Foundations and Applications of Logotherapy to Improve Mental Health of Immigrant Populations in the Third Millennium

Although migration is a natural phenomenon, a number of special conditions of this third millennium result in a rising number of populations exposed, worldwide, to the impact of risk factors for mental health associated to immigration and asylum. In this scenario, the vulnerability to distress and mental health problems such as depression, anxiety disorders and PTSD is increased in these immigrant populations due to the severity of traumatic experiences while struggling in their attempts to reach their destinations but also a poor capacity of immigrant/host to handle the situation once there. The risk for psychological and mental health problems worse with time, failure of expectancies, lack of knowledge of resources or lack of support, among other difficulties. Here, we analyzed the foundations and applications of logotherapy on immigrant mental health problems, showing the benefits that ‘finding meaning and purpose in live’ can have in these populations. Thus, among the interventions that urge to reduce depression and anxiety symptoms among older adult immigrants, we propose three logotherapy techniques, namely, paradoxical intention, dereflection and Socratic dialogue. After development and adaptation to the specific scenarios (populations/ destinations) these logotherapy techniques can have a huge potential to become effective therapeutic strategies improving the mental health of the current immigrant populations facing misfortune in the Third Millennium (Figure 1).


INTRODUCTION
Although migration is a natural phenomenon, a number of special conditions of this third millennium result in a rising number of populations exposed, worldwide, to the impact of risk factors for mental health associated to immigration and asylum. In this scenario, the vulnerability to distress and mental health problems such as depression, anxiety disorders and PTSD is increased in these immigrant populations due to the severity of traumatic experiences while struggling in their attempts to reach their destinations but also a poor capacity of immigrant/host to handle the situation once there. The risk for psychological and mental health problems worse with time, failure of expectancies, lack of knowledge of resources or lack of support, among other difficulties. Here, we analyzed the foundations and applications of logotherapy on immigrant mental health problems, showing the benefits that 'finding meaning and purpose in live' can have in these populations. Thus, among the interventions that urge to reduce depression and anxiety symptoms among older adult immigrants, we propose three logotherapy techniques, namely, paradoxical intention, dereflection and Socratic dialogue. After development and adaptation to the specific scenarios (populations/ destinations) these logotherapy techniques can have a huge potential to become effective therapeutic strategies improving the mental health of the current immigrant populations facing misfortune in the Third Millennium ( Figure 1).

MENTAL HEALTH PROBLEMS AMONG IMMIGRANTS IN THE THIRD MILLENIUM
Migration has been a natural phenomenon throughout the history of humanity resulting in a melting pot of civilizations, cultures and races. However, in the words of the UN Refugee Agency (1), the world is now witnessing the highest levels of displacement on record. The Global Migration Data Portal notes that in 2019 (2) the number of international people residing in a country other than their own reached 272 million (3.5% of the global population), 51 million more than in 2010. They also highlight an important issue: although many of these individuals migrate out of choice, many others migrate out of necessity. Thus, at the end of 2018, the number of globally forcibly displaced people topped an unprecedent 70.8 million, including almost 26 million refugees, 3.5 million asylum seekers, and over 41 million internally displaced persons.
Immigrants face several life-threatening situations such as war, violence and persecution as well as losses during their journey, which hugely compromise their quality of life and mental health (3). These challenges are augmented by postmigratory stressors, such as tense asylum procedures, poverty, isolation, marginalization, fragmented social networks, discrimination and racism, acculturation, language barriers, poor access to healthcare and consequent compromised therapeutic approaches, among others (4)(5)(6)(7)(8). Coping with these challenges sometimes results in mental health problems and illnesses, particularly among low socio-economic backgrounds and those who are more vulnerable such as women, children, the elderly (9, 10). Immigrants experience injustices, human-instigated incidents of trauma, and subsequently respond with anger or anger-related responses. A study on Holocaust survivors and American war veterans showed that anger responses were crucial to their experiences (11). This trend was also shown in post-migration contexts, with anger responses developing independently of anxiety and depressive behavior. In these studies, morality was found to act both as protective and survival factors in the victims' anger behavior.
It's known that people with post-traumatic stress disorder (PTSD) -the most prevalent mental health problem in these immigrants -are also more likely to experience other mental problems, including anxiety, depression, and substance abuse disorder (12). Despite the well-researched effects of PTSD, studies indicated that the contemporary PTSD models fail to capture the complexity, human variation, and international characters of the migration-related traumas (13)(14)(15). As such, the available interventions suggest the uncontrollability of these problems, thus threatening the overall quality of life of the patients and their communities. Nevertheless, immigrant populations remain highly under-diagnosed compared to the rest of the population, thus suffering from low treatment levels (16). Moreover, mental health interventions used are limited in several ways when dealing with the immigrant population (17). Limitations include lack of sufficient evidence on specific mental problems immigrant populations suffer from, therapeutic models developed from studies conducted in Europe and North America, assumptions that specific mental health therapies can be applied across all populations and non-consideration of cultural diversity in applying mental health problems (18)(19)(20). Though mental health risks among immigrants are well documented, there are still multiple gaps in understanding barriers to access and the use of mental health services among various groups of immigrants (21).
In order to develop an effective intervention model it is important to evaluate the patients' entire pre-migration, migration, and post-migration stages as they lead to different levels of risks to mental illnesses (22). Interventions should be based on hope and building confidence and optimism (23). They should also leverage the patients' spirituality, religion, and other cultural factors (24). Logotherapy is thus suggested to have the potential to assist patients in finding new meaning to life and cope effectively with the past and present stressful experiences (25).

FOUNDATIONS OF LOGOTHERAPY
Logotherapy is a meaning-based, value-centered psychiatric therapy developed from the works of Viktor Frankl in the early 2000s. He based logotherapy on the principle that the main motivational force of human beings is to find purpose or meaning in life. Frankl held that no other psychotherapy existed except the theory of mankind. Though he agreed that a man would never be free from all conditions, his experience of life inside the Nazi concentration camps made him believe that man has the capability of resisting and braving the most terrible conditions (26). Therefore, the primary premise of logotherapy is to help patients respond to suffering in a more meaningful way (27)(28)(29). This approach is based on the argument that mental health patients who found meaning can realize their potential and cope with their struggles in a more effective manner. Logotherapy assumes that every human person has a healthy inner core consisting of unique human and adaptive attributes such as sense of humor, love, and capacity to undertake different causes in life. The primary elements of logotherapy include the meaning of life, will to meaning as well as freedom of will (30). Based on these elements, the intervention aims at actualizing the most meaningful values to the patient meaning thereby that there is a purpose for human life (31). Will to meaning implies that the person should be able to access their unique human attributes and should be motivated to make personal sense of life, actions, and actual approach to life. Freedom of will refers to the recognition that the patients have choices and imperative to take responsibility for their choices (32). A person discovers meaning when she/he actualizes personally meaningful values. For this purpose, the person must be committed to defining what they value i.e., experiential value, creative value, or attitudinal value (33). Experiential values refer to experiences, such as love relationships, which the person picks from their environment. Creative values include skills and behaviors associated with work, hobbies, and creative endeavors and usually earn tangible outcomes for the person (34). Attitudinal values are expressed in the manner one approaches life. Logotherapy focuses on the person's ability to make responsible decisions that are adaptive and consistent with their meaningful values (35). In this regard, logotherapy insists that despite the person's circumstances, life still has meaning. Finding meaning in one's life should, therefore, be their primary motivation. Furthermore, all human persons are free to find meaning to whatever they are experiencing in their lives (36). A person's psychological wellbeing would be compromised if their search for meaning is blocked or hindered (37). It is interesting to note that, currently, the transitions from biomedical to emergent recovery-oriented practices in mental health care are also person-centered approaches based on the premises that it is possible to adapt to a mental health condition and that personally centered meaningful goals will contribute to the recovery (38)(39)(40).
Most importantly, logotherapy approaches help the person to deal with their four existential concerns of freedom, isolation, meaninglessness, and death. According to Frankl (15,41), freedom is an existential concern as every person should be able to determine who and what they are, while isolation is the reality that there is a gap in existence between the person and others in the society. Addressing these existential concerns requires effective psychological or psychiatric interventions intended to empower people to find meaning in work, suffering, and relationships (42). Immigrants are free to pursue the meaning from their experiences and how they have responded to the experiences (43). Through this process, an immigrant having a mental health problem can find meaning to life that helps him/her to readjust their attitudes and perceptions of potentially adverse conditions in their life journeys. After finding meaning to these difficult situations, the person will emerge, stronger, safer and happier, thus leading a resilient improved quality of life (44).

APPLICATION OF LOGOTHERAPY TO TREAT IMMIGRANTS IN THE THIRD MILLENNIUM
Logotherapy is developed from a multicultural lens, thus making it potentially more effective when dealing with mental health problems affecting populations of immigrants from diverse backgrounds and places all over the world (45). It leverages on the specific person's beliefs and spirituality in finding meaning to their lives and enhancing their psychological wellbeing (46). Though logotherapy was initially designed to build faith and relationship with God, Crumbaugh and Henrion (47) found that it can be effectively applied to deal with different mental health problems, especially PTSD among immigrants who have endured difficult and stressful conditions, such as war and persecutions (48). Logotherapy follows a philosophy of phenomenological reality. Based on it, logotherapy suggests that the patient is an active participant in their treatment as he/she is an expert in their perceptions of their situations. Logotherapy not only focuses on building the relationship with the higher power but also recognizes that there is a vast variety of cultures around the world, and members of these cultures face distinct existential dilemmas of isolation and meaninglessness. Thus, Asian cultures dealt with existential meaninglessness and isolation as they work their reality towards Nirvana and ultimate transcendence (49).
Generally, logotherapy interventions are based on three primary techniques: paradoxical intention, dereflection, and Socratic dialogue. Paradoxical intention is an attempt to help clients face the situations they are most afraid of (50). This technique works by establishing the anticipatory anxiety that the immigrant is suffering from that is making it hard for them to move forward. Here, the immigrant is guided to overcome anxiety without the use of medications. On the other hand, dereflection is developed from the idea that when a person is suffering from mental health problems, such as anxiety, they are more likely to become hyper-reflective, thus focusing more on themselves and their perceptions (51). The dereflection technique helps to deflect internalization that manifests in perpetual self-examination and assist in seeking external meaning to the experiences and behaviors (52). Lastly, the socratic dialogue technique is an interview-based therapy where questions are asked in a manner that guides the client to take personal responsibility for their life's meaning and purpose (53). Questions asked here are designed to assist the patient in finding meaning to traumatic experiences (54). Usually, this technique involves a counsellor who helps in midwifing the knowledge and capability of the patients into their consciousness (55).
To tackle mental health problems that immigrants are suffering, there is need to recognize the diversity of the immigrants' populations, extent of mental health problems, and diagnosis and treatment limitations, among others before drawing intervention plan (56)(57)(58). In mental health intervention, it is important to consider all the three techniques of logotherapy as people possess different belief systems and will require different approaches to their problems (59). Thus, in the Connecticut in-patient veteran's use, mandatory community service to develop resilience failed in some patients as they increase anticipatory anxiety negatively affecting the road to wellness. (60). In this case, dereflection can be augmented with dialogues to help these patients acquire coping mechanisms that they can apply whenever they experience trauma (61).
In many cases, immigrants are traumatized by the experiences of terrorists attacking travelling buses (62). In such cases, paradoxical intention assists the patient to focus on the other times where he/she made it home safely without any incidences. The technique is based on a reality principle relying on patients understanding the reality of their expectations (63). This process helps the client in readjusting the expectations when going out next time. It is essential to note that many immigrants of violence and conflicts often face the problem of perpetual self-observation to rationalize their trauma regardless of where they come from. In this case, dereflection procedures are applied to help in minimizing their vulnerability to thinking of the stressful events that may increase the chance of depressive disorders (64).
In conclusion, the effectiveness of logotherapy is demonstrated in helping patients to find meaning and purpose in their experiences and lives, and this can be applied to various mental health problems that immigrants face. Three techniques, namely paradoxical intention, dereflection, and Socratic dialogue, empower immigrants to accept their responsibility to live a meaningful life. Nonetheless, studies of logotherapy on immigrant populations are still scarce. We, therefore, suggest future studies should focus more on logotherapy applications and the development of effective therapy for diverse groups of immigrants.