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International Congress Series 1241 (2002) 271 278

Migration-related stress
and psychosomatic consequences
Riyadh Al-Baldawi*
Transcultural Centre, Stockholm County Council, PO Box 859, SE-167 24 Bromma, Sweden

The migration process is a dynamic process including a number of changes and losses. The
migrant shows various mental and somatic symptoms due to migration-related stress. These
symptoms can be a natural reaction to all these changes. This presentation aims at showing the
clinical picture of migration-related stress observed on migrants after their arrival to the new country
and under 3 years. To define the psychosomatic manifestations due to stress from the pathological
symptoms is an important and difficult task, but it is necessary to reduce the risk of over- or
underdiagnosing the clients problem, as well as to choose the correct treatment strategy to promote
better and quicker integration. D 2002 Elsevier Science B.V. All rights reserved.
Keywords: Migration; Stress; Psychosomatic manifestations

1. Introduction
Migration is a complicated, dynamic and often long process. It begins when individuals
or families choose voluntarily, or are forced, to leave their native countries [1]. There are
various reasons for migration, in some cases to escape crises such as local or regional
wars, ethnic or religious conflicts, in other cases for work or study. Migration is not just a
matter of movement in space and time; it also concerns movement between different social
and economic systems. The encounter with new cultures and methods of production
requires a reconstruction of the individual internal schema in order to adapt to these
changes and to find ways for better integration. Many research findings [2 8] have shown
that an immigrant may experience this situation as stressful.

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E-mail address: (R. Al-Baldawi).

0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved.

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The following five types of acculturative stress reaction among immigrants have been
identified in the literature [9]: 1feelings of distress; 2homesickness; 3depressive
reactions, going along with alienation and hopelessness; 4psychosomatic complaints,
vulnerability to diseases; 5psychosocial maladjustment, psychopathic behaviour.
Migration can take place within the country (domestic) or within the same region
(regional), and between different countries (international). All these types of migration
entail different losses, which affect the individuals relations with surrounding environments. In my opinion, there are three levels of environment: the microenvironment, which
illustrates the individuals internal schema (the self) with its biological (genetic) basic
aspects, history and life experiences; the macroenvironment, which illustrates the closer
environment surrounding the individual, such as family, relatives, friends and the local
society comprising neighbourhood and school; and the mega environment, which includes
the native countrys culture and traditions (Fig. 1). A perfect interplay and interaction
between these levels provides the basis for attaining feelings of well-being and mental

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2. The individuals reactions to acculturative stress

The losses experienced in connection with migration negatively influence the interactions between these levels. In the domestic and regional types of migration, the
individual often loses the macro environment but still maintains support from the mega
environment, whereas international migration often involves losses in both macro and
mega environments. This is why the latter type of migration usually precipitates the
development of a deeper psychosocial crisis, which affects the individual negatively and
renders him defenceless in the encounter with socio-economic changes. Many immigrants
are also faced with adjusting and adapting to new cultural expectations and behavioural
norms. There are tough challenges, at least in the beginning of their lives in the new
country. This crisis therefore demands a personal preparedness, as well as the need for
external social and financial support from different institutions in the receiving country.
The lack of such support may result in many somatic and/or psychiatric problems, such as
depression [10]. The losses sustained by the individual during the migration process
should be recognised as one of the traumatic factors, with negative consequences for
feelings of security and contributing to a loss of self-confidence.
This situation destroys the harmony between the micro, macro and mega environments,
which negatively influences the individual adaptation process to the host countrys social

Fig. 2.


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and economic system. The loss of security leads to stress and anxiety and other psychiatric
distress that may be more evident amongst recently arrived immigrants [10]. Stress in this
situation can be recognised as a self-defence and in some way a natural healthy
reaction. This reaction helps the individual to survive the changes and many challenges
that he/she meets in the new environment (see Fig. 2). It is very important to identify the
character of the reaction. For individuals with a history of traumatic events, the stress
inherent in migration usually exacerbates their crises necessitating more care from
specialist psychiatric and social services. Unfortunately, the lack of methods for identifying these reactions leads to many social and medical institutions often interpreting the
immigrants problems as a pathological condition. It is thus possible that a proportion of
immigrants are treated as patients and receive relatively long-term and expensive treatment
interventions, whereas their problem may just be a natural reaction to the acculturative
stress they meet in the migration process. These treatment interventions negatively affect
immigrants active involvement in the new society and delay their integration process.

3. Migration process and stress

The migration process usually consists of three phases: the native country, the transit
(temporary exile), and the recipient (host) country phase [11]. There are many different
factors influencing all these three phases (Fig. 3). The individuals socioeconomic
background, education level, as well as the reason for migration play the most important
roles in the native country phase. Circumstances during their flight and the stress and
length of their temporary residence in the second phase, without the necessary support,
generate very painful feelings, which have long-term negative psychosocial consequences.
Some immigrants are forced to stay in prison during this phase and others to become
soldiers and participate in a war they have attempted to escape from.
For my interviews with 32 adult immigrants/refugees on health conditions and emotional state, I adapted the Brief Syndrome Index (BSI) using questions from a scale which
we have developed at the Orient Health Center in Stockholm.1 The questions were
translated into 4 languages (Arabic, Persian, Serbo Croat and Tigrean). These individuals
had come to Sweden in the past 2 years (1999 2000). Twelve of them are immigrants
(seven guest students and five guest workers), the other 20 are refugees. The refugee group
spent between 4 and 10 months waiting for the permanent residency permit. They came to
Sweden from different countries, the majority from the Middle East (9) with the rest
coming from Asia (3), former Yugoslavia (4), and East Africa (4). All participants were
interviewed on four occasions, once before receiving the residency permit and again after
3, 12, and 18 months. These interviews show that the individual goes through different
periods in the recipient (host) country phase, which affect his/her emotional state (Fig. 4).
At the beginning, the immigrant experiences positive feelings of hope and expectations,
which improve the emotional state. This period continues in different ways depending on

The Orient Health center is an multiethnic and multiprofessional center working with immigrants,
individuals and families which have various psycho-social problems related to the Migration process and
adaptation of the new countrys culture and structure.

R. Al-Baldawi / International Congress Series 1241 (2002) 271278


Fig. 3.

various factors (individual and social). The following period is dominated by feelings of
guilt and despair. The feelings of guilt are for those members of the family (wife, children,
parents or relatives) and friends who still live in the native country under very poor
economic and/or political conditions. The feelings of despair concern the future and the
many challenges to be overcome. These feelings exert a negative influence on the
individuals emotional state with high risks for stress and anxiety. This stress can be
considered as a condition, created by the migration and manifested in various psychosomatic symptoms, which I have called migration-related symptoms (MRS), the clinical
picture is illustrated in (Fig. 5).
These symptoms appear in almost all people who have left their native countries, in
different intensities and combinations. This is why these symptoms can be recognised in
the majority of the cases (as a natural reaction) against the changes and losses inherent in
the migration process. The individual strategies for dealing with and recovering from these
symptoms vary and depend on many different factors. The most important factor is the


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Fig. 4.

way in which the individual adapts to, and integrates with, the surrounding environment.
This depends on the individuals own resources as well as the encounters and opportunities
in the new society. In a study of psychosocial distress and psychosomatic complaints
among refugees in Sweden, Sundquist et al. [12] found that, . . . a low sense of coherence,
poor acculturation (men only), poor sense of control, and economic difficulties in exile
seemed to be stronger risk factors for psychological distress in this group than exposure to
violence before migration.
Many immigrants can deal with these natural symptoms by themselves with the help
of adequate social and economic support programmes from the authorities and voluntary
organisations in the new society. Immigrants who quickly acquire the new language
increase their opportunities of finding a job equal to their education level. Nevertheless,
the active involvement of the immigrant in the new countrys social life is connected with
the level of discrimination and xenophobia in the society generally and the labour market
in particular. Also, giving immigrants equal opportunities, adequate support and the
security that they need increases their chance of recovering from their problems by
It is very important to develop sound clinical and social methods to identify those
immigrants who are suffering from a severe form of post-traumatic stress disorder (PTSD)
and/or other psychiatric disorders, in order to provide them with adequate treatment and the
necessary support. To refer all immigrants suffering from migration-related stress symptoms
to specialist somatic or psychiatric services may exacerbate their problems by making them
passive members of society, thus negatively affecting their integration process. We need to

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Fig. 5.

develop a system of services capable of, as early as possible, identifying the cases needing
specialist treatment, and supporting the rest with other active social programmes.

4. Conclusions
Migration-related stress is a result of the changes in the interplay between the micro,
macro and mega environments, and is manifested in different psychosomatic symptoms.
These symptoms are natural reactions to these changes and must be distinguished from
the pathological symptoms developed as a result of psychiatric or somatic diseases. The
development of social as well as clinical methods requires more thorough studies and
research on the migration process in order to minimise the stereotype analyses of cases.
Adequate social, economic and medical support makes it possible for immigrants to
recover from many of the problems created by the migration process. In actively
stimulating their own internal resources, the immigrants create better chances for quick
integration resulting in less economic and social problems for the recipient country.
[1] P.H. Rack, Race, Culture, and Mental Disorder, Routledge, London, 1993, pp. 24 39.
[2] J.W. Berry, Human Ecology and Cognitive Style: Comparative Studies in Cultural and Psychological
Adaptation, Sage/Halsted, New York, 1976.


R. Al-Baldawi / International Congress Series 1241 (2002) 271278

[3] J.W. Berry, Acculturation and psychological adaptation: a conceptual overview, in: J.W. Berry, R.C. Annis
(Eds.), Ethnic Psychology: Research and Practice with Immigrants, Refugees, Native Peoples, Ethnic
Groups a Sojourners, Swets and Zeitlinger, Amsterdam, 1988, pp. 41 529.
[4] J.W. Berry, R. Klain, D.M. Taylor, Multiculturalism and Ethnic Attitudes in Canada, Government of
Canada, Ottawa, 1977.
[5] J.W. Berry, U. Kim, T. Minde, D. Moke, Comparative studies of acculturative stress, International Migration
Review 21 (1987) 491 511.
[6] P.G. Schmitz, Acculturation styles and health, in: S. Iwawaki, Y. Kashima, K.S. Leung (Eds.), Innovations in
Cross-Cultural Psychology, Swets and Zeitlinger, Amsterdam, 1992, pp. 360 370.
[7] P.G. Schmitz, Acculturation and adaptation processes among immigrants in Germany, in: A.M. Bouvy,
F.J.R. Van De Vijver, P. Boski, P.G. Schmitz (Eds.), Journeys Into Cross-Cultural Psychology, Swets and
Zeitlinger, Amsterdam, 1994, pp. 142 157.
[8] X. Zheng, J.W. Berry, Psychological adaptation of Chinese sojourners in Canada, International Journal of
Psychology 26 (1991) 451 470.
[9] P.G. Schmitz, Individual differences in acculturative stress reactions: determinants of homesickness and
psychological maladjustment, in: M.A.L. Van Tilburg, Ad.J.J.M. Vingerhoets (Eds.), Psychological aspects
of Geographical Moves: Homesickness and Acculturation Stress, Tilburg Univ. Press, The Netherlands,
[10] B. Good, M. Good, R. Moradi, The interpretation of Iranian depression, illness and dysphoric affect, in: A.
Kleinman, B. Good (Eds.), Culture and Depression, University of California Press, London, 1985, pp. 369
[11] R. Al-Baldawi, Transkulturell kunskap nodvandig (Transcultural knowledge essential), Swedish Medical
Journal 93 (40) (1996) 3483 3486 (In Swedish).
[12] J. Sundquist, L. Bayard-Burfield, L.M. Johansson, S.E. Johansson, Impact of ethnicity, violence and acculturation on displaced migrants. psychosocial distress and psychosomatic complaints among refugees in
Sweden, The Journal of Nervous and Mental Disease 188 (2000) 357 365.