.34,55 In a recent
Norwegian study, participants’ narratives suggested that HPs
who used “personal connection” and saw them as persons beyond
their substance use problems were considered facilitators for
treatment.56 In addition, participants acknowledged aftercare as
an important factor to prevent relapses and improve treatment
outcomes. Aftercare could be seen as long-term monitoring and
support in SUD treatment56 and could be individualized to
meet the needs of persons of immigrant background. Also,
aftercare could be understood as follow-up care in treatment
models which allows individuals to cope and regain a meaning-
ful life when they are no longer in treatment settings, along with
having a sense of being a contributing member of their com-
munity.57 This process can also aid in overcoming stigma by
developing resilience toward stigma and/or actively fighting
against it and can provide people with MHD/SUD with a sense
of empowerment and control over their lives by exercising their
rights and responsibilities as other citizens.25
Further, participants’ experiences revealed that the greater
their awareness about the consequences of SUD and MHD,
the higher was their engagement to treatment. It was also
reported that many of their co-users were unaware that care
was available and hence did not initiate treatment. Fong etal.
suggested that creating alternative 12-step groups focusing pri-
marily on support and education and less on confrontation
would facilitate treatment,45 which is in line with participants’
experiences in our study. In addition, immigrants’ perceptions
of the need for treatment were dependent on social embedded-
ness,44 hence strategies for reducing stigma within the social
context may facilitate treatment among immigrants. Another
treatment facilitator is the supportive network of peers and
family.48 Being open with family and friends harnesses help-
seeking enablers,44 along with raising the family’s mental
health literacy,47 which is in agreement with the participants’
experiences. Further, having a supportive network gave the par-
ticipants a feeling of inclusion.
Lastly, our study was able to include only men due to the
challenges in recruiting immigrant women with co-occurring
SUD and MHD. We had initially planned to recruit both
women and men who met the inclusion criteria. We argue that
the recruitment of immigrant men was extremely challenging
due to the hidden nature and stigma attached to SUDs and/or
MHDs. Our participants reported that there were many men
and women with a similar diagnosis but they were not willing
to participate in the study because of fear of being recognized
and detected within their small communities in Norway. We
believe that this fear and stigma are probably even more preva-
lent among immigrant women with co-occurring SUD and
MHD, due to their perceived potential risk of greater harm if
they are detected and identified and different cultural norms.
In addition, due to experiences of shame, discrimination, and
marginalization, immigrant women are less likely to report
their SUD and/or MHD and are less likely to access the avail-
able care and treatment.58
Limitations and strengths
This qualitative study provides insights into treatment experi-
ences of immigrant men living with co-occurring SUD and
MHD in Norway, which to our knowledge has not been previ-
ously explored. The results are based on our participants’ expe-
riences and may be argued about the relevance beyond the local
context. However, in exploring subjective experience involves
focusing on the meaning of the participants, which may be
transferred to other contexts and other people. Moreover, these
insights are believed to be of relevance for future research.
Further, we argue that our results provide insights into the
experiences of a group of persons who are considered hard to
reach and often stigmatized. Furthermore, the credibility in our
study was enhanced by collaborating with a competency group
in all stages of the study, starting from writing the protocol,
preparing the study, recruiting the participants, analyzing the
data, to compiling the results. In addition, in interview settings,
both the participants and the first author were non-ethnic
Norwegians, which facilitated the interview process, where the
participants could trust the interviewer and feel connected,
which helped to provide meaningful data. This could be under-
stood as “diversity in proximity”, meaning that interaction
between migrant researcher and migrant participant is effective
when both of them can recognize the ties that bind and the
social fissure that divides in a host country.59 We also believed
that “diversity in proximity” enhanced the credibility of our
study. Lastly, this study could only recruit immigrant men
because of the challenges in recruiting immigrant women liv-
ing with co-occurring SUD and MHD.
Conclusion and future recommendations
Immigrant men living with co-occurring SUD and MHD
interpreted their lived experiences of treatment in mental
Kour et al. 9
health and addiction services in Norway as both negative and
positive. Lack of connection and individually tailored treat-
ment along with stigma were important ongoing barriers to
treatment and hence led to low treatment engagement.
However, HPs with multicultural competence, aftercare and
strategies for raising awareness and reducing stigma acted as
facilitators to treatment, increasing treatment engagement.
Improving the health of immigrants would benefit Norway
and other countries, as migration is increasing worldwide.
Hence, we argue that the insights from the participants are
timely and that the knowledge from their treatment experi-
ences can broaden the perspectives of practitioners and policy
makers to provide more culturally tailored services. Further, we
suggest that strategies that reduce barriers to treatment will
require increased prevention and education efforts tailored to
individual needs. We also suggest that treatment engagement
may increase with a greater emphasis on strategies that provide
more person-centered and culturally competent services. We
suggest future research on how to better understand the impact
of these barriers on the diagnosis of individuals and their par-
ticipation in the society.
Acknowledgements
The authors wish to express their appreciation to all the partici-
pants for generously sharing their time, insights and experiences.
We also thank the members of the competency group, who have
been vital in recruitment and have provided invaluable insights
and reflections throughout the study. Finally, we would like to
thank Innlandet Hospital Trust for funding the study.
Author contributions
PK conducted the study and initial data analysis. All the authors
contributed in further analysis and drafting the final article.
ORCID iD
Prabhjot Kour https://orcid.org/0000-0001-5716-6683
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Table 1. Description of participants.
PARTICIPANT AGE IN YEARS REGION OF
ORIGIN
AGE AT
MIGRATION TO
NORWAY
AGE WHEN
STARTING TO USE
SUBSTANCES
DROP-OUT FROM
TREATMENT
133 Middle East 1.5 y 12 Several times
242 West Africa 7 y 14 Twice
332 Middle East 5 mo 12 Several times
425 East Africa 16 y 17 Once
5Around 30 (not conrmed) African descent 12 y 17 Several times
638 South Asia Born in Norway 12 Several times
729 South Asia Born in Norway 19 Once
842 Middle East 11 y 15 Several times
953 Middle East 21 y 8Several times
10 39 Middle East 24 y 16 Several times
Appendix A
... This situation may be aggravated by health professionals' limited knowledge of immigrants' backgrounds, leading to immigrants' dissatisfaction with the services. [16][17][18] The rate of immigration to Norway has considerably increased over recent decades; immigrants form a growing proportion of the Norwegian population, 19,20 which leads to an ethnically diverse society. 21 The share of immigrants in Norway's total population is 18.2%, while 10.8% of the population are 2 Substance Abuse: Research and Treatment immigrants from middle-and lower-income countries. ...
... 28 Moreover, several factors influence their utilization of health services 20 and may lead to lower treatment engagement. 18,[29][30][31] These factors may include their expectations based on experiences in their home countries, lack of culturally tailored services, and previous negative and discriminatory experiences with health services in the host country. 32 Understanding the process of treatment engagement among immigrants with co-occurring SUD and MHD through health professionals' experiences can provide a basis for the treatment. ...
... In former research on treatment experiences of immigrants living with co-occurring SUD and MHD, some participants narrated various reasons for their lower treatment engagement in mental health and addiction services in Norway; these included a lack of culturally competent staff. 18 Health professionals are crucial in providing and promoting healthcare and thus there is a need to understand their experiences of treatment engagement among immigrants with co-occurring SUD and MHD, which to best of our knowledge has not been previously studied in Norway. ...
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... These different discourses enabled men to circumvent or buffer the stigma attached to treatment seeking and maintain their masculine identities. Kour et al. (2020) In-depth interviews 14 men who self-identify or have been formally diagnosed with an eating disorder (mean age= 27.8) Men reported fear of potential stigmatization, shame and backlash for revealing their eating disorder (ED) to colleagues in the workplace, especially in male dominated workplaces. To avoid stigma, many men chose not to disclose their ED and to blend into the culture of the organization. ...
... The authors note that African Americans have historical trauma experiences in relation to mental health care services which prevails as mistrust and suspicion. Similarly, Kour et al. (2020) described how immigrant men (Middle Eastern, Asian, African) with co-occurring substance use disorders and mental illness were fearful of being stigmatized and ostracized in their small cultural communities wherein being known to seek psychiatric help would lead to them being labeled as "mad." Similar to Samuel (2015), treatment adherence among men was low due to the shame and stigma for using mental health services. ...
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... These findings are not surprising given that only three of the 32 sites were able to provide SUD services in isiXhosa, the most frequently spoken African language in the Western Cape. Associations between absence of culturally tailored, person-centred SUD treatment and suboptimal SUD outcomes among African migrant populations and racial minorities in high-income country studies [47,48] underscore the need for systems-level interventions to improve Black/African patients' experience of care. Interventions that increase the cultural and language diversity of SUD providers in the Western Cape, expand SUD workforce training efforts to include cultural explanations of SUDs, and implement training to not only improve providers' cultural competence but also address their unconscious biases towards people of Black/African descent may help improve the SUD treatment experience of Black/ African patients. ...
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Rationale: Despite the benefits and availability of drug treatment in Western countries, research has shown low utilisation rates, especially by mothers. Studies have indicated internal barriers (e.g., shame) and external/structural barriers (e.g., poverty) to women's utilisation of drug treatment, but little is known about the interrelated axes of marginalization that create such barriers and, even less, facilitators of treatment. A promising avenue for examining this path may be the theoretical perspective of intersectionality, which has often been used to illustrate how women's experiences are shaped by gender in conjunction with other factors, including class, age, and race. Objective: The purpose of the study was to obtain a deeper understanding of the barriers and facilitators of drug-abuse treatment among substance-abusing mothers, including practical implications. Methods: In-depth interviews were conducted with 25 Israeli-born and immigrant mothers known to child protection and welfare agencies. A critical feminist theoretical perspective informed by intersectionality was adopted to examine the barriers to and facilitators of their enrolment in drug treatment. Results: Thematic analysis revealed three themes in the interrelationships of different factors and treatment utilisation. First, the threat of losing child custody was interrelated with lack of social and family support, immigration status, being post-partum, and economic hardship to shape barriers to treatment. Second, a set of coping resources originating in their marginality was interrelated with opportunity for treatment. Last, the participants suggested changes that would encourage treatment utilisation, with focus on non-judgmental referral procedures. Conclusions: The findings indicated that barriers and facilitators are interrelated and co-constructed, reflecting the interlocking of power and oppression across the axes of class, gender, and ethnicity. Focusing on social inequality and gender in policies and research on women's drug treatment, the findings may inform the development of strategies to overcome treatment barriers.