A third individuation: immigration, identity, and the psychoanalytic process

Do we know our place? The role of psychoanalysis in public life

The contributions to this Psychoanalytic Controversies section explore the question of what psychoanalysis may be able to contribute to thinking about some of the challenges currently confronting humanity and how such communications can be made effectively. This introduction to the section frames the debate with some reflections on anxieties that have been expressed about the application of psychoanalytic ideas beyond the clinical context, the risks of insularity, the need for appropriate humility, and the reality of the embeddedness of analytic practice, in particular social, cultural, and historical contexts. Contributions from Claudia Frank, Sudhir Kakar, Eli Zaretsky, Michael Rustin, Pratyusha Tummala-Narra, Magda Khouri, and Sally Weintrobe are introduced.

El Género Como el Nuevo Lenguaje de Rebeldía Adolescente

El número creciente de adolescentes con identidad de género no conforme parece estar asociado a lo que los autores consideran ser la manifestación contemporánea del fenómeno de la crisis de identidad adolescente. Ésta se expresa a través de un rechazo deliberado y una revaloración de los roles y las normas convencionales de género. La crisis de identidad adolescente, tal y como fue conceptualizada inicialmente por Erik Erikson (1956), constituye un fenómeno multifacético inconsciente que se manifiesta en el contexto familiar y social. Los autores hacen una revisión histórica de la terminología pertinente, seguida de la presentación de cuatro bocetos clínicos, seleccionados para mostrar este fenómeno y los conflictos familiares que comúnmente se producen como resultado. A continuación, se presenta un caso clínico que abarca el proceso de evaluación clínica, formulación psicodinámica, consideraciones del tratamiento y el trabajo con los padres. Se enumeran las fuentes de información disponibles para los pacientes y sus familias. Las ilustraciones clínicas están compuestas de varios casos sobrepuestos y los datos se han alterado para proteger la privacidad y confidencialidad de los pacientes. Por último, los autores hacen un llamado a la comunidad científica a realizar indagaciones profundas a largo plazo sobre este fenómeno clínico.

Il Genere come il Nuovo Linguaggio di Ribellione dell’Adolescenza

Il crescente numero di adolescenti con identità di genere non conforme sembra essere associato a quello che gli autori considerano essere, in epoca contemporanea, una manifestazione del fenomeno della crisi d'identità dell'adolescente. Questa si presenta con un deliberato rifiuto del proprio genere e con una rivalutazione dei ruoli e delle norme di genere convenzionali. La crisi d'identità dell'adolescente, così come inizialmente concepita da Erik Erikson (1956), costituisce un fenomeno poliedrico inconscio che si manifesta nel contesto familiare e sociale. Gli autori conducono una revisione storica della terminologia pertinente, seguita dalla presentazione di quattro casi clinici, selezionati al fine di illustrare questo fenomeno ed i conflitti familiari che comunemente ne derivano. Successivamente, viene riportato un caso clinico specifico che concerne il processo di valutazione clinica, la diagnosi psicodinamica, le considerazioni sul trattamento psicoterapeutico ed il lavoro con i genitori. Sono inoltre citate le fonti di informazione disponibili per i pazienti e per le loro famiglie. Al fine di proteggere la privacy e la riservatezza dei pazienti, i casi clinici sono raccontati in modo combinato. Infine, gli autori concludono l'articolo con un invito rivolto alla comunità scientifica a condurre indagini prospettiche a lungo termine su questo nuovo fenomeno clinico.

Gender as the New Language of Teen Rebellion

The growing occurrence of adolescents with gender nonconforming identities appears to be associated with what the authors believe is the contemporary manifestation of the adolescent identity crisis phenomenon. This phenomenon is expressed through a deliberate rejection and reappraisal of conventional gender roles and norms. The adolescent identity crisis, as initially conceptualized by Erik Erikson (1956), constitutes an unconscious multifaceted phenomenon that is outwardly displayed within familial and societal frameworks. A historical overview of pertinent terminology is provided, followed by the presentation of four clinical vignettes chosen to exemplify this phenomenon, alongside the resultant family conflicts that often ensue. Additionally, an anonymized clinical case is presented, encompassing the evaluation process, the subsequent psychodynamic formulation, treatment considerations, parent work, and the available resources for patients and families. The clinical illustrations are case composites and the data disguised to protect patient privacy and confidentiality. A plea is made to the scientific community for in-depth long-term research into this clinical phenomenon.

Race and Analytic Neutrality: Clinical and Theoretical Considerations

Neutrality remains a key concept underpinning the psychoanalytic attitude, but its operation in the clinical setting must be reconfigured if the countertransference is to be used as a source of data, conveyed by projective identification. Subjective responses thus mobilized in the analyst need to be processed before attention can return to the evenly suspended state, from which greater objectivity flows. Theory, internalized as part of the analyst's emotional learning, operates preconsciously in the session; in clinical work with racial matters this includes, crucially, familiarity with internal racism, of which a model is briefly described. These ideas are illustrated via two clinical vignettes in which these themes are traced.

Social Trauma, Nostalgia and Mourning in the Immigration Experience

Immigration and exile can qualify as social traumas. The individual is deprived of a holding, secure environment in which to continue their life. The process of mourning is a necessary step to connect with "going on being." Another psychic experience in migration is nostalgia; it helps the immigrant defend against the aggression resulting from current frustrations. The feeling of nostalgia can also be used to protect the ego from inadequacy. The complex components of nostalgia come from positive ones such as joy and gratitude connected with sadness about the associated loss of security, familiarity, and historical continuity. At other times, nostalgia cannot evolve, particularly in forced migration or exile. In this case, the individual enters a depressed state with accompanying feelings of self-pity, resentment, envy, and guilt, which prevents the mourning process from developing. To deal with these painful experiences, the person resorts to linking objects or linking phenomena that help them continue having contact with the past, while adjusting to their new environment.

A Brief Pastoral Topography for Migrating People

Like God, humans are always on the move. Migrating people reflect the imago Dei of God the Earthroamer. Unlike God, humans do not always move with freedom as geopolitical forces, from societal disintegration to war and climate change, force migration. The experiences within migration reflect elements of a "personal knowledge" (Michael Polanyi). This essay recognizes that much of the migrating experience may escape verbalization, which not only impacts migrating people but also the scholars and researchers studying migration. Drawing on narratives in the Judeo-Christian tradition, the essay identifies seven pastoral-theological polarities to describe the migrating experience: Anticipation and disappointment; trouble and restoration; curse and blessing; at home and being a stranger; becoming and continuity of being; articulation and silence; and alone and in communitas. These themes are illuminated by pastoral-theological, cultural, psychological, and psychodynamic theories.

"I Have No Capacities That Can Help Me": Young Asylum Seekers in Norway and Serbia - Flight as Disturbance of Developmental Processes

Most studies on refugee populations are organized around trauma-related issues and focus on explaining pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence how developmental tasks are negotiated. This study is part of a larger mixed method study seeking to identify resilience-promoting and resilience-inhibiting factors, on individual and contextual levels, among asylum seekers and refugees on the move (passing through Serbia) and settled in reception centers in Norway. A strategic sample of 20 adolescent and young adult refugees/asylum seekers during flight in Serbia (10) and after arrival in Norway (10) was chosen from a sample of 178 refugees interviewed in depth in Serbia and at receptions centers in Norway. The sample reflects the focus of this paper, which is to explore adolescent and young adult refugees/asylum seekers' psychological and social needs and resources during flight to and after arrival in the host country, including how developmental tasks are negotiated. Through qualitative analysis, experiences associated with the developmental changes the participants experienced before, during, and after flight are contextualized. Their sense of self, their relationships with their families and their perceptions of their situation as adolescents or young adults in a highly unpredictable situation are presented in the light of relevant theory and findings from similar refugee studies. All the participants have fled from dangerous and intolerable situations in their home countries. They describe extreme dangers during flight in contexts that are unpredictable and where they feel lonely and unsupported. Most have unmet psychosocial needs and have received little support or help for their mental health issues during flight or after arrival in Norway. Suggestions for interventions and resilience-promoting actions are given based on the findings of the study.

Towards a psychoanalytic migration studies: A son, a brother, a father, an American, and his house in a Cameroonian village

Around the world, migrants are building houses in their countries-of-origin. For the women and men who create them, these houses are unambiguously significant. Yet, in academic migration studies, they are often seen as peripheral—interesting rather than important. This article follows recent work that aims to show why these houses really do matter. These houses are where migrants can seek to process the trauma of the disconnection that is inherent in migration and are how they repress the anxieties that arise from transnationalism. Migrants’ emotions are externalised onto the house. Based on ethnographic fieldwork in Cameroon between 2013 and 2018, this article develops a case study about one transnational migrant, his family, and his house. It uses the example to develop two arguments: first that these houses sit within transnational networks, but the networks are subject-centred so a theory of the subject is needed to analyse them. Secondly, that human subjects make a deal when they exchange infantile egocentrism for collective inter-subjectivity, which is similar to the deal made between transnational migrants and their ancestral home when they receive permission to leave in exchange for continuing to connect—a link that is materialised in the house. Both these arguments combine to support an underlying claim that migration studies in general, and studies of migrant housing in particular would benefit from building further on existing work that draws on psychoanalytical approaches.

Learning and Teaching Latino Mental Health, Social Justice and Recovery to Visiting Students: A Pilot Study

Almost 18% of the U.S. population is estimated to be Hispanic (United States Census Bureau, 2019), and of that, 15% had a diagnosable mental illness in the past year (Substance Abuse and Mental Health Services Administration, 2020); still, Latinos receive half as often mental health services compared to Caucasians (Office of Mental Health, 2020). Evidence suggests that minority ethnic groups may receive more inferior care standards due to biased beliefs or attitudes held by health professionals (Shepherd et al., 2018). The number of Latino Psychiatrists is not enough to care for the on-growing Latino population in the U.S. (Alarcón, 2001; American Psychiatric Association, 2017). There is a need to train medical students and residents in cultural competencies pertained to the Latino Culture and Health Services (Alarcón, 2001). We developed a pilot study of a curriculum created by Latino bilingual and bicultural mental health providers. The course lessons include (a) Health Disparities and Implicit Bias, (b) Recovery in Mental Health, (c) Immigration and Acculturation, (d) Cultural Formulation Interview, (e) Latino Values, and (f) Mental Health Systems. All topics focused on Latino Mental Health and used the “reverse classroom” teaching technique with interactive exercises. We measured the impact on knowledge, attitudes, and comfort level related to the concept taught in the lessons of this course. Teaching Latino Mental Health has a positive impact on improving the comfort level and knowledge of students. Nevertheless, there are not enough educational opportunities and information about these topics. Therefore, replicating this curriculum and expanding the education in Latino Mental Health will improve the health services provided to this community.

Learning and Teaching Latino Mental Health, Social Justice and Recovery to Visiting Students: A Pilot Study

Almost 18% of the U.S. population is estimated to be Hispanic (United States Census Bureau, 2019), and of that, 15% had a diagnosable mental illness in the past year (Substance Abuse and Mental Health Services Administration, 2020); still, Latinos receive half as often mental health services compared to Caucasians (Office of Mental Health, 2020). Evidence suggests that minority ethnic groups may receive more inferior care standards due to biased beliefs or attitudes held by health professionals (Shepherd et al., 2018). The number of Latino Psychiatrists is not enough to care for the on-growing Latino population in the U.S. (Alarcón, 2001; American Psychiatric Association, 2017). There is a need to train medical students and residents in cultural competencies pertained to the Latino Culture and Health Services (Alarcón, 2001). We developed a pilot study of a curriculum created by Latino bilingual and bicultural mental health providers. The course lessons include (a) Health Disparities and Implicit Bias, (b) Recovery in Mental Health, (c) Immigration and Acculturation, (d) Cultural Formulation Interview, (e) Latino Values, and (f) Mental Health Systems. All topics focused on Latino Mental Health and used the “reverse classroom” teaching technique with interactive exercises. We measured the impact on knowledge, attitudes, and comfort level related to the concept taught in the lessons of this course. Teaching Latino Mental Health has a positive impact on improving the comfort level and knowledge of students. Nevertheless, there are not enough educational opportunities and information about these topics. Therefore, replicating this curriculum and expanding the education in Latino Mental Health will improve the health services provided to this community.

What's race got to do with it? A proposed framework to address racism's impacts on child and adolescent mental health in Canada

This commentary responds to current events that have highlighted the ways that systemic racism affects a wide variety of health outcomes. We specifically discuss how systemic racism adversely affects the mental health of children and adolescents in a Canadian context and use a structural framework to demonstrate how race is embedded in various Canadian systems and thus affects child and adolescent mental health in both conscious and unconscious ways throughout the lifespan. Experiences of systemic racism affect the mental health of Canadian young people in multiple complex and intersecting ways including access to care, experience of mental health services, and outcomes of care. We currently lack a national best practice framework for mental health professionals that unifies approaches to research, education, and clinical care for young racialized Canadians; in addition, concerted efforts to collect race-based data are lacking. We suggest that a blueprint for improved services for racialized young people in Canada would include: Development of a funded and sustainable research agenda responsive to community expertise, development and implementation of a Canadian Child and Adolescent task force focused on educational strategies on racism and service provision at both the postgraduate and continuing professional development (CPD) levels, and consideration of clinical parameters that improve access to, and experience of, care for Canadian racialized youth.

Displacement trauma: complex states of personal, collective and intergenerational fragmentation and their intergenerational transmission

Originally presented at the Journal's one day conference entitled 'Displacement: Contemporary Traumatic Experience' held in London in November 2019, this paper expands on the author's theory of the implicit psychological organizing gestalt, an associated pattern of psychic functions which operate in an integrated way to simultaneously structure and organize our experience of self-cohesion and self-continuity. The gestalt, which implicitly links the formation of psychic skin, body image, cultural skin and both personal and cultural identity with place, functions as an emergent non-conscious permanent presence or background 'constant'. It develops over time and emerges out of embodied emotional experiencing with the total environment - both human and non-human. The author argues that it is the rupture of this gestalt and the disorganizing consequences of its loss which underlies the experience of displacement trauma. If disruptions in the formation of the gestalt and/or its later rupture remain unrecognized and unrepresented then the absence creates a void which can be intergenerationally transmitted. Case material is presented which describes this and which highlights the ways in which the gestalt can contribute to our understanding of collective displacement anxiety, cultural trauma and cultural complexes.

Oppression, liberation, wellbeing, and ecology: organizing metaphors for understanding health workforce migration and other social determinants of health

Background

The Commission on Social Determinants of Health (CSDH) identifies the maldistribution of power, money, and resources as main drivers of health inequities. The CSDH further observes that tackling these drivers effectively requires interventions to focus at local, national, and global levels. Consistent with the CSDH’s observation, this paper describes the eco-psychopolitical validity (EPV) paradigm, a multilevel and transdisciplinary model for research and action, thus far insufficiently tapped, but with the potential to systematize the exploration of the social determinants of health.

Results

Using the physician migration from Sub-Saharan Africa (SSA) to the United States as illustration, this paper articulates how the EPV model can be applied to the systematic analysis of a complex social problem with health inequity implications. To help explore potential determinants of physician migration, a comprehensive coding matrix is developed; with the organizing metaphors of the EPV model–namely oppression, liberation, and wellbeing–serving as analytical categories. Through the lens of the EPV model, migrating physicians are revealed as both ecological subjects enmeshed in a vast web of transnational processes linking source and destination countries, and potential change agents pursuing liberation and wellbeing. While migration may expand the opportunities of émigré physicians, it is argued that, the pursuit of wellbeing by way of migration cannot fully materialize abroad without some efforts to return home, physically or socially.

Conclusion

Clarifying the relationship between various social determinants of health and health inequities at different levels of analysis is a more complex but essential endeavor to knowledge generation than using a one-dimensional frame. With its roots in interdisciplinary thinking and its emphasis on both individual and contextual factors, the EPV paradigm holds promise as a model for examining the social determinants of health.

Migrantes colombianos en Chile: Tensiones y oportunidades en la Articulación de una Historia Personal

Este artículo presenta y discute los resultados de un estudio cualitativo desarrollado en Chile, que exploró y analizó las significaciones atribuidas por migrantes colombianos adultos a sus experiencias. Se utilizaron relatos de vida y creaciones visuales para producir datos. Los resultados evidenciaron la pluralidad de significaciones en torno a la migración, así como el proceso continuo de elaboración y evaluación que supone dar sentido a la experiencia, pues esta revela la naturaleza contingente de la identidad, el estilo de vida y las prácticas culturales. Los participantes tendieron a significar positivamente su experiencia migratoria, pero evidenciaron la presión por salir adelante con base en sus propios recursos, caracterizando la migración como proyecto inherentemente personal, reflejando tendencias culturales a la individualización social.

Immigration, Psychic Dislocation, and the Re-creation of Community

Communities are "psychic entities" that serve powerful psychological functions for the individuals living within them. They also serve multiple functions, including as a potential space where individuals are "held" and within which individuals "play" in ways akin to Winnicott's formulations regarding how infants "use" the me-not-me zone of experiencing, the potential space created by the gap between symbiotic engagement and the maternal object, in a zone between desire for fusion and fear of disintegrating abandonment. This paper explores the psychic destruction of community and the attempts to reconstruct "usable" community in migration, drawing from Winnicott and other psychoanalytic theorists to help us understand how communities work as psychological spaces and, specifically, to understand the near universal clustering that we see in immigrant communities.

Variations on the Migratory Theme: Immigrants or Exiles, Refugees or Asylees

When a country is engulfed in war, or overrun by a dictator who begins killing, its citizens are forced to flee. In such situations, the only compassionate response is to take people in. With the ongoing mass migration to Europe, these refugees pay smugglers to take them to safety, but there is no safe place to go since nobody wants them. They leave in a rush to save their lives and their families due to political and religious fear, death threats, rape of women, or forced labor. They do not have time to mourn the losses, there is no time for "ideal migration" where destination countries can choose whom they will take in. The initial hope and dream to escape to a safe "haven" is transformed into a nightmare of humiliation and fear. These asylum seekers will be or already are suffering from PTSD due to massive psychic trauma.

Technical Challenges Faced by the Immigrant Psychoanalyst

This paper delineates the technical challenges faced by immigrant analysts. These include (i) maintaining cultural neutrality toward "native" patients, (ii) wondering about the patient's motivations for choosing an ethnoculturally different analyst, (iii) scanning the patient's associations for interethnic clues to deeper transferences, (iv) negotiating the dilemmas posed by conducting analysis in a language other than one's mother tongue, and (v) avoiding shared projections, acculturation gaps, and nostalgic collusion in working with homoethnic immigrant analysands. While by no means irrelevant to the clinical work of non-immigrant analysts, these tasks seem to have a greater importance for the immigrant analyst. Brief clinical vignettes are offered to illustrate these propositions and to highlight the tension between the universality of fundamental intrapsychic and relational configurations, on the one hand, and the nuances of cultural and linguistic context, on the other.

THE ROLE OF AN IMMIGRANT MOTHER IN HER ADOLESCENT'S IDENTITY FORMATION: "WHO AM I?"

Immigration is a complex bio-psycho-social process and the immigrant mother has a truly complex task in lending her ego strength to her adolescent offspring. The normal adolescence's decathexis of the love object and the consequent search for a new object may not happen smoothly for those adolescents whose mothers are immigrants. The immigration experience may cause the immigrant mother, who lost her motherland, deeper disturbance in self-identity as well as disequilibrium in her psychic structure, which in turn impacts adversely her adolescent's development. The adolescent's inadequate early experience with an immigrant mother may result in a deeper disturbance in his separation-individuation process as well as his identification process. An immigrant mother who has not mourned adequately, with a different sociocultural background has to go through a far more complex development of motherhood. The case of an adolescent boy, Jason, demonstrates the impact of immigrant motherhood on his ego development.

Inaccessible Masturbation, Impossible Mourning: Collective Melancholia, the Prohibition on Female Sexual Subjects in India, and Masturbation Fantasy as a Zone of the Strange

This paper explores a subjective experience-and identification-that a cohort of Indian women identifies as "home." This experience of "home" provides an attachment to a collective melancholia that keeps in place a prohibited female sexual subjectivity. The paper provides a brief historical overview of the prohibition of female sexual subjectivity and erotic agency in India. Following this, it discusses women's masturbation fantasies that illustrate the toggle between women's permitted and prohibited identifications. A clinical case example is presented to illustrate the hopelessness and mourning inherent in the psychoanalytic journey into subjectivity, a journey involving a departure from a shared cultural history.

IDENTITY FORMATION DIFFICULTIES IN IMMIGRANT ADOLESCENTS: THREE CASES FROM GERMANY

Adolescence is a period of instability caused by biological changes and restructuring of the personality. An immigration background renders the process of identity formation even more difficult or fragile, with an additional burden coming from persecution and harassment. Three case studies of mentally disturbed adolescents with different immigration backgrounds illustrate the problems in diagnosis and psychotherapy. All three cases share a common feature--the particular influence of the native country on the psychic disorder of the adolescent, be it a suitable target of narcissistic self-aggrandizement, a reactivated metaphor of the past or a deposited conflict. I point out and discuss the danger of diagnostic colonization and activation of perpetrator-victim constellations--such as the Nazi past in the present. Offering a transcultural transitional space as a container yields a therapeutic approach to the different worlds of these borderland adolescents.

Giving birth in exile: motherhood as reterritorialization

This paper explores the effects of exile on the subjectivity of pregnant migrant women through the lens of the processes of deterritorialization and reterritorialization. Having escaped the gaze of the parental superego, the subject's encounter with sexuality becomes possible. However, in addition to the emancipatory aspects of migration, we observe particular somatic-psychical effects on reproductive ability. These "exile" pregnancies are generally experienced as difficult and painful, laying bare a symptomatology that is as much psychical as somatic, and which highlights the cost of a desire for independence. In this context, where perinatal risks must be evaluated and treated through an interdisciplinary approach, a clinical accompaniment proves to be indispensable for the maternity to progress smoothly on foreign soil.

Seeing double, being double: longing, belonging, recognition, and evasion in psychodynamic work with immigrants

Psychically immigrants live double lives, simultaneously dwelling in the world they have left and the world in which they live, and into which most try to fit to avoid the alienating experience of being "other". Doubleness is not a conscious act, but it is a preconscious counterpoint to just about every social interaction. I argue that successful psychodynamic treatment allows immigrants to take the doubleness for granted, in effect seeing double and being double. In this way they come to effortlessly privilege one self-state over the other. The recognition and acceptance of competing self-states proves transformative in any treatment, but never more so than in working with immigrants who contend with several culturally competing selves in their daily lives and seek one relationship in which they can all be seen and heard. I describe treating an immigrant who, when I began to work with her, excelled at seeing double, but being double posed a terrifying dilemma. At least two self-states were engaged in a tug of war; she feared that the winner would take all.