Keywords

FormalPara Case

“Marina,” a 17-year-old Caucasian Jewish student originally from the Former Soviet Union, was referred to a university counseling center for treatment of depression and test anxiety and a declining academic performance. At intake, she reported depressed mood, tearfulness, hopelessness, anhedonia, constant anxiety and worry, early and middle insomnia, and feelings of worthlessness. She noted significant preoccupation with her academic performance which had steadily declined over the course of the academic year. She reported significant problems with attention and concentration and with internalizing learned material. Marina described struggling to focus and described sitting in front of the same chapter or article for hours, reading and rereading the same sentence. She said that she would not be able to recall what she had read and that she would find herself becoming distracted with other thoughts, most of them judgmental and self-deprecating thoughts of her own shortcomings. She noted several instances of panic attacks that had occurred during exams; she would freeze and not be able to recall material. She also endorsed tachycardia, racing thoughts, and marked gastrointestinal distress, including stomach pains, nausea, and diarrhea that would accompany these episodes of panic and her overall anxiety. One episode that she described took place during a major Biology test. Marina became so overwhelmed with panic that she ran out of the room and proceeded to cry, shake, and vomit in the hallway bathroom outside the lecture hall. When she had returned to the classroom to finish the exam, she only had 20 min left on the test and ended up failing the exam, as she had felt too humiliated by her panic attack to explain to her instructor what had happened and ask for an extension or a retest. She also noted that her parents would frequently rely on Marina to travel back to her hometown to help out with her aging, ailing grandparents’ numerous medical appointments, as well as to help them parent her younger teenage brother, further exacerbating her stress. She reported that she missed her family, but also felt resentful toward them for asking her to come home, as she would miss out on social events taking place on campus at the weekend. Marina experienced a lot of pressure from her family to live at home and commute to campus in order to save money and spend more time with her family.

Marina was born in Moscow to an educated, middle-class Jewish family. Her father was an engineer, and her mother was a physician. The couple lived with Marina’s maternal grandparents, as was typical for the living standards of Moscow during the early 1990s, in a three-room apartment. Marina loved her childhood, but was also aware that her family expected her to perform well academically. She denied abuse and had a particularly tender relationship with her grandparents. Marina was 5 years old when her brother was born; she would begin primary school the following year. As a young child, she had shared a bedroom with her parents, but upon her brother’s birth, she would be moved to the pullout sofa in the main room. She felt resentful of the attention that her brother was getting while also being fascinated with the baby. She was encouraged to hold him and attend to him. As Marina and her brother grew older, she would be asked to watch out for him, and Marina would be expected to walk with her brother to and from school, help him with his homework, and keep an eye on him when the two would play with their peers outside. When she began primary school, she was encouraged to study hard and was taught that as a Jew, she would have to outperform her Russian peers academically to achieve the same positions in life. Her initial encounters with anti-Semitism occurred during primary school – a group of her classmates chased Marina and another Jewish student. They called them “kikes” and yelled at them to “go back to Israel.” She was told that Jews make matzos out of the blood of Russian infants by another classmate, and another boy pelted her with rocks on a walk home from school. However, the same peers spoke to her and engaged with her in the classroom at other times.

Marina was 9 when her parents began the emigration process, and along with her family, she would be awarded religious and political refugee status. At age 14, along with her family, she relocated to the United States, settling initially in a working-class neighborhood of a major northeastern city. The city boasted a large Soviet-Jewish immigrant community, and her parents enrolled her in a local middle school with a sizeable Russian-speaking immigrant population. Marina remembered that as someone from Moscow, she was seen as spoiled and rich by peers who had immigrated from more peripheral cities and towns. She also recalled a fair amount of segregation at her middle school, noting that the school had a large, diverse immigrant population, and students would mostly keep to their own ethnic and immigrant social groups. At that time, Marina had felt particularly lonely, as her parents were too busy working to spend time with her. Her mother worked as a laboratory technician and, then, as a pharmacy technician, all the while studying for her United States Medical Licensing Exam to become qualified to practice medicine in the United States. When her mother matched to a medical residency program, her long work hours precluded her from spending much time with Marina. Marina’s father struggled to find an engineering job, working several menial jobs delivering pizza, and installing carpet until he secured his first professional position. Marina noted that her parents were fairly lucky, as both had been reasonably fluent in English upon immigration and found professional employment fairly quickly. She recalled her mother’s sadness and worries over the possibility of becoming credentialed as a physician in the United States and noted admiring her mother’s determination. Her parents placed a lot of responsibility on her for taking care of her brother. Busy with work and their studies, they would send Marina to parent-teacher conferences at his school, as her grandparents did not speak enough English. When her grandparents’ health began to deteriorate, Marina was expected to accompany them to medical appointments and interpret her grandparents’ concerns for their providers. Nonetheless, Marina excelled academically and joined her high school swim team. Her parents were skeptical about her extracurricular involvement but encouraged her once they learned that extracurricular activities would make her a compelling college candidate. They also encouraged her to become involved with a Jewish youth organization in the area. Marina felt awkward joining this particular group, as most other participants were American-born residents of affluent neighboring suburbs. She felt marginalized as an immigrant from a relatively poor and urban immigrant background. She assumed that it would be easy to make friends in this group, but was snubbed by other Jewish teenagers. She felt self-conscious about not having the right kinds of clothes, of speaking with a slight Russian accent, and of living in an apartment in a working-class urban neighborhood as opposed to a single-family home in the suburbs. Most of her peers from this group attended high schools in the suburbs that were academically more competitive than her urban high school. Despite these differences, she developed a particularly strong friendship with one young woman in that group.

Marina was accepted to a top-tier university 2 h away from her family home and accrued considerable financial aid through grants, scholarships, and loans, enabling her to live on campus. Her parents and grandparents expressed their reservations about her going away to college as opposed to living at home and attending university in her home city, which was the norm in their immigrant community. Her decision to move away to college and take the opportunity to live away from home was a source of many arguments, exacerbated by dating a classmate who was neither Jewish nor of Russian decent. Her parents’ work schedules would prevented them from accompanying her to some of the orientation activities at her college. Her parents, however, helped her move into her residence hall, and purchased a used car for her, allowing her to travel home on the weekends.

Marina’s parents and grandparents encouraged Marina to pursue the sciences, engineering, or business as a major, urging her to pick a practical field that would ensure her with a steady income and a good quality of life. She half-heartedly declared Chemistry major with a premed concentration, although she noted interest in the arts and humanities, including creative writing. Since beginning her freshman “weed-out” courses, she has struggled academically, to her great anxiety and worry. She felt fearful of letting down her parents due to the tremendous sacrifices they had made to bring her and her brother to this country. She also felt disloyal to her parents for disliking her science courses. She thought that she lacked the study skills that other students had accrued at more competitive institutions and procrastinated, engaging in the phobic avoidance. She experienced immense amount of guilt if she chose to stay on campus to socialize with her peers instead of traveling to her hometown to help her brother with his homework and assist her parents with caring for her grandparents. The end of her high school relationship further exacerbated her symptoms of anxiety and depression. With the end of her first semester of college approaching, Marina felt increasingly more desperate with her worsening grades. She had begun to skip classes and linger in bed, sleeping through the morning. She would skip meals and began losing weight, prompting concerns from her family and friends. In the afternoons, she would attempt to study to catch up on the work she had missed, only to engage in experiential avoidance through playing games on her phone, perusing social media, or watching television shows and noted that she would have problems with falling asleep and would frequently awaken in the middle of the night. She pursued counseling at the insistence of her roommate who was troubled by Marina isolating and becoming reclusive. At her initial evaluation, she denied suicidal ideation, but endorsed hopelessness. However, as her therapeutic alliance with her therapist strengthened, she disclosed that she had experienced passive suicidal ideation without intent or plan. Simultaneously, she had found herself struggling with feelings of shame, guilt, and anxiety over experiencing suicidality while holding on to hopelessness, sadness, and a belief that she was a failure. She indicated that she was letting her family down by her worsening academic performance and also disappointing them by experiencing suicidal ideation. She believed that her suicidal ideation was indicative of her lack of resiliency and not measuring up to her parents’ persistence, perseverance, and achievement in the aftermath of immigration. She was engaged in an integrative therapeutic treatment, which included traditional cognitive behavioral therapy, including such techniques as Socratic questioning, cognitive restructuring, and relaxation training and a mindfulness-based approach that taught her to practice nonjudgmental self-compassion, present-moment awareness, and cognitive defusion. She responded well to a combination of both CBT and ACT. After 15 sessions of therapy (intake took place over a span of two sessions), she developed increased self-efficacy and hope and experienced a softening of her categorical perfectionistic thinking, and she began developing increasing flexibility. Most importantly, she was able to acquire and practice self-compassion that allowed her to experience empathy rather than shame at her past suicidal ideation. As Marina’s self-efficacy increased, so did her comfort with her bicultural, bilingual, 1.5 generation identity. She realized that she had the liberty to move flexibly across both cultural paradigms and neither lose her Russian-Jewish identity and become subsumed in American culture nor reject the American collegiate culture of her peers in favor of upholding the cultural mores and values of a bygone society. She returned for maintenance psychotherapy six times the following academic semester and no longer endorsed symptoms of depression, anxiety, or suicidal ideation. Her academic performance improved, and she changed her major to Journalism. She became more comfortable setting healthy boundaries with her parents and peers in the service of living according to her unique values, one of which included maintaining healthy, balanced relationships.

Introduction to the Population Group

It should be noted that for the sake of brevity, in this manuscript, Russian-speaking, predominantly Jewish immigrants from the Former Soviet Union are referred to as Russian-Jewish. Whereas the majority of this émigré population identifies as Jewish (and the complexity of Jewish ethnic, religious, and cultural identity in itself is far too complex to be explored fully in this brief scholarly discussion), and whereas most immigrants from the Soviet Union to the United States have Russian as their first language, many of them are in fact Ukrainian-Jewish, Moldovan-Jewish, etc. Also, Russian-Jewish and Soviet-Jewish are used interchangeably in this text, due to the lengthy cultural precedence of first, Imperial Russia and following the October Revolution of 1917, Soviet Russia, engaging in the Russification of Soviet culture in the Former Soviet Union [1]. Although historical scholars would divide the process of Russification in three distinct processes – Russification , Russianization , and Sovietizatio n [1], the particular vicissitudes of these unique phenomena are beyond the scope of this manuscript.

The history of the Russian-Jewish immigrant community in the United States cannot be examined without considering the traumatic history of the Russian-Jewish community in Russia and the circumstances surrounding the arrival of this group in the United States. Over the course of the modern era, Jews had been systematically massacred and expelled from every single European country [2]. Jews were expelled from the countries of Czarist Russia multiple times, from the 1495 expulsion from Lithuania to the 1727 expulsion from Russia proper to the 1843 expulsion from Southern Russia [2]. In 1772, all Jews within the Russian empire, including Poland, Baltic Republics, Russia, Ukraine, and Belarus, were deported to the Pale of Settlement, the few territories where Jews were permitted to reside within the Russian empire [2]. The initial immigration of Jews from the Russian Empire to the United States took place following the upswing in violent pogroms of the 1800s, and the majority of the modern-day American Ashkenazi Jewish community is comprised of descendants of this group of Jews [2]. Sixty percent of Ukrainian Jews, 65% of Belorussian Jews, 90% of Jews from the Baltic Republics, and 40% of Jews from Russia proper were exterminated during the Holocaust [2]. In the Soviet Union, between systematic persecution by Stalin’s regime in the 1930s and subsequent state discrimination against Jews in the workforce and education , including limits on how many Jews could be admitted to universities, the Russian-Jewish community and other religious minorities and political dissidents often had to contend with the threat of forced psychiatric hospitalization and forced psychiatric medication, torture, and imprisonment in labor camps [2]. Although a trickle of Soviet Jews managed to escape to Israel and the United States during the 1970s, the beginning of Perestroika, the era of government reform that would eventually lead to the demise of the Soviet Union, and the demise itself, respectively, brought a large number of Soviet immigrant Jews to Israel and the United States. From the mid-1980s and until 2008, more than a million immigrants from countries of the Former Soviet Union (FSU) were admitted to the United States, with the majority of those immigrants emerging from the three Slavic republics of the FSU, including the Russian Federation, Ukraine, and the Republic of Belarus [3]. Between 1995 and 2005, 450,000 immigrants from the Commonwealth of Independent States, a conglomerate of countries that had in their previous incarnations been Republics of the Soviet Union, have been documented by the Immigration and Naturalization Service [4]. Additionally, an additional 250,000 undocumented immigrants had arrived around the same time, bringing the total number to 700,000 [4]. At present, 44% of all European-origin emigrants to the United States hail from Russia and countries of the Former Soviet Union , including Ukraine [5], and the majority of this population are native Russian speakers.

Some studies indicate that as many as 67% of this group have been Jewish religious and political refugees escaping persecution by the Soviet state, as well as the pervasive institutional oppression and culturally sanctioned anti-Semitism [2, 6, 7], although due to systemic repression of religious and cultural expression by the Soviet state, many remain secularized and religiously nonobservant [3]. Among Jewish refugees from the FSU, their lack of knowledge of religious rituals and Hebrew or modern Jewish culture may serve as a barrier for their acculturation into the American Jewish community [2]. Limited English-speaking ability may isolate them from the American community at large upon arrival into the United States, contributing to feelings of worthlessness and depression [8,9,10,11] which are further worsened by the disruption of extensive, multigenerational friendship networks, loss of professional identity, and economic uncertainty [10, 11]. Many Russian-Jewish immigrants retain somatic symptoms of anxiety and depression after as many as 6 years in the United States [9]. Research also supports higher rates of alcohol abuse in the Russian-speaking population (e.g., [12]).

Other Russian-speaking and non-Jewish immigrants from the FSU include Muslim refugees escaping sectarian violence , the war with Chechnya, and political disintegration in the wake of the dissolution of the FSU and Slavic origin immigrants who immigrate to the United States for economic reasons. Some of these immigrants escaping sectarian violence may be struggling with the additional stress of anti-Muslim prejudice and racism from the general American population [13] while simultaneously feeling isolated from their Russian-Jewish peers due to marked religious and cultural differences. At the same time, they may flounder in acculturating in a Western country after emerging from a conservative Muslim surrounding. The trauma of fleeing a war-torn country and disintegration of immediate and extended family networks may further complicate their acculturation process [13].

Due to the systemic enforcement of collectivist Soviet norms, most Russian-origin immigrants have been raised with a more collectivist mindset than their Western counterparts. In Russian-origin families, child-raising practices place importance on serving the welfare of the whole family unit and society at large rather than the individual [14]. Soviet child-rearing literature recommends parental withdrawal or love and privileges as methods of punishment and discipline, and immigrant parents from the FSU to Israel report restrictive methods of isolating or ignoring the child to counteract disobedience [15]. Some studies suggest that Soviet parenting styles have assimilated the emphasis on high behavioral control and harsh punishment evocative of the Soviet regime’s style of education [16, 17]. Thusly, Soviet immigrant parenting tends to advocate for harsher punishment and less positive reinforcement than Western parenting [16, 17]. Studies comparing Russian immigrant youth with their Israeli-born peers found that Russian-origin youth perceive their parents as less warm and less supportive than their native-born counterparts and as less emotionally expressive [15, 16, 18, 19]. Another study demonstrated a relationship between harsh, punitive parenting and aggression and conduct disorder in Russian-origin adolescents [16]. In a seminal study examining the suicidal ideation of Israeli adolescents, Ponizovsky, Ritsner, and colleagues found that Jewish immigrants from the FSU were comparatively more distressed and prone to suicidality than their Israeli-born peers [20]. They also established that the risk for suicidal thoughts was highest among those adolescents experiencing family discord, strained relationships with parents, hostile peers, difficulties with language barrier, and heightened anxiety and depression [20]. This finding echoes research coming out of Russia that suggests that strained relationships with parents, single-parent households, and anxiety and depression factored significantly in the rates of youth suicide in Siberia [21, 22].

Marina was born and raised in intact family and noted loving relationships between her family members. She was also relatively privileged, as her parents’ education afforded her with a higher quality of life in terms of economic stability and cultural and educational learning opportunities than someone her age raised in a more rural setting or in a working-class environment. Having grown up in a middle-class family in a city with one of the largest Jewish populations in the FSU but also high incidences of anti-Semitism, she self-identified as Jewish since childhood and reported being keenly aware of her being different from her non-Jewish Russian peers. She cited several instances of anti-Semitism directed specifically at her, and she also remembered her parents encouraging her to outperform her non-Jewish peers academically, as they had been keenly aware of the double standards applied to Jews and non-Jews in terms of exam scores, admissions to universities, and professional advancement. Upon immigration, she was given increasingly more responsibility caring for her younger brother and translating for her grandparents. This is in line with research that has indicated a higher prevalence of parentification in Soviet immigrant families [23, 24]. Researchers posit that parentification in immigrant families enhances family interdependence and relatedness and allows immigrant children more autonomy [23, 24]. In immigrant families, parentification is indicative of a positive relationship with parents and increased positive coping with stressful life events [23, 24]. As Marina spends more time in the United States and becomes more acculturated into American teenage norms, however, she begins to chafe at the spousal role taking and parentification that her parents impose upon her, which is consistent with research in this area [25]. While parentification contributes to her having more self-efficacy, she still feels put upon and exhausted, as she struggles to manage the academic responsibilities of college and the social demands of ordinary American student life, contributing to her feelings of distress.

Community psychologist Dina Birman has extensively examined the acculturation process in Soviet-Jewish immigrant adolescents and their parents. She has found that typically, acculturation progresses in a linear pattern, with behavioral acculturation and evolving cultural identity over time increasing for both immigrant adolescents and their parent group, while Russian language competence remains intact regardless of length of residence for the parent group [26]. However, she observed that Russian-born adolescents maintained their identification with Russian culture over time more than their parents [26], and she also observed that Russian-born peers supported their fellow Soviet immigrant adolescents’ acculturation to Russian cultural norms [27]. She also found that high levels of acculturation to American culture were predictive of support from American peers and higher grades [27]. Both adolescents who had successfully adapted to American cultural norms and those who had remained aligned to Russian culture, reported having their parents’ support and scored low on measures of loneliness [27]. However, successful acculturation to American culture directly influenced distress [26, 27], whereas acculturation to Russian culture predicted less distress only if high levels of perceived parental support were also present [26,27,28]. In Marina’s case, she perceived her parents as supportive of her education but hesitant to support activities that were more typical of an American adolescent, such as nonacademic extracurricular activities or dating someone outside of her cultural group, mitigating her adjustment.

Russian cultural norms of behavior include a collectivist ideation and imposed social support, including unsolicited encouragement, information and care [29, 30], and genuine expression of emotion, including value placed on experiencing both strong positive and strong negative emotions in the service of growth and authentic living [31]. While Russians tend to report being less happy than Westerners [31], it is plausible that expression of negative emotion is simply more culturally sanctioned in Russian respondents than in the Anglo-oriented culture of the United States. Russian society also demonstrates unique gender norms, as men have the power in patriarchal decision-making, such as an expectation of men proposing marriage, providing financially for their family, and showing gallantry toward women [31]. However, women are expected to maintain the paradoxical dichotomy of balancing both meaningful careers and managing family, children, and household finances [31, 32]. Women are also expected to maintain their appearance and femininity [32], including remaining slender, wearing makeup, having their hair done, and wearing fitted, ultrafeminine attire.

Risk Factors

The stress of immigration constitutes one of the most comprehensive and pervasive disruptions in family life (see Table 12.1). Prior to immigration to the United States, Russian-origin immigrants may have incurred dissident experiences, religious prejudice, cultural discrimination, and institutional racism, as well as exposure to the Chernobyl nuclear disaster and its aftermath and the political unrest secondary to the collapse of the FSU. During migration, immigrants may suffer loss of material possessions, status, and employment and disruption of social networks. Finally, during settlement in the United States, immigrants have to cope with re-settlement stress, including limited employment opportunities and subsequent financial problems; increased care-taking responsibility for ailing, aging elderly and young children; and language problems, impacting their psychological health [10, 11, 33, 34]. Research has consistently demonstrated that adolescent perception of parental attitude and support predicts adolescent functioning [19, 23, 26,27,28, 35]. However, immigration weakens family roles and disrupts boundaries, creating financial concerns and instability, problems in familial relationships and communication, a reduction in family resources, an increase in the number of single-parent households, and increased responsibility being placed on the adolescent, while, simultaneously, linguistic boundaries and financial concerns limit the ability of many parents to be involved in their children’s learning process and functioning [16, 18, 35, 36]. This is similar to Marina’s experience of becoming parentified, while her parents were less involved in her educational journey due to the challenges of their own studies and work. The culture shock of transitioning from countries of the FSU to the United States often leads to depression and demoralization in recent immigrants, exacerbating existing mental health problems [2]. Simultaneously, Russian-origin parents desire to maintain a separate social identity, and culture may contradict the social pressure for immigrant adolescents to acculturate to a new identity [37, 38]. Birman and colleagues have found that over time, Russian teenagers in the suburbs of Baltimore acculturate to American culture similarly to the Russian immigrant adolescents in Israel acquiring Israeli cultural norms [26, 39, 40]. However, she noted that they tend to hold on to their Russian identity in an effort to find or maintain their own sense of identity [26]. She postulates that for the parents of immigrant adolescents, Russian identity has to do with shared history, friendships, Russian language and literature, music and food, and a mutual understanding that comes from noticing others of the same culture, while, for adolescents, many of whom may be quite young at the time of immigration, being Russian may simply mean belonging to a particular group [26]. It is possible that in some instances, the use of this label is used pejoratively by faculty or other students as referring to those immigrant students who have been identified as troublemakers or having a particularly difficult time with adjustment. In comparing the experiences of Soviet adolescents in a concentrated community, a community where many Russian-Jewish immigrants reside in close geographic proximity to one another, vs. in a dispersed community, where Russian-Jewish immigrants are relatively spread out and have more contact with Americans, she has found the notion of acculturative press at work [41], where Soviet adolescents in the concentrated community hung on to their Russian identity in response to discriminatory experiences and negative perceptions of themselves as Russian [41]. This, in turn, may lead them to underperform, academically as well as socially. Marina came of age in such a concentrated community and experienced some discriminatory experiences, both from peers hailing from the Former Soviet Union but more provincial cities and towns and from American teenagers and immigrant teenagers from other immigrant groups.

Table 12.1 Risk factors and protective factors for suicidality in Russian-origin youth
Full size table

Other research has repeatedly pointed to the increased incidences of bullying and peer aggression and violence in first-generation immigrant adolescents [42]. However, still other studies postulate that second-generation immigrant youth are at a higher risk than first-generation immigrants for behavioral problems, including conduct disorders, substance abuse, and eating disorders [43,44,45]. Pumariega et al. suggest that experiences of poverty, racism, and marginalization without the secure identity and traditional values of their parents impact the second-generation adolescent who has not yet developed a secure bicultural identity and skills [46]. It may be possible that points of crisis occur at different times for first-generation FSU immigrant adolescents vs. second-generation immigrant adolescents; for first-generation immigrant adolescents, they might be caught between the stress of immigration, pressure from their parents to maintain the values and behaviors of their home country, and the struggle to form social relationships and fit into American educational and social norms. They might revert to the norms of their home country for comfort and experience homesickness for friends and loved ones left behind, and they may struggle to learn a new language and acclimate to new educational and professional goals . Therefore, crisis points may occur shortly after migration or within a few years of immigration to the United States. For 1.5 generation adolescents who become acculturated into American values, or for-second generation adolescents, born into American culture, the crisis might occur when their newly assumed American values clash with their parents’ more traditional upbringing, such as when they might decide to live outside of the family home while attending college or date someone of a different ethnic, religious, or racial background, as in the case of Marina.

Further, it is also plausible that in terms of religious identity, how a particular adolescent sees him or herself may be disrupted by the process of immigration. In the FSU, Jews were seen as a distinct ethnic and religious minority and were targets of significant anti-Semitism, racism, and institutional oppression. They were not viewed as ethnically Russian and registered in their passports as having a Jewish nationality. In the United States, Jews are often viewed as a predominantly White, assimilated non-minority, and many non-Jews tend to view Jews as insular and economically privileged [2]. Birman and Trickett document that both the American Jewish community, largely responsible for bringing Soviet Jews to the United States, and the American society at large would expect that Soviet Jews would assimilate easily into American society, as they tend to be highly educated, employed in professional occupations and White [26]. However, Soviet Jews tend to retain a strongly Russian cultural identity and a secular religious observance, which often isolates them from the American Jewish community [47]. Many scholarly discussions of multiculturalism, oppression, and privilege exclude Jews. Noted feminist scholar, sociologist, and writer Melanie Kaye/Kantrowitz has posited that Jewish oppression “does not fit previously established analyses” (1991, p. 270, as cited in 2). Evelyn Torton Beck, another renowned author, psychologist and scholar posited:

If the concept ‘Jew’ does not fit the categories we have created, then I suggest we need to rethink our categories. This is what feminists have said to the builders of patriarchal theories into which women do not fit, and it is what lesbians have said to feminist theorists who excluded lesbian identity – ‘not we, but your theories are inadequate’. The unwillingness to rethink the adequacy of our categories...suggests a refusal to consider the politics behind our namings and a refusal to face the implications of our questioning (1991b, p. 193, as cited in 2).

Immigrant adolescents from the FSU may not find themselves represented either in position of power, prestige, and privilege or among the underprivileged minorities. A distressed adolescent may not find a space or a voice to address his or her particular concerns. Raised in largely secularized homes, many lack the knowledge of Jewish rituals and may find their lack of familiarity a barrier to integrating into the American Jewish community [2]. In analyzing factors contributing to suicidal ideation in Jewish adolescents , literature has repeatedly documented that religious observance has shown to be a protective factor [48], although in comparison to Jewish teens of other ethnic origins, immigrant teens from the FSU are at an increased risk for suicidality [48], as many of them hail from a relatively secular upbringing in the FSU. Particularly in newer immigrants, lower levels of religious observance, a sense of social isolation, loss of familial and social support networks, identity crises, difficulties with learning a new language, a sense of estrangement, and family conflict have been shown to contribute to suicidal ideation [48]. In comparing a US sample of Jewish adolescents to an older, community sample, Kakhnovets and Wolf found that for a younger population, mean age 18.98, Jewish affiliation was not a moderator between ethnic identity and spirituality [49]. The authors proposed that younger people might have competing activities that occur on the Jewish Sabbath, whereas for older adults, attending services might serve as a means of social contact. This may be particularly salient in examining the susceptibility of immigrant youth to suicidal ideation, as secular immigrant adolescents residing in more diverse environments may be even less likely to pursue religious engagement in the service of identity development, further predisposing them to psychological complications. Regardless of level of religious observance, however, research has shown that Jewish adolescents will identify as Jewish [49], and other research has demonstrated that a strong Jewish ethnic identity is predictive of a higher self-esteem and tends to moderate the relationship between perceived discrimination and depressive symptoms in Jewish Americans [50]. In fact, Jewish adolescents rate themselves as consistently higher on measures of ethnic identity than White Americans, but not as high as ethnic minorities [50]. Interestingly, in a survey examining Jewish identity in Soviet-Jewish immigrants vs. American Jews of Eastern European descent, Rosner, Gardner, and Hong found that Soviet Jews felt that their Jewish identity could be a bridge between American and Eastern European ethnic identities, indicative of a kinship with other Jews regardless of their national origin [51]. However, for American-born Jews, their Jewish identity did not bridge the gap between American and Eastern European ethnic identities [51]. This finding further corroborates the notion that for recent Soviet-Jewish immigrant adolescents coming from a more secular and less religiously observant background, their perception of their own Jewish identity may be strikingly different than that of American-born Jewish teenagers who may be more well versed in religious ritual but have less cultural and ethnic affinity to their Jewish culture than their Soviet-Jewish counterparts. In fact, in order to address the unique needs of the Soviet-Jewish adolescent immigrant community, Young Judaea, a national Zionist youth movement, has begun a program called “Havurah,” Hebrew for “Fellowship” specifically for Russian-speaking immigrant adolescents in grades 8–11. The aim of this nationally recognized program, the first of its kind in the United States, is “to strengthen their Russian-Jewish identity, culture and heritage...allow them to build a community. [The Hevurah program at] Camp Tel Yehudah is the perfect environment for teens to be in a balanced environment that allows them to focus on their Russian-Jewish background, while being part of the greater Jewish community in North America” (http://www.telyehudah.org/program/havurah/) [52].

The use of alcohol or other drugs, parental alcohol and drug addiction, smoking, and poverty were also shown to predict suicidality and suicide attempts in the Russian adolescent population [21, 22]. In the Russian immigrant community, somatic complaints are more socially acceptable expressions of psychological distress than reporting depression or anxiety directly [20]. Post-traumatic stress may also be responsible for somatic complaints [9,10,11, 53, 54]. Forced psychiatric hospitalization of Jewish dissidents and political prisoners in the Soviet Union and cultural norms that enforce the separation of public and private personae in the group may make it difficult for immigrants from the FSU to seek psychiatric or psychological services, which results in recasting psychological phenomena as physical illness and increased somatization [2, 8, 53].

Moreover, in the collectivist Russian culture, friendship networks tend to be multigenerational and span the whole family [53, 55, 56]. Those networks are broken by immigration, and in the process of immigration and resettlement in another country, priorities of new immigrants tend to shift to more pragmatic matters, such as securing a dwelling and finding employment. Whereas the immigrant community may bond together to assist new immigrants in situating themselves in the United States, it is less likely that complex and richly intimate multigenerational friendship networks formed in Russia would be established in a new country over the course of just a few years, with issues of resettlement taking precedence. A small study found that many Russian-speaking immigrants reported significant practical social support from fellow immigrants, such as bringing food to a bereaved family after a loved one’s death or coming together to celebrate a child’s wedding, but few reported feeling true relational intimacy and mutuality , the feeling of being heard, understood, validated, and connected to another fellow being [8]. School adjustment, including feeling great internal and external demands to succeed academically and adjusting to new social norms and practices, may likewise worsen immigration stress for adolescent immigrants [57]. The level of school environment , including parental support at school, such as monitoring and school involvement, as well as teacher support and peer relationships, including perceived peer acceptance and peer rejection, have shown to be significant predictors of immigrant adolescent mental health outcomes and risk behaviors [58].

More recent research has extensively explored the concept of resilience a nd its relationship to psychological functioning, specifically in immigrant and refugee populations. While additional investigations are needed to examine the various causal mechanisms managing the complex relationship between stress, resilience, and psychological outcomes (e.g., [59]), compelling research has demonstrated that while immigration may be a particularly stressful event, not all immigrants are likely to experience lasting psychological distress or functional impairment as a result of migration [60]. In a study of 450 Russian-origin immigrants to Israel, Aroian and Norris found that resilience significantly increased the likelihood of not being depressed [61]. In their sample, immigrants who were older, female, and less resilient and those who experienced greater immigration demands were more likely to be depressed [61]. In a study that utilized epidemiological data and multivariate statistical analysis and incorporated a comparison group of Jews still residing in Russia, Ritsner and Ponizovsky found that distress, hopelessness, depression, and anxiety were predictive of strikingly higher suicidal ideation in recent Russian-Jewish immigrants to Israel [40]. A sense of identity confusion, powerlessness, and loss and lack of social support were also predictors of suicidal ideation [40].

This seems to support the Perez-Foster hypothesis of multiple domains of migration stress, pre-, peri-, and post-migration, impacting immigrant functioning [10, 11]. Interestingly, national origin seemed particularly predictive of suicidal ideation in that more urban immigrants from regions with traditionally elevated rates of suicide, such as Moscow and the Baltic Republics of the FSU, demonstrated markedly more suicidality than those from less industrial, more rural, and more traditional Caucasian and Middle Asian republics (2000). Ponizovsky et al. suggest that increased religiosity, strong national traditions, and more stable intergenerational family networks are predictive of less suicidality in those populations [20]. Hailing from a secular, urbane, and highly educated family environment in Moscow, Marina appears at a higher risk for suicide although her risk is mediated by a warm and supportive relationship with her parents. Having a rich social life with both American- and Russian-born peers in her hometown and in college is also a protective factor for Marina’s risk of suicide.

In comparison with examining prevalence and risk factors for suicidal ideation in Russian-Jewish immigrants, Ponizovsky and Ritsner compared Russian-born Jewish immigrants to Israel, aged 18–74 to indigenous Jews in Russia. They had found that a 1-month prevalence rate of suicidal ideation in the immigrant sample (15.1%) was significantly higher than that in their Russian-based controls (6.6%) [40]. Being younger, living without a spouse, low levels of perceived social support, being a physician or a teacher, a history of immigration from the Baltic countries or Moscow, and duration of stay in Israel from 2 to 3 years are risk factors for suicidal ideation. Of note, physicians and teachers probably experienced higher rates of suicidal ideation due to the lengthy, costly, and challenging journeys those professionals would have to undertake in order to be qualified in their respective professions in the Former Soviet Union . The authors extrapolated that young people must have felt particularly vulnerable and more prone to suicidality due to the identify confusion, dislocation, powerlessness, and multiple losses engendered by immigration and associated rapid cultural change [40]. Also, the researchers had found that suicidal ideation in recent immigrants peaked among those who had spent 2–3 years in the country, suggesting that persistent resettlement difficulties, hardships that remain unsolvable, and ongoing adjustment difficulties may have contributed to the development of suicidal ideation [40]. Finally, high levels of psychological distress, including anxiety, depression, and hopelessness, also contributed to suicidal ideation among immigrants [40]. Other studies, examining the long-term impact of the 1986 Chernobyl nuclear reactor on the population of immigrants from the FSU, found that having lived in close proximity to the damaged nuclear reactor and cognitive belief in exposure to radiation predicted current psychological distress, including depression, anxiety, and trauma in immigrant populations [34, 62]. It is plausible that those adolescents, whose parents have experienced ongoing trauma symptoms and psychological distress stemming from the Chernobyl nuclear disaster, might be at higher risk for developing suicidal ideation. This finding is particularly relevant for those communities with large amounts of immigrants from the Ukraine and Belarus, which were particularly affected by the Chernobyl disaster.

Cultural Specific Symptoms and Expressions

In a comparison study of immigrant adolescents with native-born Israeli adolescents, Ponizovsky and his colleagues at the Ministry of Health found a high rate of acculturation in immigrant children and adolescents, particularly those that moved to Israel from the FSU before the age of 5 and between the ages of 6 and 10, suggesting that they had adopted Israeli ways of coping and cultural approaches to problem-solving [39]. This confirms other research on acculturation of immigrant youth and expressions of psychological distress [60, 63]. Researchers have found a higher rate of suicide attempts among recent immigrants than either Israel-born adolescents or those Jewish teens that were still residing in Russia [20].

It has been documented that Russian-Jewish adult immigrants tend to overutilize medical services and somaticize symptoms of psychological distress [7, 54, 64, 65]. A qualitative study that examined health service utilization by Russian-Jewish immigrants in the Boston area found high levels of depression and somatization in the population [53]. One immigrant described the stress caused by immigration:

The whole process of immigration ...the preparations, the expectations, the waiting and then coming here and dealing with all the problems... is very difficult. This translates into major depression. People abandoned jobs they loved, miss their family and relatives, the places they used to like. They even miss their language [53].

Another immigrant explained:

When you have bad moods, you start feeling physical aches and pains. You don’t feel well. You feel fatigued. You can’t find anything to distract you from these thoughts [53].

A provider alluded to the tendency of immigrants from the FSU to somaticize emotional distress :

Somatization is a feature of these people. They won’t complain like Americans about feeling depressed. They complain about a pain over there, a pain over here.

Other studies of Russian-Jewish immigrant adults have confirmed the finding that physical manifestations of anxiety and depression presented as heart or chest pain, feelings of weakness in various body parts, and nausea, as well as headaches, backaches, and a variety of other physical symptoms, are quite common in this population [7, 65]. In an examination of the levels of psychological distress in Russian-Jewish immigrants in a primary care setting , 82.5% experienced psychological distress and 43.9% experienced clinically significant symptoms of depression [66]. Hopelessness, anhedonia, lack of optimism, and a dysfunctional attributional style, as contributing to psychological distress, were endorsed by Russian-Jewish immigrants [66]. Ponizovsky has demonstrated that levels of distress in immigrant populations may peak immediately after immigration, as well as several years later [39]. The emergence or exacerbation of family difficulties and underemployment in later stages of acculturation are factors unique to this immigrant population that seem to worsen adjustment and predict psychological distress at later stages in acculturation [39]. While Ponizovsky in Israel [39] and Birman in the United States (e.g., [26,27,28]) found that in many ways Russian-Jewish immigrant successfully acculturate to their host countries and express their psychological distress similar to native-born adolescents, perceived levels of parental support and parental functioning mitigate how immigrant parents and immigrant adolescents might express their distress. Consequently, this impacts where and how the adolescents might seek mental health services. Based on this data, it seems prudent to conclude that medical providers should pay close attention to somatic manifestations of psychological distress among Russian immigrants, as they are often on the front lines in terms of diagnosis and treatment of anxiety and depression.

Further complicating Russian immigrants’ psychological presentations, research has found that adolescents raised by a single or divorced mother have been shown to underutilize mental health services [39, 67]. A recent study found that divorced mothers of immigrants were four times less likely than mothers of Israel-born adolescents to consult someone for emotional or behavioral concerns regarding their child [67]. Also, the same study, examining the prevalence of mental disorder and service utilization in immigrant vs. native-born adolescents in Israel, found that immigrant mothers perceived their children as engaging in less prosocial behaviors and more conduct and hyperactivity-inattention problems than mothers of Israeli-born adolescents [67]. It seems that parents, particularly single parents, may struggle with their own acculturative difficulties and their teenage children’s functioning. This may include developmentally appropriate separation and individuation , acculturation to the host country, and emerging psychopathology. A recent study described Russian immigrants in treatment as a “paradoxical mix of modern and traditional values” referring to expressions of psychological distress, collectivism, gender norms, social support, and parenting styles. Researchers suggested that Russian immigrants constitute a unique amalgam of Western and non-Western, religious and secular, and culturally and ethnically laden beliefs, values, behaviors, and expressions of distress [31]. Based on this often contradictory information, it seems plausible that Russian immigrant parents might hesitate to seek out mental health services for their children, resorting instead to pursuing traditional medical settings for treatment of somatic complaints. However, acculturated immigrant adolescents might behave similar to their native-born peers in seeking psychotherapy or medication. In Marina’s case, she was encouraged to seek counseling by her roommate, and she was amenable to pursuing services but hesitant about disclosing that she was in therapy to her parents. She believed that her parents would judge her as deviant or exceptionally troubled or that they would deem her unable to cope if they knew that she was in treatment. On the contrary, once she did disclose to her family that she was pursuing therapy and antidepressant medication , they expressed their full support, although they were understandably concerned about her prognosis. They did note puzzlement at how therapy might help her cope with her worsening academic performance, and they continued to encourage Marina to work hard, as they tended to conceptualize her academic difficulties as stemming from poor work ethic rather than psychological distress. Marina would often find it burdensome to educate them about her symptomatology, which would continue to remain a source of contention between her and her parents.

Diagnostic Considerations

Ponizovsky and Ritsner found that among those immigrants with suicidal ideation, psychological distress, particularly anxiety and depression, was endorsed most prominently, and the prevalence rate of suicidal ideation for highly distressed immigrants was ten times that of their non-distressed counterparts (38.8% vs. 3.6%, p < 0.001) [20]. Marina endorsed symptoms of depression and anxiety, and she met DSM-V criteria for major depressive disorder, including depressed mood and sadness, anhedonia, sleep problems, including early and middle insomnia and hypersomnia, psychomotor agitation, loss of energy, disproportionate feelings of guilt, and problems with concentration [68]. At the time of her presentation to the counseling center, she was in considerable distress, and she also endorsed marked gastrointestinal problems including nausea, upset stomach, diarrhea, and vomiting, as well as other somatic symptoms, such as bruxism and chest tightness, in line with the somatization that is exhibited frequently by Russian-Jewish immigrants , including adolescents and adults [7, 9, 10, 20, 53, 54]. She also reported symptoms in line with diagnosis of generalized anxiety disorder, including apprehensive expectation, particularly in regard to school work, difficulty controlling worry, irritability, poor sleep quality, restlessness, and concentration problems [68]. Her interpersonal functioning, as regards to her academic work, social life, and family relationships with her parents, brother, and grandparents, was disrupted by both her anxiety and depressive symptoms. Upon further query, she had admitted passive suicidal ideation without intent or plan. Of note, she would also meet criteria for a panic attack specifier, as she would experience panic attacks in the context of exams [68]. Marina would report that she had been diagnosed with bruxism and irritable bowel syndrome (IBS) by her primary care doctor, conditions that have a significant association with anxiety disorders [69, 70]. In line with the somatization observed in Russian-origin immigrants, Marina had been diagnosed with bruxism and IBS by a medical doctor earlier than receiving diagnosis of major depressive disorder and generalized anxiety disorder by a mental health specialist.

While Marina did not struggle with externalizing behavioral problems, such as conduct issues or hyperactivity, research has documented a higher rate of those conditions in Russian-Jewish immigrant adolescents [67] than native-born adolescents. She also did not endorse substance use or abuse, although elevated rates of substance abuse have been well documented in the Soviet-Jewish immigrant population [12, 71]. Marina’s confluence of psychiatric symptomatology, Russian-Jewish immigrant status, and current distress necessitated a thorough interviewing for suicidal ideation and close monitoring. The convergence of her challenging adaptation to college, recent termination of a romantic relationship, tension in her relationships with her parents, and academic stress, coupled with precipitating stress of immigration , rapid culture change, identity confusion, and powerlessness, made her a high risk for a suicide attempt.

Intervention Approaches and Evidence

Jurcik et al. [31] recommend a framework of adapting services to Russian immigrant patients that would adapt more Westernized psychotherapies to the paradoxical Russian amalgam of Eastern, Western, and uniquely Russian values and mores. They suggest examining pre-migration, peri-migration, and post-migration discrimination and trauma experiences along with assessing the levels of acculturation to American vs. native Russian culture including English language proficiency, education, employment, housing and sources, and quality of social support [31]. In Russian culture, stoicism when dealing with suffering, avoidance of disclosure for the benefit of the collective at large, and not asking for advice directly are common social norms. Thus, a clinician may have to take a more active and directive approach [31, 72] while respecting the family’s beliefs.

In formulating treatment for adolescents and their families, it is also important to honor the interdependent relationships between Russian-origin parents and their children, as opposed to individualistic, Western relationships [30]. Russians value and expect parentified and mutually obligatory relationships [23, 24]. They expect their children to be submissive to parental authority figures and often provide them with direct, unsolicited social support [29, 30], while also encouraging them to achieve self-sufficiency [31]. For adolescents acculturated to individualistic, Western culture that values less intrusive , more indirect, and more individualistic Western relationships, the mixed message about submissive obedience and resilient independence may be perceived as controlling, confusing, and oppressive. To a clinician unfamiliar with Russian cultural norms, such parenting may seem enmeshed, boundary-less, and intrusive. In Marina’s case, as she acculturated more to the norms of a Caucasian American university student, she chafed at her parents’ expectations that she maintains her filial obligations to help them parent her younger brother and assist them in caretaking her aging grandparents. She also felt enormous guilt at potentially letting down her parents, both in terms of not living up to these cultural expectations and also in disappointing them with her lackluster academic performance. Thus, she perceived herself as weaker and inferior to them since she could not maintain strong performance in the face of the stress and trauma of immigration.

Russian society demonstrates unique gender norms in patriarchal decision-making powers that rest with men, including an expectation of men proposing marriage, providing for their family, and showing gallantry toward women [31], while women are expected to maintain the paradoxical dichotomy of leading meaningful careers as well as managing family, children, and household finances and all the while maintaining their appearance and femininity [32]. In Marina’s case, she admired her mother enormously and hoped to emulate her. Her mother’s resiliency and persistence in relaunching her career as a physician and her ability to continue to direct the household while practicing her own challenging career were qualities that she admired, and Marina noted worrying that she did not have her mother’s dogged stoicism and endurance and, thus, lacked a fundamental character quality necessary to succeed in life.

Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) is a manualized approach theoretically grounded in cognitive behavioral therapy, dialectical behavioral therapy, and targeted approaches for suicidal, depressed youth [73]. While it has not been validated specifically on Russian-Jewish youth, it has been studied on several multicultural populations, and its pragmatic approach and focus on creating self-efficacy may be particularly beneficial to Russian-Jewish adolescents. This approach is predicated upon the diathesis-stress theory of suicide that suggests that situational stressors, such as school- or work-related difficulties, may trigger suicidal ideation in an individual that possesses the diathesis, a predisposition to suicidality garnered from genetic, cultural, and religious components, psychosocial stressors, and childhood experiences [73].

A chain analysis of vulnerability factors, activating events associated with the crisis that predicated the suicide attempts and adolescent emotions, thoughts, and behaviors around these events, is conducted in order to select intervention strategies and give the opportunity to the patient to feel understood and, also, to help the provider to conceptualize the biopsychosocial framework of patient’s a suicidality and assessment of future risk [73]. The next step in this treatment protocol involves safety planning, including steps that the adolescent can take behaviorally to manage suicidal urges until the next therapy appointment, including internal strategies and external strategies, such as reaching out for social support from family and friends. The therapist would also work with the client to develop a Hope Kit, a concrete implementation of the reasons that the teenager might want to stay alive, including events and activities that he or she may look forward to, people that may care about the client or interests that the adolescent cares about; this kit helps provide the client with a sense of purpose and gives him or her another practical, concrete tool that can be used in a crisis situation [73]. Assessing the client’s strength and involving the adolescent in behavioral activation, mood monitoring, emotion regulation and distress tolerance techniques, cognitive restructuring, assertiveness training, and functional problem-solving, among other skills, can be tailored to the individual’s problem-solving style and based on the case conceptualization and chain analysis conducted in the earlier phase of treatment [73]. Strategies for relapse prevention are then addressed in treatment [73] in order to help the client develop further hope and self-efficacy, and in vivo imagery is used to help him or her practice applying the skills learned in therapy to his or her symptoms [73]. A culturally sensitive version of this approach, incorporating work with a suicidal adolescent’s family, could be utilized to help a suicidal Russian-Jewish immigrant adolescent.

In Marina’s case, she was engaged in a more integrated approach, as she did not have a suicide attempt at the time she had presented for treatment, to manage her depressive and anxious symptoms and passive suicidal ideation. She was introduced to the cognitive model and engaged in developing a biopsychosocial formulation of her anxiety and depression, incorporating a review of her and her family’s peri-migration and migration stressors and the difficulties that they had faced adjusting to the United States. She successfully implemented cognitive restructuring to her distorted thoughts and was able to utilize cognitive restructuring and relaxation techniques to cope with her test anxiety, contributing to an improvement in academic performance. She was also encouraged to share her therapy homework with her parents during her visits at home, which served to engage her parents in intimacy-building conversations with her and helped bolster their support of her. Further, she was engaged in behavior activation, including regular exercise, and encouraged to join a Jewish student group on campus. Eventually, she would become involved in an effort to organize a Russian house on her college campus, a student group interested in promoting immersion in Russian language and culture, with the support from the faculty in the Russian studies department. A pivotal conversation between Marina and her parents regarding her choice of major helped her vocalize her passion for writing and change her major to journalism, nurturing her love for the written word.