Working with Immigrant Women: Introduction

From: Working with Immigrant Women: Issues and Strategies for Mental Health Professionals

Sepali Guruge and Enid Collins

While immigrant women face common issues that can influence their health, how they respond to and deal with these challenges is unique to each woman’s situation. In this book, we explore how multiple identities—such as age, race, gender and class—among other social identities—intersect to influence immigrant women’s mental health. By bringing together various theoretical, research and clinical perspectives, we have attempted to capture the complexity and diversity of immigrant women’s experiences.

We recognize that immigrant women’s experiences of mental health and mental illness are integrally related to the totality of their life experiences. However, women also claim unique experiences that are shaped by the economic, cultural, social and historical contexts in which they currently live. To effectively care for immigrant women as clients in the mental health care system, professionals need to move beyond the singular focus on culture to understand their individual experiences. They need to explore the varied and complex ways women experience migration and resettlement, and how this affects their mental health.

Part 1: Understanding the Context of Immigrant Women’s Lives

In Chapter 1, Guruge and Collins describe emerging trends in Canadian immigration and challenges for newcomers. They provide statistics around the growing numbers of immigrants coming to Canada. The authors also describe the many challenges immigrant women confront as they resettle in Canada, and the impact that these challenges have on their mental health.

Part 2: Theoretical Perspectives

In this section, the authors examine various theoretical perspectives and conceptual frameworks surrounding the intersection of gender, race and class with variables such as age, citizenship status, culture and sexual orientation in order to understand women immigrants’ mental health and illness concerns.

In Chapter 2, Collins and Guruge provide a summary of a number of key theoretical perspectives—including transcultural nursing, anti-racism strategies and postcolonial feminist perspectives—with a critical view to understanding how each framework might guide mental health practitioners’ work toward effective and quality mental health care to women of all backgrounds and cultures. The authors invite readers to question whose interests are being served when mental health professionals incorporate into their practice particular ways of thinking, understanding and acting in relation to social differences.

In Chapter 3, Gustafson discusses both explicit and hidden assumptions in two key theoretical approaches—namely, the cultural competence approach and the critical cultural approach—to working with newcomer women with mental illnesses. Using examples, the author invites the reader to reflect on the strengths and limitations of each approach and to examine how each approach can be used in health care professionals’ practices. She encourages professionals to move beyond the notion of cultural sensitivity to focus on advocating for change in institutional practices and processes that create and sustain power dynamics that affect the everyday life of newcomer women and the mental health professionals who care for them.

Part 3: Current Realities for Immigrant Women and New Paradigms for Mental Health Practice

This section looks at the current realities of immigrant women’s experiences and explores their implications for clinical practice. Among these realities is the fact that women who immigrate to Canada experience racism, sexism, classism and heterosexism, and cope with other challenges to resettlement that increase their vulnerability to mental illness. They are also confronted by a mental health care system that does not address the social determinants of mental health; that fails to recognize what is integral to their health and well-being (such as spirituality); and that presents barriers to accessing care (such as lack of trained interpreters).

In Chapter 4, Mawani examines social determinants of depression among women immigrants and refugees. While depression may be a universal phenomenon, there is variation in its prevalence and clinical presentation between countries around the world, between communities within each country, and between women and men. While women are more likely to experience depression than men, this phenomenon remains poorly understood, with research failing to emphasize the totality of women’s life experiences. The chapter includes a review of the empirical literature on intersecting social determinants that influence women’s depression, such as gender, socio-economic status, discrimination, social support, and violence and trauma. It concludes with evidence-based practice strategies to address these determinants.

Women give and receive social support when they connect with other women. The meanings, expressions and practices of spirituality can link women with each other, and bring extended families and community together. When separated from familiar culture and community, women lose these connections and the ability to take part in rituals, which can create challenges, stresses and resulting ill health. In Chapter 5, Collins examines the important role of spirituality in addressing mental health and illness concerns of women. Using a synthesis of concepts from critical feminism, feminist spirituality and anti-racism, the author suggests that when immigrant women become recipients of health care, they experience a disconnect between their lived experience and approaches used in “mainstream” mental health services. The meaning and expression of mental illness, help-seeking and spirituality are often interrelated, and can be incorporated in mental health care. The author presents holistic strategies that mental health practitioners can use in their practice.

In Chapter 6, Abraham and Rahman examine the intricacies of addressing the language and cultural interpretation needs of women seeking mental health services. The consequences of not having an interpreter to bridge the communication barriers, and the debates and controversies surrounding language versus cultural interpretation are also discussed. In addition, the authors highlight such issues as: lack of funding; challenges faced by health care institutions in setting up professional interpretation services; the implications of inadequate interpretation services on clients receiving mental health care; and approaches to address these concerns. They provide guidelines for working with interpreters and suggest the need for public policy that recognizes the right of all people to access the care and services they need.

Demonstrating the link between immigration, settlement and mental health in Chapter 7, Collins, Shakya, Guruge and Santos address the importance of settlement services and other resources that address social determinants of health. Key features of various programs and services at the societal, community, neighbourhood and familial levels are discussed. The authors note that despite the existence of many programs and services, some newcomer women encounter barriers in accessing them. They highlight three agencies that address the mental health and illness needs of immigrant women—one at the national level and two in the Greater Toronto Area.

Part 4: Working With Specific Groups

In this section, the authors address particular issues and concerns related to working with specific groups: newcomer girls, Sudanese women, Caribbean women and their children, lesbian and bisexual women of colour, women refugees and older women. While there are commonalities among the mental health care concerns of women, in general, the socioeconomic, ethnocultural, political and historical location of women in society affect their vulnerability to illness and influence their ability to access care and treatment.

In Chapter 8, Berman and Jiwani discuss critical issues facing racialized newcomer girls and young women in Canada. The authors contest the narrow notion of “the newcomer girl” —recognizing that girls are not defined solely by their newcomer status, but also by the multiple and intersecting realities of their everyday lives. Based on a review of the literature, the authors address a number of complexities surrounding this group, including how they develop and negotiate identities within the context of family, peer, community and society at large. While newcomer girls use a number of strategies when trying to fit in with Canadian born peers and the Canadian culture, the authors propose that such practices could be interpreted as a response to racism and discrimination in the larger context of society. Programs and policies that fail to consider gender are of particular concern for newcomer girls. The chapter concludes with recommendations for mental health professionals working with this group to address systemic racism, sexism and other forms of oppression, and to foster a more equitable and just society.

Drawing from a number of theoretical frameworks, in Chapter 9, Baya, Simich and Bukhari discuss the varied and complex influences of resettlement experiences on the mental health of Sudanese women in Southern Ontario. The chapter draws substantively—but not exclusively—from the first major study in Canada on the settlement and integration experiences of recent Sudanese immigrants from a protracted conflict zone. In spite of diversity within this community in Ontario, the women share commonalities in their struggle to adapt, settle and integrate into Canadian society. The many ways they experience oppression within Canada’s stratified and racialized social system interact to negatively affect their mental health. Family issues that were once a communal responsibility become the sole burden of the couple—and particularly the woman—as they struggle to cope with issues such as role reversal and increased work for women. Based on their research and practice within this community, the authors provide guidelines and strategies for working with Sudanese women that incorporate a broader, holistic, anti-racist paradigm of mental health.

Incorporating Bowlby’s theory of attachment, in Chapter 10, Campbell and Flaman discuss the importance of maternal-child attachment in the context of separation and reunification of Caribbean women and their children in Canada. The chapter emphasizes the diverse roles that many Caribbean women, as heads of families, undertake to improve their lives and that of their children, which includes seeking better employment opportunities in other countries such as Canada. The authors address the physical, social and emotional challenges both the mothers and their children face when reunited after a period of separation. Some of the factors addressed include the impact of length of separation, financial concerns and familial factors (such as other significant attachments the child forms while separated from the mother). The authors offer strategies for health care providers to respond to families’ needs and suggest areas for future research, including the influence of fathers on the outcome of reunification and the need to learn from successful reunions the variables that contribute to their success.

Based on their psychotherapy practice grounded in an anti-oppression framework, in Chapter 11, Doctor and Bazet explore the complexities of counselling lesbian and bisexual women of colour in the context of racism and heterosexism. The authors address the cultural, social and emotional losses experienced by clients and the importance of community connections. Lesbian and bisexual women of colour face multiple challenges in their lives. The authors examine the factors that contribute to clients’ complex identities, including being bicultural, bilingual or multi-racial. They also discuss the impact of these identities on clients’ daily life, and some strategies they use to survive an often hostile environment. Clinical cases are used to illustrate themes of assimilation and integration into “mainstream” Canadian society as well as “mainstream” lesbian and bisexual communities. The authors address issues of racism within clients’ intimate relationships. They also explore power dynamics inherent in therapeutic relationships and how racism and heterosexism are expressed within these relationships.

In Chapter 12, Ortiz addresses a number of clinical and ethical issues encountered in his work with refugee claimants receiving mental health care. He notes that refugee women are confronted with complex social issues including poverty, distrust, limited language skills, devalued qualifications and social isolation—all of which can have a negative impact on their mental health. The chapter reviews some of the difficulties women face in negotiating the complexities of the immigration system—including filing and successfully obtaining refugee status (and later, permanent residency) in Canada. Case examples describe people who are pressured to go “underground” with no legal status, who have no health coverage, and who are without a work permit (thus are unable to find paid employment nor garner an income) and the influence of these factors on seeking and receiving care. Of special concern are women fleeing domestic violence, sexual abuse and/or discrimination due to their sexual orientation. Ortiz discusses ethical issues mental health professionals face in caring for women refugee claimants when their role involves supporting—or not supporting—the client’s immigration application (and process).

Drawing on their community-based settlement work in Canada and research within the Sri Lankan Tamil community, in Chapter 13, Guruge, Kanthasamy and Santos discuss the often neglected topic of older immigrant women’s mental health needs. Their review of health sciences literature on the topic—and their work with the Sri Lankan Tamil community in the Greater Toronto Area—highlight common health and settlement concerns among older immigrant women. Focusing on the intersection of gender, race, ethnicity and culture, the authors examine critical issues for this group of women, and highlight how their concerns are linked to both the pre-migration context in war-torn Sri Lanka as well as the influence on mental health of changing family dynamics, social isolation, altered social status and increased vulnerability to abuse in the post-migration context. The authors discuss gaps in services for older immigrant women, and provide recommendations for health and settlement workers to more effectively address the needs of this group.

Part 5: Highlighting Critical Mental Health Concerns

Most women seeking refugee status in Canada flee their countries for reasons related to violence and traumatic events. Some have survived wars or conditions similar to war, experienced torture, kidnapping, rape and/or witnessed murder of loved ones. Some women might have fled such situations with the help of people demanding high prices to smuggle them out of their country. However, we know little about the plight of women who experience such situations and how their mental health is affected. Similarly, little attention has been paid to the topic of postpartum depression, which—until recently—was considered a concern unique to women in western countries. In this section, authors explore these critical mental health concerns.

In Chapter 14, Saphir locates women’s trauma and suffering within their socio-cultural context, and emphasizes the strong values placed on women’s roles within the family and the conflicts they experience when they are separated from family. She bases her writing on her experience of working with Latin American women dealing with multiple forms of trauma. Saphir notes that the traumatic experience dealt with in the therapy is not based on a single event but, rather, reflects a lifetime of upheaval. Dealing with trauma often entails reopening old wounds before dealing with and receiving care for the mental (and physical) health consequences of trauma and violence. The author proposes that therapeutic approaches must entail a holistic approach to healing that incorporates the physical, emotional and cognitive aspects of the woman’s experience.

Highlighting a number of gaps in Canadian health sciences literature on intimate partner violence (IPV), in Chapter 15, Hyman and Mason identify the need for more in-depth research into factors that influence the choices women make when facing new and unique barriers in Canada. Using the available literature, they address: the prevalence and etiology of ipv; its risk and protective factors; its health impacts; and legal, contextual and cultural barriers to help-seeking. Implications for mental health professionals are discussed in terms of documentation, risk assessment, safety planning, mandatory reporting and referral. The authors highlight the importance of developing primary prevention strategies at the individual, couple, community and societal level.

In Chapter 16, Ardiles, Dennis and Ross use a health promotion framework, together with a broader social determinants of health approach, to critically review the literature to-date on postpartum depression (PPD) among immigrant women. Based on the findings of Canadian and cross-cultural studies, the authors address prevalence rates of PPD, limitations in its measurements, barriers to assessment, potential risk factors (including acculturation, acculturative stress, and social isolation and loss of support), gaps in intervention and culturally appropriate preventive care and treatment approaches. The authors discuss the role various social and cultural practices and rituals might play in reinforcing social bonds and protecting women from ppd. Strategies for multidisciplinary teams to facilitate continuity of care for women experiencing PPD in the post-migration context are proposed.

Part 6: Conclusion

Despite the fact that Canada’s foreign-born population is increasing at a rate that is four times higher than the Canadian-born population, the needs of immigrants and refugees are not adequately addressed nor understood. Accordingly, much work remains to be done in order to adequately address the mental health concerns, care needs and treatment of mental illnesses among this group. Using the information, insights and speculations presented by the book’s contributors as a jumping off ground, Collins and Guruge offer ways of moving forward in Chapter 17: they make recommendations for education, practice and policy, and suggest areas for future research.

Working with Immigrant Women: Issues and Strategies for Mental Health Professionals

Acknowledgments
Preface / PDF
Introduction / PDF
Part 1: Understanding the Context of Immigrant Women’s Lives
Part 2: Theoretical Perspectives
Part 3: Current Realities for Immigrant Women and New Paradigms for Mental Health Practice
Part 4: Working with Specific Groups
Part 5: Highlighting Critical Mental Health Concerns
Part 6: Conclusion
About the Editors / PDF
About the Authors / PDF
Testimonials