Immigration and Logotherapy: Addressing Mental Health Problems among Muslim Immigrants in Europe ^†

Abstract

Depression, stress, anxiety disorders, and PTSD are some of the mental health problems that are prevalent among immigrant populations despite being underdiagnosed. Stigma, difficulties in adapting, cultural barriers, and reduced access to mental health support can seriously hamper their ability to build resilience and recover. Other limitations include assuming that therapies can be universally applied, the lack of sufficient evidence on mental health issues of this population, and the use of therapeutic models developed on Caucasian populations. Here, professional guidance to find the meaning of life through interventions such as logotherapy could help them in this process. The present work systematically reviewed studies investigating the effectiveness of logotherapy in diverse populations and its relevance to a Muslim immigrant population in Europe. Following PRISMA guidelines and the keywords ‘logotherapy, mental health problems, immigrant, and treatment’, the search identified 16 relevant studies conducted since 2005. The studies revealed that logotherapy could be implemented through paradoxical intention, de-reflection, Socratic dialogue, and attitude modification. All these techniques have the potential to help the client to realize long-term relief for underlying stressors associated with migration and settling in a new location. Though data on logotherapy are still scarce, it is evident that it deserves more research so that a structured, evidence-based, and effective therapy for Muslim immigrants in Europe can be developed and tested. In this regard, we propose that the four logotherapy techniques have huge potential in helping psychiatrists develop an effective therapy for mental health problems among these immigrant populations confronting adversity.

1. Introduction

Mental health problems are some of the main challenges that immigrants strive to overcome as they settle into their new locations [1]. Studies indicate that mental health problems, such as stress, depression, and anxiety disorders, tend to be higher among immigrant population groups compared to the general population [2]. However, immigrant population groups remain underdiagnosed and suffer low treatment levels for mental health problems. Assessment difficulties and social stigma have been linked to the low diagnosis and treatment levels among this population group. These factors lead to delays in diagnosis and compromise the effectiveness of the therapeutic approaches used [3]. With the increasing number of immigrants in Europe, especially young Muslim immigrants from the Middle East and North Africa, the cases of mental illnesses are projected to increase and, thus, so does the need to come up with new approaches to address this problem [4]. There is a need for forward planning and strategic mental health service delivery to not only ensure equitable access to mental health services for all but also to ensure that mental illnesses among Muslim immigrants can be treated effectively [4]. In this regard, the present paper critically reviewed how logotherapy can be applied to address mental health problems among the Muslim immigrant population in Europe.

It is important to note that immigrant populations often face challenges that are considerably different from the rest of the population. For example, refugees struggle to cope with leaving loved ones behind, the loss of property, and trying to settle in a totally new country [5]. On the other hand, immigrant-receiving countries must ensure the appropriate planning and delivery of health services using evidence-based and culturally competent models. Unfortunately, policymakers and practitioners tend to use mental health interventions, which are limited in various ways [6]. First, due to a lack of sufficient evidence on the mental health issues of the immigrant population, the therapeutic models used are developed based on studies conducted on Caucasian populations [7]. Second, policymakers and practitioners assume that specific mental health therapies can be universally applied even in a culturally diverse population. Third, studies have yet to confirm if there are any specific models or interventions that are more effective in treating mental health problems among the immigrant population [8]. To address the limitations associated with treating immigrant populations, the present work systematically reviewed studies that investigate logotherapy applications in diverse populations and evaluated its effectiveness and relevance to a Muslim immigrant population in Europe.

2. Method

The literature used in this study was sought from the following databases: Cochrane Central Register of Controlled Trials, CINAHL, Web of Knowledge, PsychINFO, and MEDLINE. Keywords used to identify appropriate studies for the review included logotherapy, mental health problems, immigrants, and treatment. The selected studies were those conducted between 2005 and 2019. However, only studies that met the following criteria were included in the review: (1) research approach, i.e., quantitative, qualitative, or mixed, is explicitly or implicitly referred, (2) treatment for the mental health symptoms comprehensively described, (3) the described treatment applied logotherapy principles, (4) the participants in the selected studies were 18 years old and above, and (5) the participants were diagnosed with mental health problem symptoms, such as stress, anxiety, or depression. After the evaluation of the studies against the criteria, fifteen articles were included in the final analysis.

3. Critical Analysis and Discussion

Mental Health Problems among Muslim Immigrant Populations

To understand mental health problems faced by immigrant populations, it is important to understand the migration stages. The first stage, pre-migration, encompasses making the decision and preparing to leave. The second stage, migration, involves relocating from the current physical location to a new location. The final stage, post-migration, consists of the assimilation process of the immigrant into the new society [9]. All these stages of migration come with varying levels of psychiatric illness risks; thus, individual mental health should be assessed at all these stages. These stages are also characterized by different risk factors for mental health problems. At the pre-migration stage, factors such as socioeconomic status, personality, and age have been found to influence a person’s ability to cope with mental conditions, such as stress. During migration, studies indicate that mental health risks are enhanced by poor living and traveling conditions and also exposure to violence. As Muslim immigrants move from the Middle East to Europe, the risk of psychiatric illnesses increases as they face more hardships crossing country borders and mingling with new cultures and languages. The hardships lead to increased levels of depression, somatic complaints, and post-traumatic stress disorder (PTSD) compared to non-immigrants [3]. In Europe, Muslim immigrants experience culture shock and a loss of the language and support systems, thus increasing their vulnerability to mental health conditions.

Resettlement into a new country also comes with varied mental health challenges. Though reaching a safe place is associated with hope and optimism, factors such as social isolation and difficulties in starting an education or finding work can be stressing experiences [9]. Immigrants are also faced with problems such as access to housing and appropriate healthcare. Due to these challenges, studies have found that, despite their higher vulnerability to mental illnesses, immigrants were less likely to seek mental health treatment compared to the rest of the population. Immigrants chose to solve their problems alone for fear of stigmatization and misunderstanding of their cultural context. Furthermore, racism and discrimination put obstacles on the immigrants’ ability to establish a successful post-migration life, and cultural change makes it harder to balance the assimilation and maintenance of cultural identity [3]. In this case, the Muslim immigrants in Europe feel that they do not have a great orientation toward or connection with the Spanish culture [5]. Given the highlighted barriers towards access to mental health services among immigrants, a treatment intervention would build the hope and confidence of the patient. Logotherapy is recommended in this case as it has the potential to help the patient find new meaning in his/her life and cope better with past-present-future experiences that bring them grief.

4. Logotherapy

In 2006, Viktor Frankl developed the logotherapy concept based on the idea that the main motivational force for any individual is finding meaning in life [10,11]. Unlike Freud’s psychoanalysis and Adler’s individual psychology, logotherapy was founded on an existential analysis that focuses on Kierkegaard’s will to meaning and differs from Adler’s will to power and Freud’s will to pleasure doctrines. Logotherapy posits that every individual strives to find meaning in their lives. Some of the basic principles of logotherapy include (1) under all circumstances, even the miserable ones, life has a meaning, (2) finding meaning to one’s life is the main motivation for living, and (3) humans are free to find meaning in what they do or experience [12]. According to Frankl, a person’s psychological wellbeing can be compromised if a person’s search for meaning is blocked. In this regard, a person should be supported to find their life’s purpose and meaning in relation to issues such as strong religious beliefs, life values, and goals [11]. Logotherapy is closely related to other adult development and maturity theories that emphasize how a clear comprehension of the meaning, purpose, and direction of one’s life could positively enhance one’s wellbeing.

Logotherapy can play an important role in helping a person deal with the four existential concerns, including death, freedom, isolation, and meaninglessness. Frankl argued that freedom is an existential concern because every individual should be responsible for the creation of whom or what they are [10]. Isolation is the reality that there is an existence gap between a person and others, while meaninglessness refers to striving to create meaning out of an entirely meaningless existence. To address these existential concepts, logotherapy intends to empower individuals to find meaning in their work, relationships, and suffering. Logotherapy insists that there is meaning to suffering, and a person’s main objective is to find this meaning. According to Frankl, every individual has the freedom to derive meaning from their experiences and reactions to such experiences [10]. In this regard, a person can find meaning through a readjustment of their attitudes and perceptions of potentially adverse conditions in their developmental life cycle. Frankl argued that the person will be stronger after experiencing and facing a difficult situation [12].

Applying Logotherapy to Mental Health Patients among the Muslim Immigrant Population in Europe

Logotherapy interventions are based on the three primary techniques of paradoxical intention, de-reflection, and Socratic dialogue [13]. Paradoxical intention refers to attempting to make clients face the situations that they are most afraid of. This technique highlights that, when an immigrant wants to improve their life in their new place, he/she develops anticipatory anxiety that makes it harder to move forward in their plans. Devoe [11] indicated that the paradoxical intention technique is used in therapies to help clients, such as immigrants suffering from PTSD, without indulging in habit-inducing medications. Many immigrants complain that even a routine walk on the streets can trigger intrusive recollections due to PTSD. It is important to acknowledge the horrific experiences that these Muslim immigrants have endured before reaching Europe. For instance, a refugee coming from Syria has endured the deaths of neighbors due to gunshots, improvised explosive device (IED) explosions, as well as gunfire on the streets. To some of them, they can say they are lucky to even move past their towns. In Syria, terrorist groups and local fighters use IEDs hidden on roadkill carcasses in potholes, making it difficult to use any form of transportation.

The paradoxical intention technique challenges the client, who is a Muslim immigrant, to confront their fears regarding road travel and to try to see how often they can leave their home and move on roads using care. Often, the immigrant expects IEDs to be hidden in potholes or that the people they are about to meet are a terrorist aiming to attack them [14]. This technique motivates the client to focus on the numerous times that they have made it home without any bad encounters. This technique is based on a reality principle that relies on the examination of how realistic particular expectations are. For example, when an immigrant’s phenomenological belief is that they will encounter an IED, this belief is put to the test and fails. This helps the client in readjusting their expectations when they go out next time.

De-reflection is based on the idea that, when a person is suffering, they become hyper-reflective, focusing inward on themselves and their perceptions. The de-reflection process involves getting the client to deflect the internalization that manifests as perpetual self-observation when they seek external meaning to their behaviors [15]. For example, a Muslim immigrant in Europe may perpetually internalize his or her experiences, falling into a constant state of self-observation. The goal of de-reflection is to help the client to seek and find meaning to their traumatic experiences by replacing self-observation with a meaningful pursuit for the attainment of existential wellness. De-reflection offers multiple ways that can be used to counsel immigrants [16]. One of the most common examples is outlined in the Connecticut in-patient veteran’s use, where mandatory community service was recommended so that the clients can think more towards helping other people than focusing on their predicaments [13]. However, this approach is not applicable in all cases, as some people are not good at helping others; thus, mandatory community service could enhance their level of anticipatory anxiety and adversely affect their work towards achieving wellness.

Meanwhile, it is essential to note that de-reflection plays an important role in helping people who have been through horrific experiences, such as refugees, to eliminate anticipatory anxiety [10]. In this regard, refugees can also be asked to look inside their experiences and try to learn through facing the traumatic experiences head-on. When the patient is suffering from perpetual self-observation to rationalize their trauma, they are more vulnerable to thinking about the distressing event, increasing risk of depressive disorders. Once the depression occurs, the immigrant might attempt to stop thinking of the distressing event, but the failure to do so results in the onset of anticipatory anxiety. Logotherapists should, therefore, recommend that the client thinks or rationalizes their traumatic experience as long as they can [15]. This challenge can be difficult but can potentially help the immigrant to minimize traumatic thoughts and instead bring them to consciousness and rid them of anticipatory anxiety, which might have hindered their healing process. This technique can help the immigrant to understand that they are not responsible for suppressing thoughts related to the event; thus, it should not impede them in completing their tasks.

Alternatively, the Socratic dialogue technique encompasses interviews that are designed to elicit patients’ wisdom, helping them to midwife the conscious knowledge that is already in the client’s possession. Socratic questions are used to assist the client with taking responsibility for life’s meaning and purpose [14]. These questions are asked so that the client can find potential meaning to all the experiences in their lives. The use of Socratic dialogue often manifests where the client interacts with the counselor so that the issue can be addressed through the use of interviews. According to Frankl [15], Socratic dialogues revolve around the idea that the client is aware and is capable of perceiving meaning in situations that may look meaningless. However, the client needs a counselor to assist in midwifing this knowledge and capability into consciousness [17]. In the case of immigrant refugees in Europe, the main goal of these dialogues should be to help them acquire coping mechanisms and apply them whenever they experience trauma.

Besides, when using the Socratic dialogue technique, the therapist should not assume that he/she knows the right solution for the client. The therapist must acknowledge that the client is the only person who truly knows how to cope with the experiences. From this perspective, the client has a position of power and autonomy that can help them to influence their own reality [11]. This technique helps the immigrant to gain sufficient control of their perceptions in relation to a traumatic event. The counselor’s responsibility is to convince the client that he/she is the only one that truly understands and perceives the traumatic experiences, which is the cause of their existential isolation. The counselor asks the immigrant several questions intended to midwife coping mechanisms into consciousness [14]. Some of the potential questions may include: Given your suffering, what is life asking of you? How do you find the courage to continue? These questions are designed in a way that highlights the client’s reality and the intended outcomes. These questions allow the client to derive meaning and purpose from their current and past experiences [18]. In all three approaches, paradoxical intention, de-reflection, and Socratic dialogue, the immigrant is empowered to accept the existential responsibility to live towards a specific meaning and purpose.

5. Conclusions

The goal of this review was to illustrate how logotherapy could help in addressing mental health problems facing Muslim immigrants in Europe. First, we acknowledged various risk factors that enhance immigrants’ exposure to mental health problems, such as stress, anxiety, and depression. We propose that logotherapy can be effective in solving these mental health problems as it helps the client to find his or her life’s meaning or purpose. Studies revealed that logotherapy can be divided into the three techniques of paradoxical intention, de-reflection, and Socratic dialogue. All these techniques were found to have the potential of helping the client to realize long-term relief for underlying stressors associated with migration and settling in a new location. Though data on logotherapy is still scarce, it is evident that it deserves more research so that a structured, evidence-based, and effective therapy for Muslim immigrants in Europe can be developed and tested.