Keywords

Introduction

There is increasing awareness among scientists, clinicians, and policy makers that understanding the role of context in pathways to mental health and illness is key to the development of effective support and interventions for individuals, families, and communities [17, 76]. In disadvantaged populations, mental ill health intertwines with a multitude of physical and complex social problems [47]. This is especially relevant for children and adolescents who develop in interaction with the contexts that surround them. Children growing up in deprived circumstances disproportionally suffer from mental health problems (e.g., [5, 16, 49]). Exposure to violence and traumatic events in childhood or adolescence has a particularly detrimental effect on children’s mental well-being [4, 19, 39]. Accumulating exposure to risk factors disproportionally increases the probability of mental health problems [3, 24, 35]. In adolescents, poor mental health is strongly intertwined with lower educational achievements, substance abuse, violence, and poor reproductive and sexual health [48, 73]. For young refugees, displacement adds extra complexity to this accumulation process. Already at risk by the conditions causing flight, the process of flight, and the long periods in refugee settlements or under asylum-seeking procedures, the few children and adolescents who are resettled into third countries face stressors related to marginalization, discrimination, and other post-migration stressors, which all increase children’s vulnerabilities [26, 27, 43]. Furthermore, ongoing tension in the home country may continue to negatively affect refugee children and their families [50, 63].

The cultural environment has particular salience in the interaction of biological, psychological, social, and environmental factors that determine vulnerability for and resilience to mental health problems [12, 46, 72, 76]. Cultural values underpinning family and community cohesion, positive parenting practices, peer and school support, and neighborhood connectedness may protect children from the negative effects of adverse events [8, 39, 66, 66,67,, 67,67,, 71]. In environments marked by conflict and flight, such protective resources are often severely damaged, e.g., due to broken family and community structures [7, 15, 40].

Agreement on the importance of the socio-cultural contexts in pathways to child mental (ill) health has led to an abundance of studies from intersecting fields of (cultural) psychology and psychiatry, public and global mental health, and health social science, including medical anthropology. Yet there is no agreement on how to unpack “context” or “cultural context.” Context may be operationalized by quantifiable determinants. For instance, to understand how the context of war impacts on children’s mental health, the number of experienced traumatic events may quantify “exposure,” and an epidemiological study may show how higher levels of exposure are associated with increased vulnerability for mental health problems (e.g., [70, 75]). A qualitative researcher may argue that the mental health impact of living in a war context can only be understood by investigating all contextual dimensions – ecological, historical, political, social, economic, and cultural – that shape children’s experiences and mental well-being, including their own perspectives and those of other stakeholders. Epistemological and methodological differences hinder the development of a unified language to discuss the role of context and culture and of interdisciplinary theories and methodologies to study cultural contexts in ways that could inform interventions.

This chapter describes how to conceptualize context and culture in relation to causal pathways in mental health of young refugees. After brief definitions, two common paradigms that operationalize cultural context will be discussed. The first considers human society as a system in which the different parts function together to sustain the whole. In this paradigm, cultural context refers to how people’s worldview supports their institutions and practices, and value theories may be useful to explore the role of culture in pathways to (ill) mental health. The second, ecological paradigm conceptualizes context as component of a dynamic process involving interactions between an individual child’s capabilities on one hand and the environment in which the child is embedded. Here, the cultural context is not a system with specific functions next to other systems, but overarches all other system levels. Cultural values embedded in institutions at the macro level operate at different ecological levels in shaping or withholding opportunities to individual children. An ecological paradigm is useful to understand how certain values may impact children’s resourcefulness and mental health. We will describe which approaches may help identify cultural contexts and investigate cultural processes influencing mental health problems.

Defining “Context”

Despite general agreement that context matters, there is no single accepted definition. In Latin, contextere means “a weaving/joining together.” In common discourse, context conveys the interrelated conditions – the setting – in which something exists or occurs.Footnote 1 Theoretically, “context” in children’s pathways to mental (ill) health refers to the dynamic social, cultural, and environmental surroundings against which children’s biological and psychological development can be profiled. A small excursion into cognitive linguistics may clarify why it is futile trying to map such context as a whole. Porto Requejo provides the example of the concept “FINGER,” which.

… can only be appropriately interpreted if profiled against another concept, HAND, which acts as a base. Thus, both base and profile together conform the meaning of the lexical item FINGER. This means that no linguistic unit can be understood isolatedly because all lexical concepts presuppose others. Congruently all our knowledge of the world can be seen as a huge network of interconnected concepts; a word is actually (...) just the starting point of the process of meaning construction. The range of possible associations that can be made during the process is potentially infinite. [51]

How then do we pragmatically operationalize cultural context to understand young refugee’s pathways to (ill) mental health? What approach helps contextual exploration of the most relevant associations with young refugees’ mental (ill) health so that locally salient and optimally effective interventions may be developed?

Culture as a Social System

Context is often specified by adjectives: we speak of historical, political, economic, cultural, and medical contexts, among others. Dividing context in such components seems logical for institutional bodies governing our societies. For instance, the political context incorporates how authority is developed, which is supported by rules of government and institutions. Similarly, medical context refers to the health system: the way in which people, institutions, and resources are organized to promote, restore, or maintain a population’s health. Policy documents often reflect such a systematic view on context. For instance, in relation to humanitarian emergencies, the WHO/UNHCR toolkit recommends a structure for desk studies, whereby general context is composed of demographic, historical, political, religious, economic, gender, and family aspects, cultural aspects, and general health aspects [77: 61].

From a practical perspective, defining context in terms of components based on institutional realities can help inform policy and practice. It is important for humanitarian workers to understand the contextual opportunities and obstacles faced by the children whose needs they address. For instance, some refugee children may be found missing from care because they lack birth certificates or are lost to follow-up not because of willful non-adherence but because they are forced to move to another setting. Mapping how the legal system facilitates and/or hampers a refugee child’s access to care may help psychosocial workers in identifying points for action and intervention at system level (cf. [65]). Developing alternative modes of legal registration for refugee children born during flight can answer the host nation’s duty to fulfill article 7 of the Convention on the Right of the Child that pronounces a child’s right to a name. Similarly, the medical system may be put under scrutiny how it can adapt its procedures to refugee children’s mobile lives (cf. [57]). Within an environment dominated by institutions, defining context in terms of its social functions and in-depth knowledge of the institutions that represent them may be pragmatically sound.

Philosophical Approach

Definitions of context in terms of the social functions of its components (e.g., governing, health, justice) are supported by a notion of human society as an organism in which the different parts function together to sustain the whole. In terms of its social functions, “cultural context” refers to people’s worldview, their shared systems of knowledge, values, norms, roles, and attitudes, as they are embedded in and reinforce cultural institutions and practices. From a philosophical perspective, culture can be understood to provide answers to universal ontological questions, questions on what it means to be human. Five domains of human existence can be discerned: (a) the intra-human (mind–body); (b) the inter-human (social interactions); (c) the super-human (e.g., ancestors, god, embodied entities and forces); (d) extra-human (ecology, nature, cosmos, animals); and (e) time (the relationship between the past, present, and future).Footnote 2 Societies differ in the answers they provide and use these answers to structure their institutions, hence the wide differences in cultural contexts. For instance, the mind–body dualism characteristic for Western European thought has led to boundaries between neurology and psychiatry reflected in the organization of hospitals, training of specialists, and journals that publish advances in science.

Culture thus structures how people live their lives and deal with others and the world around them. A framework in terms of culture as a social system may help reflect on cultural differences in how human suffering is given meaning and acted upon in various medical traditions. For instance, in biomedicine – including psychiatry – the intra-human usually receives most attention, even though a biopsychosocial approach may be propagated that pays attention to a person’s social relations. In African healing, what transpires in the individual body/mind is often immediately interrelated with social and spiritual dimensions, for instance, when a healer attributes a woman’s infertility to ancestor wrath over societal conflict. De Jong and Reis [20] show how a philosophical model may help compare how different local healing resources (including psychiatry or psychology) address mental health problems.

Value Theories

In epidemiologically oriented (cultural) psychology and psychiatry, cultural context is only considered a useful construct if it can be measured. Therefore, operational definitions are needed in terms of variables, so that factors can be identified that effect an outcome, for instance, mental health. Value theories are popular frameworks to operationalize cultural context in quantitative designs. Hofstede’s theory distinguishes five value dimensions on which all nations vary and can be scored: (1) collectivism–individualism, (2) power distance, (3) uncertainty avoidance, (4) masculinity–femininity, and (5) long-term versus short-term orientation [30]. The model was meant to be applicable to nationally prevalent styles of organization. Critics, mostly the field of international management and organizational anthropology, demonstrated flawed methodologies, lack of empirical evidence to substantiate the model, lack of attention to cultural change, and an ethnocentric and deterministic mind frame underlying its assumptions (e.g., [21, 42]). Notwithstanding these critiques, the theory is still used and referred to, for instance, in the field of cross-cultural nursing (e.g., [44]).

In Schwartz’ less controversial value theory, and more in line with the philosophical perspective outlined above, three core dilemmas are postulated that societies universally need to solve, pertaining to: (1) the relation between the individual and society (embeddedness versus autonomy), (2) the social order (hierarchy versus egalitarianism), and (3) people’s relationship to the natural and social world (harmony versus mastery). Schwartz [61] emphasizes that all values are circularly interrelated and they have explanatory power only in combination. Heim et al. [29] apply this theory in a recent study on the relation between cultural values and mental disorders and claim to have found a clear and consistent relation of affective disorders with cultural values [29: 103].

Fraser and colleagues warn us, however, that it is not possible to evaluate cultural values outside of their relevant context. There is cross-cultural variation of what behavior is adaptive and normative. Certain values may cause unique risks to certain populations, and cultural risk and protective factors may operate differently for children in different cultural groups. Also, among migrant populations both low and high levels of acculturation to the culture of the host country are associated with mental health problems [28: 26–27]. Paraphrasing Boyden and De Berry [12], cultural factors can render the individual stronger or weaker depending on the specific context.

Clinical Approach

The problem is that the notion of value systems as coherent wholes belies that cultures are open and dynamic. Approaching the cultural context as a social system with specific functions risks neglecting individual agency – how adults and children perceive and intentionally act upon themselves, others, and the world – and cannot explain conflict and social change. Although cultural variables may carry relevance as determinants for mental health at the level of a population – e.g., refugee children – they may lead to unhelpful stereotypes at the level of an individual living in specific contexts, e.g., an Iraqi child living in a refugee setting in the Netherlands [9, 10, 31].

June 2019. The youth health service of a municipality in the Netherlands received a case about a “cultural conflict” between a refugee family from Iraq and a local school. The family’s youngest son had kicked his female teacher in an angry outburst in class and the school asked for advice on how to deal with religious values that might be implicated in the disrespect shown to his teacher. Careful analysis revealed that the conflict had started with the parents’ fierce resistance to the school’s advice to enroll their eldest son in special education, leading to the boy not going to school for months. The refugee parents, highly educated with prosperous positions before their flight, were deeply concerned about the educational opportunities for their children. Unfamiliar with the educational system in the Netherlands, they interpreted special education as an obstacle to what they saw their son’s only way out from an otherwise bleak refugee situation, rather than how it was meant, to allow the child more time and support to catch up with schooling. Mounting tensions between the family and the school culminated in the youngest child expressing the family’s distress in an angry outburst with a teacher he had a good relationship with.

Although value theories may sensitize practitioners to potential cultural differences, in clinical practice they need to understand the specific cultural context of illness experience of their clients for effective diagnostic assessment and clinical management [2]. The Cultural Formulation Interview (CFI), part of a chapter on Culture in the DSM-V, was developed in answer to this need [2]. Although the focus is on discerning cultural factors, the CFI does not aim to measure cultural traits; it provides practitioners with a semi-structured format for exploring the social-cultural context around a client and his or her mental health problem. Culture is defined as sets of values and orientations that individuals derive from membership in diverse social groups, aspects of an individual’s background, developmental experiences, and current social contexts that may affect his or her perspective and the client’s social network. These broad definitions are further operationalized in 16 open questions over 4 domains:

  1. 1.

    Cultural definition of the problem

  2. 2.

    Cultural perceptions of cause, context, and support

  3. 3.

    Cultural factors affecting self-coping and past help seeking

  4. 4.

    Cultural factors affecting current help seeking

The CFI has been evidenced to support clinicians to base their therapeutic interventions with migrant or displaced clients on accurate and culturally valid diagnoses [38]. In a case study, La Roche and Betz Bloom [37] show that the CFI is also applicable to (refugee) young children. They also observe, however, that the CFI relies much on language, among other shortcomings, and is not able to tap into young children’s own cultural views. They plead for the development of a supplementary module for young children that would encourage children to communicate through creative means their views about themselves and their significant contexts. Interestingly they describe children’s contexts or worlds in terms of self, home/family, school, and neighborhood [37]. This brings us to ecological notions of context and culture.

Cultural Context in an Ecological Mode

Frameworks tailored to assessing risk and protective factors for mental health often fail to capture how pathways to mental (ill) health unfold in constant interaction between individual children and the context in which they grow up. Epidemiological frameworks in particular usually pay little attention to the way in which people make sense of their experiences and how intentional actions based on such appraisals play a role in these pathways. Ecological theory offers an important alternative way to theorize context, including cultural context. Instead of focusing on risk and protective factors, an ecological approach conceptualizes children’s resilience as a dynamic process operating across the lifespan [59] involving interactions between children’s capabilities on one hand and the environment in which they are embedded. Capabilities include children’s social skills and potential to work toward goals relevant to them [56, 71].

Individual children vary in their abilities to convert resources into valuable outcomes and their freedom to choose the kind of lives they have reason to value [62, 71]. Children’s capabilities in themselves are shaped and influenced by the contexts in which they grow up. Self-regulation skills allow children to appropriately respond to their environment [13], but vary between individuals. Incorporating one or more self-regulation components in interventions has been shown to be successful in enhancing positive mental health outcomes [13]. In an ecological framework, cultural context is framed as an “opportunity structure,” bolstering or restricting the capabilities of children to negotiate the resources they need [71: 28].

Like any other person, children are active participants in shaping their environments. For instance, cultural values centering around respect may prevent children from expressing their negative emotions openly ([55]; cf. [1]). At the same time, around the world, children in deprived communities collectively use and reshape the locally salient idioms of distress available to them, in ways that force adults to pay heed to children’s suffering.

Cultural idioms of distress are shared, culturally distributed sets of symbols, behaviors, language, or meanings that are used by people to express, explain, and/or transform their distress and suffering [32]. For instance, in Northwest Uganda, the belief in cen, haunting spirits of the dead, allows internally displaced children in Northwest Uganda to express their bereavement and feelings of guilt and anxiety [54]. Similarly, in the first decade of this century, asylum-seeking children in Europe started to exhibit life-threatening withdrawal behavior that embodied and expressed the state of helplessness and hopelessness of their social situation and could only be effectively treated when psychiatric care was matched with legal interventions ensuring their families refugee status [53]. Children’s power to disturb may engage adults in unexpected ways. Our example of a young Iraqi child acting out his family’s distress over a conflict with the school in kicking his favorite teacher is a case in point. It is important to remember that context comes first: how children navigate and negotiate resources depends first on the opportunity structures available to them and second on their capabilities as they are informed by these structures [71: 27]. For example, poor access to mental health services leads to less negotiation power to protect themselves from abuse and neglect (cf. [41]).

The Cultural in Socio-Ecology

How we unpack “cultural context” depends on our definition of culture. Above, culture refers to people’s worldview, their shared systems of knowledge, values, norms, roles, and attitudes, embedded in and reinforcing cultural institutions and practices. In ecological models, for instance, in Bronfenbrenner’s framework, children are thought to develop in interaction with immediate and more remote environments, ranging from micro- to macro-system levels, nested layers that differ in proximity and strength of influence on the individual child [64]. In these models culture usually pertains to the macro-system level: to cultural blueprints overarching and influencing all other system levels [46, 68]. Cultural values embedded in institutions at the macro level operate at different ecological levels in shaping or withholding opportunities to individual children. Bronfenbrenner’s “chrono-system ecological theory” captures the important dimension of time. Capabilities of children to negotiate resources and how they are enabled or restricted by their environment are influenced by the social continuities and changes occurring over time through the life course and the historical period during which the person lives. History affects all other levels [14]. This dynamic process leads to different and sometimes conflicting values active at the macro level, complicating a systematic representation in terms of a value system [46].

Case Example

Like some 300 other asylum-seeking children in the Netherlands, 2 Armenian asylum-seeking children (aged 12 and 13 years old) lived in the Netherlands for a decade unsuccessfully applying for refugee status, despite widespread public support for their appeals. When they lost their final legal bid and deportation was planned for the next day, they ran away from their foster home overnight. The police appeal to the public to help them locate the missing children was met with a public outcry: offers of hiding places circulated the media with explicit references to the resistance to German occupation during the second world war. The next day the Dutch government granted them the right to stay after all, allegedly because of concerns for their safety. This event has fostered hope for children in similar circumstances. As we speak, Christian ministers are guiding a continuous service relay race in a church that shelters an Armenian asylum-seeking family to prevent them from being deported. In the dilemma between obedience to the authorities and the fundamental value of compassion, they navigate the law that forbids the police to enter during church service.Footnote 3 The children’s decision to go into hiding resonated with deeply embedded values regarding civil resistance.

The overarching cultural context is not a static and harmonious system, but a continuously changing chaotic and contested field fraught with ambivalences and contradictions. These characteristics complicate systematic descriptions of the cultural resources that may be converted by children into outcomes they have reason to value.

Struggles with different and competing values may also occur because of contrasts between pre-flight, flight, and settlement contexts [50]. Children may then be confronted with competing values at home versus at school, for instance. Frequently occurring changes in family structures due to conflict and displacement may also disturb values underpinning the roles of children and their caretakers. For example, the government or the United Nations High Commissioner for Refugees (UNHCR) may take over parental tasks of providers [60] or children may be asked to assume adult roles, e.g., as translator for their parents [40]. At the individual level, “culture” does not refer to remote macro-structures but to socially inflected, shared, learned, and internalized dispositions to oneself, others, and the world that structure and give meaning to how one lives one’s life. How children feel and think about themselves and the world takes shape as specific desires that are culturally constituted [32, 45: 63–64]. In ecological theory, “meaning” is recognized as an important and indispensable element in the process of resilience. On one hand, meaning determines the resources their family, school, community, and nation provide. On the other hand, meaning also determines the decisions that people make regarding the resources they value [71: 22]. In other words, the cultural context not only shapes what resources are available for children and their actual abilities to convert resources into valuable outcomes but also the kind of lives children have reason to value. Anthropological research has shown that refugee children may suffer both personal and cultural bereavement or, in terms of psychopathology, individual trauma and historical trauma [22]. Their strategies may be tailored more to the suffering of others than their own suffering. For instance, Akello et al. [1] describe how internally displaced children in Gulu may hide their distress in an attempt to prevent triggering distress in others. Likewise, Tize, in her study about Palestinian refugee families in Berlin, shows how the eldest girls in the family disrupt their education to support their parents in taking care of the youngest children, as the parents are too busy trying to procure income. Moreover, as the children are witnesses to their parents’ stress and resulting ill health, the girls silence their own suffering in the household [66].

Researching Cultural Context in an Ecological Approach

To understand the role of culture in the processes and mechanisms that lead to children’s mental problems or resilience, it is senseless to try and map all cultural resources theoretically available to children. In reality, many theoretical possibilities do not exist for specific children in specific circumstances. Contextual exploration of the most relevant associations of culture with young refugees’ mental (ill) health must start with young refugees themselves. This agrees with anthropological findings on how employing child-actor perspectives and participatory approaches in humanitarian contexts may provide insight in how children and adolescents navigate their volatile environments [6, 11, 12, 33].

Cultural context can be explored as an opportunity structure. Values related to parenting practices, peer group dynamics, educational programming, neighborhood connectedness, and family and community cohesion may be assessed by indicators associated with individual outcomes. Rapid participatory assessments using key informant interviews, focus groups, observation, and in-depth case studies have been shown to help make surveys more culturally relevant, for instance, by informing research instruments with contextually specific questions (e.g., [25, 74]).

However, to understand the processes that lead to mental (ill) health and to identify the causal mechanisms at stake, methodologies are needed that can capture how pathways unfold in time. Paying attention to life course dynamics may help identify culturally patterned exposures and experiences during development and understand how vulnerabilities for mental ill health vary and may accumulate over the lifespan and how time, context, human agency, or social circumstances and sensitive periods and critical events may lead to turning points in a child’s mental well-being [18, 23, 34, 52]. Life course research may incorporate longitudinal quantitative designs as well as qualitative approaches that study in depth children’s own worldview and cultural dispositions, their capabilities, and their experiences in navigating the cultural resources that are available to them.

Panter-Brick and Eggerman’s [46] longitudinal research in Afghanistan offers an excellent example of how mental health surveys can be combined with qualitative enquiries in different mixed-methods designs to allow for cultural contextualization of quantitative findings and inform interpretation. By combining standard checklists enquiring into traumatic events with open-ended questions asking for respondents’ appraisals of the relevance of these events in their lives, they were able to identify the importance of everyday violence. Further surveys and in-depth qualitative work with children provided understanding of the relevance of family relationship quality for children’s outcomes and how the value of keeping children in school is an expression of hope and resilience in a high-risk environment. Their findings also revealed how cultural values governing life course norms (e.g., secure a good marriage or job) may lead to “cultural entrapment” and negative mental health outcomes in an environment lacking the opportunity structures needed for the expression of such values in their lives.

Interventions Incorporating an Ecological Approach

A life course perspective may help develop interventions that take into account the dynamics that govern children’s developing capabilities, their constantly changing environments, and the complex negotiation process between children’s capabilities and their immediate and more remote contexts. It can do so by informing our understanding of how to identify and implement prevention programs appropriate for the different (cultural) contexts and life stages [58]. Development of effective prevention strategies requires the translation of modifiable risk factors over the lifespan into programs and policies, particularly parenting and school-based interventions [18]. An approach that recognizes the importance of historical events and the timing of events over the life course is of pertinent value for addressing the mental health need of young refugees.

Conclusion

In our chapter we distinguished two broad approaches to operationalize cultural context. The first considers culture as a social system with specific functions to provide people with answers to ontological questions, help structure their social relations and interactions, and shape their institutions. We discussed how in this approach value theories may help explore how cultural orientations play out in pathways to (ill) mental health. Such theories are critiqued for the lack of substantiation at the population level and irrelevance at the individual level. However, their cultural dimensions and variables might be used as sensitizing concepts to help practitioners explore cultural differences and the role of the cultural context around a child’s mental health problem. The Cultural Formulation Interview is a tool to help professionals to base their therapeutic interventions with migrant or displaced clients on accurate and culturally valid diagnoses. In the second approach, the cultural context is considered to overarch and interact with all other ecological system levels. At the macro level, culture operates as a dynamic and contested field fraught with ambivalence and contradiction. More than others, refugee children and adolescents may be confronted with competing values, and these confrontations may offer them new opportunities but also accumulate their vulnerabilities to mental ill health. Theoretically, the cultural context is as unbounded as the range of possible associations that give meaning to a word. In the real lives of young refugees, cultural context emerges as resources and restrictions manifested and negotiated in their interaction with immediate and more remote environments as these evolve and change over their life course. By exploring children’s pathways to mental (ill) health from an ecological life course perspective, taking culture seriously as it is expressed in resources as well as resourcefulness, effective strategies may be developed to prevent the negative accumulations that may spiral children and adolescents into mental ill health.