IMMIGRATION/SHAME
From Adolescent Psychiatry: Biological Underpinnings and Psychosocial Understandings, presented by the
American Society for Adolescent Psychiatry and the Southwestern Medical Center
| MIGRATION AND REFUGEE MENTAL HEALTH —Eugenio M. Rothe, MD, Associate Professor of Psychiatry
and Pediatrics, University of Miami School of Medicine, Miami, FL
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| Introduction: most recent census counted ≈31.1 million foreign-born individuals in United States; greatest
number of immigrants to United States come from Latin America, followed by Asia, Europe, and Africa;
most common states through which immigrants enter include California, Texas, New York, and Florida
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 | Hispanic immigrants: greatest numbers come from Mexico, Cuba, Dominican Republic, and El Salvador
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| Reasons for immigration: most come to United States because of poverty in their home countries, but others
include professionals seeking work in their fields, students seeking education, refugees seeking asylum, and
exiles
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| Psychodynamics of migration and exile: culture shock consists of mourning for loss of culture, language,
friends, and predictable environment, and of transforming one’s identity; first phase (ie, cultural encounter)—
characterized by suddenness, abruptness; immigrant compares old culture and new, looking for similarities
and differences; immigrant becomes disillusioned and depressed, experiences confusion, and may suffer discontinuity
of identity; second phase—spatial disorientation leads immigrant to forget where he or she is; temporal
disorientation causes immigrant to confuse names of, eg, people or landmarks, in old country with those
in new; third phase—reorganization and integration, marked by healthy inhibiting force; immigrant eventually
integrates elements of new culture and deletes those of old, leading to sense of belonging, confirmation,
affirmation, and enrichment of self; takes time
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| Stresses of migration: circumstances of immigration (eg, voluntary or forced); cultural ceiling above which
immigrant cannot rise, regardless of effort, talent, or achievement; racism; stereotype of immigrant from
which he or she cannot escape (eg, stereotype of recent Cuban immigrants as lazy or expecting government to
provide); study showed that recent immigrants oriented toward future (ie, wanted better future for themselves
and their children), wanted to dominate culture in same way as Americans, and sought egalitarian authority
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| Culture: defined as socially transmitted system of ideas that shapes behavior, categorizes perceptions, and
through language, gives names to selected aspects of human experience; shared by social group; functions as
compass for orientational framework and coordinates behavior; conveyed across generations; helps define
identity
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| Identity: some children integrate “ethnic self-hate” in response to discrimination by larger society; development
of identity begins early; by 3 to 4 yr of age, children begin recognizing different accents, and between 4
and 8 yr of age, begin to develop ethnic orientation and become curious about groups other than their own
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| Acculturation: process occurs not only in people coming into United States from other country, but in Americans
moving from one subculture to another (eg, from rural to urban settings) within United States; these
people experience same culture shock as people coming from other countries
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| Methods of acculturation: traditionally, immigrants to United States entered through Ellis Island, NY, or San
Francisco, CA, and were expected to assimilate; they often changed family names and tried to speak English
without foreign accent; some groups became marginalized in communities (eg, “Little Italy,” Chinatown)
where customs and language of old country persisted; large portion of these immigrants did not
assimilate or integrate; today, biculturalism considered healthiest; immigrant remains connected to ethnic
and cultural roots, but also “becomes American,” picking and choosing best of both cultures; process of acculturation
complex (not linear) and takes time
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| Children of immigrants: often do worse (eg, poorer general and mental health) than first generation; may not
maintain contact with cultural roots, leading to feeling of “not fitting in,” resulting in substance abuse, depression,
and other problems; study—Mexican adolescents living in United States watch more television
and have higher rates of suicidality than those living in Mexico; television time possible marker of lack of
parental supervision; translocation results in loss of extended family and support; other psychologic
concerns—if family immigrated from country where children exposed to violence, children may have undiagnosed
and untreated posttraumatic stress disorder (PTSD); if family broken up during immigration,
children may feel abandoned, even after reunification; children might be considered exiles because they
usually have no voice in decision to emigrate
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| Schools: immigrants, especially Hispanic parents, may not have had education available to them and often desire
to provide their children with good education; schools can help children with assimilation and integration;
schools good environment in which to observe immigrant children during process of acculturation
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| Resettlement: family structure may change; if both parents work, children may take over running of household
or serve as interpreters for non-English-speaking parents; older children may have to assume care of younger
siblings; refugees—45 million worldwide; study of Cuban refugees in Guantanamo camps in 1994 found that
67% of adolescents had avoidance and repressive symptoms; severity of PTSD related to length of confinement
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| Barriers to care: refugees usually underutilize mental health services; reasons—mental health may not be
priority in their cultures; fear of stigmatization; lack of trust in mental health providers who do not speak their
language or are unfamiliar with their cultural mores; fear of reliving painful past experiences; mental health
may fall far down on hierarchy of needs, after employment, housing, acculturation, education for children
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| Few empirical studies address needs of immigrants: speaker trying to establish model where therapist becomes
self-object, love-object (transference), mentor, facilitator, advocate, and mediator, and provides emotional
safe-haven for family and children
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| SHAME AND ADOLESCENT CONDUCT DISORDER —Alan R. Wofsey, MD, Clinical Assistant Professor
of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, and Chairman, Department of Psychiatry,
The Lankenau Hospital, Wynnewood, PA
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| Introduction: shame often overlooked as motivator in human behavior; literature sparse; speaker believes that
“some of humanity’s most baffling and destructive behaviors are well understood as responses to shame and
humiliation”
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| Adolescent neurobiology: frontal lobes develop relatively slowly, lacking full adult status until individual is in
early-to-mid 20’s; at same time, “the limbic system lends youth industrial-strength affects and drives without
the cognitive horsepower to harness them”; serotonin levels drop during adolescence, lowering the threshold
to acting on suicidal or aggressive impulses; low serotonin also creates greater propensity toward major and
minor depression, anxiety, panic, social phobia, aggression, impulse-control disorders, addiction, and obsessive-compulsive
disorder; correlation established between serotonin level and social dominance or submissiveness
in primates; serotonin dysfunction likely involved in teens’ heightened sensitivity to shame- and
humiliation-related issues; problems compounded by sleep deprivation (common in teens; melatonin spikes
late at night and lingers into morning)
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| Affect theory as mode of inquiry: affect theory provides perspective for understanding patients and for healing;
speaker posits that most human interactions and social phenomena best understood in terms of affect; he
further suggests that knowledge of how shame works is fundamental to understanding and treating adolescent
psychopathology; affect connected reciprocally to drives, pain, motor function, cognition, perception, and
memory; consciousness defined as central assembly of cognitive system and motivational system; motivational
system is combination of arousal mechanism, drives, pain, and 9 innate affects (interest/excitement, enjoyment/joy,
surprise/startle, fear/terror, distress/anguish, anger/rage, dissmell [reaction to bad smell],
disgust, and shame/humiliation); nothing reaches awareness without stimulating affect system; nothing encoded
in memory without evoking emotional response
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| Shame: whenever other affect or behavior jeopardizes social bonds, shame serves as damper to emotional system;
often exists in balance of interest/excitement; if interest/excitement high, shame usually low, and if
shame high, interest/excitement usually low
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| “Compass” of shame: comprises defensive ploys to deal with shame; points of compass—1) shame avoidance
or grandiosity; 2) withdrawal; 3) attacking self; 4) attacking other; note—these defensive scripts universally
employed, but when used in extreme, may result in social and psychopathologic syndromes
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| Shame avoidance or grandiosity: alleviates shame by creating impression that individual is special case to
whom rules do not apply; unhealthy manifestations include driven perfectionism (“workaholism”); excessive
competitiveness and materialism, eating disorders, addiction, gambling, sexual promiscuity, and
lying and cheating
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| Withdrawal: healthy manifestations include stopping, self-reflection, and strategic retreat; unhealthy manifestations
include shame-driven depression and social phobia, withdrawal from competition, refusal to attend
school, avoidance of sex and romance, involvement in cyber-sex, and sexual dysfunction
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| Attacking self: serves to alleviate shame by seeking solace and support; in healthy reaction, one might employ
self-denigrating jokes; in unhealthy reaction, leads to significant social and psychopathologic syndromes,
including self-mutilation, destructive relationships, and suicidality
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| Attacking other: serves to alleviate shame by rendering another vulnerable; in extreme, may lead to verbal
barbs, bullying, assault, street crime, war, racism, or genocide
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| Internalized Shame Scale: helps determine level of internalized shame that teenagers experience; includes
occult rating for self-esteem; patterns—teens who seek treatment have highest scores on Internalized
Shame Scale; presenting complaint often depression; applications—information from scale can help adolescents
understand their experiences and emotions; counseling—explain biologic roots of shame; normalize
shame; note—typical adolescent can usually overcome shame through youthful exuberance, but
timid adolescents frequently use alcohol in effort to reduce shame
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| Advantages of understanding shame: reduces therapist’s perplexity over and distress during first evaluation
of patient; clinician who can convey clear understanding of dynamics of shame gains adolescent’s attention
and interest (“because adolescents still have a healthy dose of magical thinking they’re very impressed
with therapists who can seem to read their minds”)
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| Conclusion: reinforcing social bonds mitigates shame-related pathology; failure to validate adolescent’s feelings
of shame often results in failure of therapy; when therapist acknowledges his or her common humanity
and universality of shame experience, growth becomes possible
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Educational Objectives
| The goal of this program is to educate the listener about immigration and refugee mental health and about the
role of shame in adolescent conduct disorder. After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Explain the psychodynamics of immigration and exile.
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| 2. Discuss the process of acculturation.
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| 3. Describe some of the barriers to care that inhibit immigrants from seeking mental health services.
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| 4. Summarize the affect theory as a mode of inquiry.
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| 5. Relate the role of shame in adolescent conduct disorder.
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Suggested Reading
Beiser M: Longitudinal research to promote effective refugee resettlement. Transcult Psychiatry 43:56, 2006;
Bernstein NI: Treating the Unmanageable Adolescent: A guide to Oppositional Defiant and Conduct Disorders.
Northvale, NJ: Jason Aronson, 1996; Bradley MJ: Yes, Your Teen Is Crazy! Loving Your Kid Without Losing
Your Mind. Gig Harbor, WA: Harbor Press, 2002; Cook DR: Internalized Shame Scale: Technical Manual. Toronto,
Ontario: MultiHealth Systems, Inc., 2001; Handlin O: The Uprooted: The Epic Story of the Great Migrations
That Made the American People, 2nd Ed. Philadelphia: University of Pennsylvania Press, 2002; Hersch P:
A Tribe Apart: A Journey Into the Heart of American Adolescence. New York: Fawcett Columbine, 1998; Manson
M, Straus N: The Long Hard Road Out of Hell. New York: Regan Books, 1999; Nadeau L, Measham T:
Caring for migrant and refugee children: challenges associated with mental health care in pediatrics. J Dev Behav
Pediatr 27:145, 2006; Nathanson DL, ed: Knowing Feeling: Affect, Script, and Psychotherapy. New York:
Norton, 1996; Nathanson DL: Shame and Pride: Affect, Sex, and the Birth of the Self. New York: Norton, 1992;
Pipher M: Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Putnam, 1994; Real T: I Don’t
Want to Talk About It: Overcoming the Secret Legacy of Male Depression. New York: Fireside, 1998; Rothe EM:
Considering cultural diversity in the management of ADHD in Hispanic patients. J Natl Med Assoc 97(10
Suppl):17S, 2005; Rothe EM et al: Posttraumatic stress disorder among Cuban children and adolescents after
release from a refugee camp. Psychiatr Serv 53:970, 2002; Silverstein O, Rashbaum B: The Courage to Raise
Good Men. New York, NY: Viking Press, 1994; Tomkins S: Script theory. In: Aronoff J, Rabin AI, Zucker
RA, eds. The Emergence of personality. New York: Springer Pub. Co, 1987; Tomkins SS: Exploring Affect: The
Selected Writings of Silvan S. Tomkins. Demos EV, ed. New York: Cambridge University Press, 1995; Tomkins
SS: Affect, Imagery, Consciousness, Vols I-IV. New York: Springer Pub Co, 1992; Wurmser L: Shame: The
veiled companion of narcissism. In: Nathanson DL, ed. The Many Faces of Shame. New York: Guilford Press,
1987.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
For this issue, Dr. Rothe disclosed that he is a consultant or on the Speakers’ Bureau of McNeil.
Drs. Rothe and Wofsey were recorded at Adolescent Psychiatry: Biological Underpinnings and Psychosocial Understandings,
held March 16-19, 2006, in Miami Beach, FL, and sponsored by the American Society for Adolescent
Psychiatry and the Southwestern Medical Center. The Audio-Digest Foundation thanks the speakers and
the sponsors for their cooperation in the production of this program.
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