OPINION published: 03 June 2020 doi: 10.3389/fpsyt.2020.00451 Foundations and Applications of Logotherapy to Improve Mental Health of Immigrant Populations in the Third Millennium Shirin Rahgozar 1 and Lydia Giménez-Llort 1,2* 1Department of Psychiatry and Forensic Medicine, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 2 Institut de Neurociències, Universitat Autònoma de Barcelona, Barcelona, Spain Keywords: logotheraphy, mental health, therapy, immigrant, asylum, refugees INTRODUCTION Although migration is a natural phenomenon, a number of special conditions of this third Edited by: millennium result in a rising number of populations exposed, worldwide, to the impact of risk Roy Abraham Kallivayalil, factors for mental health associated to immigration and asylum. In this scenario, the vulnerability to Pushpagiri Medical College, India distress and mental health problems such as depression, anxiety disorders and PTSD is increased in Reviewed by: these immigrant populations due to the severity of traumatic experiences while struggling in their Devashish Konar, Mental Health Care Centre, India attempts to reach their destinations but also a poor capacity of immigrant/host to handle the Anju Devianee Keetharuth, situation once there. The risk for psychological and mental health problems worse with time, failure University of Sheffield, of expectancies, lack of knowledge of resources or lack of support, among other difficulties. Here, we United Kingdom analyzed the foundations and applications of logotherapy on immigrant mental health problems, *Correspondence: showing the benefits that ‘finding meaning and purpose in live’ can have in these populations. Thus, Lydia Giménez-Llort among the interventions that urge to reduce depression and anxiety symptoms among older adult lidia.gimenez@uab.cat immigrants, we propose three logotherapy techniques, namely, paradoxical intention, dereflection and Socratic dialogue. After development and adaptation to the specific scenarios (populations/ Specialty section: destinations) these logotherapy techniques can have a huge potential to become effective therapeutic This article was submitted to strategies improving the mental health of the current immigrant populations facing misfortune in Social Psychiatry and the Third Millennium (Figure 1). Psychiatric Rehabilitation, a section of the journal Frontiers in Psychiatry Received: 01 April 2020 MENTAL HEALTH PROBLEMS AMONG IMMIGRANTS IN THE Accepted: 05 May 2020 THIRD MILLENIUM Published: 03 June 2020 Citation: Migration has been a natural phenomenon throughout the history of humanity resulting in a Rahgozar S and Giménez-Llort L melting pot of civilizations, cultures and races. However, in the words of the UN Refugee Agency (2020) Foundations and Applications (1), the world is now witnessing the highest levels of displacement on record. The Global Migration of Logotherapy to Improve Mental Data Portal notes that in 2019 (2) the number of international people residing in a country other Health of Immigrant Populations in the Third Millennium. than their own reached 272 million (3.5% of the global population), 51 million more than in 2010. Front. Psychiatry 11:451. They also highlight an important issue: although many of these individuals migrate out of choice, doi: 10.3389/fpsyt.2020.00451 many others migrate out of necessity. Thus, at the end of 2018, the number of globally forcibly Frontiers in Psychiatry | www.frontiersin.org 1 June 2020 | Volume 11 | Article 451 Rahgozar and Giménez-Llort Foundations and Applications of Logotherapy FIGURE 1 | Graphical representation of the introduction. displaced people topped an unprecedent 70.8 million, including studies indicated that the contemporary PTSD models fail to almost 26 million refugees, 3.5 million asylum seekers, and over capture the complexity, human variation, and international 41 million internally displaced persons. characters of the migration-related traumas (13–15). As such, Immigrants face several life-threatening situations such as the available interventions suggest the uncontrollability of these war, violence and persecution as well as losses during their problems, thus threatening the overall quality of life of the journey, which hugely compromise their quality of life and patients and their communities. Nevertheless, immigrant mental health (3). These challenges are augmented by post- populations remain highly under-diagnosed compared to the migratory stressors, such as tense asylum procedures, poverty, rest of the population, thus suffering from low treatment levels isolation, marginalization, fragmented social networks, (16). Moreover, mental health interventions used are limited in discrimination and racism, acculturation, language barriers, several ways when dealing with the immigrant population (17). poor access to healthcare and consequent compromised Limitations include lack of sufficient evidence on specific mental therapeutic approaches, among others (4–8). Coping with problems immigrant populations suffer from, therapeutic models these challenges sometimes results in mental health problems developed from studies conducted in Europe and North and illnesses, particularly among low socio-economic America, assumptions that specific mental health therapies can backgrounds and those who are more vulnerable such as be applied across all populations and non-consideration of women, children, the elderly (9, 10). Immigrants experience cultural diversity in applying mental health problems (18–20). injustices, human-instigated incidents of trauma, and Though mental health risks among immigrants are well subsequently respond with anger or anger-related responses. A documented, there are still multiple gaps in understanding study on Holocaust survivors and American war veterans barriers to access and the use of mental health services among showed that anger responses were crucial to their experiences various groups of immigrants (21). (11). This trend was also shown in post-migration contexts, with In order to develop an effective intervention model it is anger responses developing independently of anxiety and important to evaluate the patients’ entire pre-migration, depressive behavior. In these studies, morality was found to act migration, and post-migration stages as they lead to different both as protective and survival factors in the victims’ levels of risks to mental illnesses (22). Interventions should be anger behavior. based on hope and building confidence and optimism (23). They It’s known that people with post-traumatic stress disorder should also leverage the patients’ spirituality, religion, and other (PTSD) - the most prevalent mental health problem in these cultural factors (24). Logotherapy is thus suggested to have immigrants - are also more likely to experience other mental the potential to assist patients in finding new meaning to problems, including anxiety, depression, and substance abuse life and cope effectively with the past and present stressful disorder (12). Despite the well-researched effects of PTSD, experiences (25). Frontiers in Psychiatry | www.frontiersin.org 2 June 2020 | Volume 11 | Article 451 Rahgozar and Giménez-Llort Foundations and Applications of Logotherapy FOUNDATIONS OF LOGOTHERAPY able to determine who and what they are, while isolation is the reality that there is a gap in existence between the person and Logotherapy is a meaning-based, value-centered psychiatric others in the society. Addressing these existential concerns therapy developed from the works of Viktor Frankl in the early requires effective psychological or psychiatric interventions 2000s. He based logotherapy on the principle that the main intended to empower people to find meaning in work, motivational force of human beings is to find purpose or suffering, and relationships (42). Immigrants are free to pursue meaning in life. Frankl held that no other psychotherapy the meaning from their experiences and how they have existed except the theory of mankind. Though he agreed that a responded to the experiences (43). Through this process, an man would never be free from all conditions, his experience of immigrant having a mental health problem can find meaning to life inside the Nazi concentration camps made him believe that life that helps him/her to readjust their attitudes and perceptions man has the capability of resisting and braving the most terrible of potentially adverse conditions in their life journeys. After conditions (26). Therefore, the primary premise of logotherapy is finding meaning to these difficult situations, the person will to help patients respond to suffering in a more meaningful way emerge, stronger, safer and happier, thus leading a resilient (27–29). This approach is based on the argument that mental improved quality of life (44). health patients who found meaning can realize their potential and cope with their struggles in a more effective manner. Logotherapy assumes that every human person has a healthy inner core consisting of unique human and adaptive attributes APPLICATION OF LOGOTHERAPY TO such as sense of humor, love, and capacity to undertake different TREAT IMMIGRANTS IN THE THIRD causes in life. The primary elements of logotherapy include the MILLENNIUM meaning of life, will to meaning as well as freedom of will (30). Based on these elements, the intervention aims at actualizing the Logotherapy is developed from a multicultural lens, thus making most meaningful values to the patient meaning thereby that there it potentially more effective when dealing with mental health is a purpose for human life (31). Will to meaning implies that the problems affecting populations of immigrants from diverse person should be able to access their unique human attributes backgrounds and places all over the world (45). It leverages on and should be motivated to make personal sense of life, actions, the specific person’s beliefs and spirituality in finding meaning to and actual approach to life. Freedom of will refers to the their lives and enhancing their psychological wellbeing (46). recognition that the patients have choices and imperative to Though logotherapy was initially designed to build faith and take responsibility for their choices (32). relationship with God, Crumbaugh and Henrion (47) found that A person discovers meaning when she/he actualizes it can be effectively applied to deal with different mental health personally meaningful values. For this purpose, the person problems, especially PTSD among immigrants who have must be committed to defining what they value i.e., endured difficult and stressful conditions, such as war and experiential value, creative value, or attitudinal value (33). persecutions (48). Logotherapy follows a philosophy of Experiential values refer to experiences, such as love phenomenological reality. Based on it, logotherapy suggests relationships, which the person picks from their environment. that the patient is an active participant in their treatment as Creative values include skills and behaviors associated with work, he/she is an expert in their perceptions of their situations. hobbies, and creative endeavors and usually earn tangible Logotherapy not only focuses on building the relationship with outcomes for the person (34). Attitudinal values are expressed the higher power but also recognizes that there is a vast variety of in the manner one approaches life. Logotherapy focuses on the cultures around the world, and members of these cultures face person’s ability to make responsible decisions that are adaptive distinct existential dilemmas of isolation and meaninglessness. and consistent with their meaningful values (35). In this regard, Thus, Asian cultures dealt with existential meaninglessness and logotherapy insists that despite the person’s circumstances, life isolation as they work their reality towards Nirvana and ultimate still has meaning. Finding meaning in one’s life should, therefore, transcendence (49). be their primary motivation. Furthermore, all human persons are Generally, logotherapy interventions are based on three free to find meaning to whatever they are experiencing in their primary techniques: paradoxical intention, dereflection, and lives (36). A person’s psychological wellbeing would be Socratic dialogue. Paradoxical intention is an attempt to help compromised if their search for meaning is blocked or clients face the situations they are most afraid of (50). This hindered (37). It is interesting to note that, currently, the technique works by establishing the anticipatory anxiety that the transitions from biomedical to emergent recovery-oriented immigrant is suffering from that is making it hard for them to practices in mental health care are also person-centered move forward. Here, the immigrant is guided to overcome approaches based on the premises that it is possible to adapt to anxiety without the use of medications. On the other hand, a mental health condition and that personally centered dereflection is developed from the idea that when a person is meaningful goals will contribute to the recovery (38–40). suffering from mental health problems, such as anxiety, they are Most importantly, logotherapy approaches help the person to more likely to become hyper-reflective, thus focusing more on deal with their four existential concerns of freedom, isolation, themselves and their perceptions (51). The dereflection meaninglessness, and death. According to Frankl (15, 41), technique helps to deflect internalization that manifests in freedom is an existential concern as every person should be perpetual self-examination and assist in seeking external Frontiers in Psychiatry | www.frontiersin.org 3 June 2020 | Volume 11 | Article 451 Rahgozar and Giménez-Llort Foundations and Applications of Logotherapy meaning to the experiences and behaviors (52). Lastly, the minimizing their vulnerability to thinking of the stressful socratic dialogue technique is an interview-based therapy events that may increase the chance of depressive disorders (64). where questions are asked in a manner that guides the client to In conclusion, the effectiveness of logotherapy is take personal responsibility for their life’s meaning and purpose demonstrated in helping patients to find meaning and purpose (53). Questions asked here are designed to assist the patient in in their experiences and lives, and this can be applied to various finding meaning to traumatic experiences (54). Usually, this mental health problems that immigrants face. Three techniques, technique involves a counsellor who helps in midwifing the namely paradoxical intention, dereflection, and Socratic knowledge and capability of the patients into their dialogue, empower immigrants to accept their responsibility to consciousness (55). live a meaningful life. Nonetheless, studies of logotherapy on To tackle mental health problems that immigrants are immigrant populations are still scarce. We, therefore, suggest suffering, there is need to recognize the diversity of the future studies should focus more on logotherapy applications immigrants’ populations, extent of mental health problems, and the development of effective therapy for diverse groups and diagnosis and treatment limitations, among others before of immigrants. drawing intervention plan (56–58). In mental health intervention, it is important to consider all the three techniques of logotherapy as people possess different belief systems and will require different approaches to their problems AUTHOR CONTRIBUTIONS (59). Thus, in the Connecticut in-patient veteran’s use, mandatory community service to develop resilience failed in Concept and review design: LG-L. Concept and review some patients as they increase anticipatory anxiety negatively development: SR. Scientific discussions: LG-L and SR. affecting the road to wellness. (60). In this case, dereflection can Graphical Abstract: LG-L. Drafting manuscript: SR. Critical be augmented with dialogues to help these patients acquire revision of manuscript: SR and LG-L. Approving final version coping mechanisms that they can apply whenever they of manuscript: SR and LG-L. experience trauma (61). In many cases, immigrants are traumatized by the experiences of terrorists attacking travelling buses (62). In such cases, paradoxical intention assists the patient to focus on the other FUNDING times where he/she made it home safely without any incidences. Financial support provided by It’s all for L.O.V.E. projects The technique is based on a reality principle relying on patients Charity Organization, 4LOVEprojects/KF/050320. understanding the reality of their expectations (63). This process helps the client in readjusting the expectations when going out next time. It is essential to note that many immigrants of violence and conflicts often face the problem of perpetual self-observation ACKNOWLEDGMENTS to rationalize their trauma regardless of where they come from. In this case, dereflection procedures are applied to help in We thank all the people supporting 4LOVEprojects.org fundraising. REFERENCES 10. Brunelli C, Bianchi E, Murru L, Monformoso P, Bosisio M, Gangeri L, et al. Italian validation of the Purpose in Life (PIL) test and the Seeking of Noetic 1. UNHCR. (2020). The United Nations Refugee Agency. https://www.unhcr. Goals (SONG) Test in a population of cancer patients. Support Care Cancer org/ (2020). (2012) 20:2775–83. doi: 10.1007/s00520-012-1399-6 2. Migration Data Portal http://migrationdataportal.org. International 11. Stegger MF, Oishi L. Is a life without meaning satisfying? J Gerontol Ser B Organization for Migration (IOM) (2020). (2004) 54:125–35. 3. Chang C, Ting C. Migratory Loss and Depression among Adult Immigrants of 12. 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Clin Psychol Rev (2020) Logotherapy in the Ethical Consideration of Coma, Brain Death, and 76:101815. doi: 10.1016/j.cpr.2020.101815 Persistent Vegetative States. In: Batthyá ny A, editor. Logotherapy and Frontiers in Psychiatry | www.frontiersin.org 5 June 2020 | Volume 11 | Article 451 Rahgozar and Giménez-Llort Foundations and Applications of Logotherapy Existential Analysis. Logotherapy and Existential Analysis, vol. 1 . (2016). p. Copyright © 2020 Rahgozar and Gime ́nez-Llort. This is an open-access article 365–76. distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the Conflict of Interest: The authors declare that the research was conducted in the original author(s) and the copyright owner(s) are credited and that the original absence of any commercial or financial relationships that could be construed as a publication in this journal is cited, in accordance with accepted academic practice. No potential conflict of interest. use, distribution or reproduction is permitted which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 6 June 2020 | Volume 11 | Article 451