Living in a maze: Health, well-being and coping in young non-western men in Scandinavia experiencing substance abuse and suicidal behaviour

Abstract

The aim of the study was to illuminate and interpret the lived experiences of emigration, substance abuse and suicidal behaviour in young non-western men in Scandinavia. The research questions were formulated as: (1) How is meaning constructed in the narratives? (2) What impact do these experiences have on health, well-being and coping? Data were collected using open-ended in-depth interviews. A phenomenological-hermeneutic approach, inspired by the philosophy of Ricoeur, was used to analyse the data. The naïve reading involved awareness of the participants’ perceived sense of insecurity in life. The structural analysis identified three themes: (1) the meaning of getting in a tight spot, (2) the meaning of being in a fog and (3) the meaning of the burning bed. A comprehensive understanding of the data was formulated as “living in a maze”. Ill health involved having a sense of liminality, which impaired one's possibilities to define and re-define goals. Substance abuse and suicidal behaviour were explicit expressions of not being well, when living in a maze that was perceived as closed. Both problem-focused and emotion-focused coping were used by the participants. These provided the motivation for substance abuse and suicidal behaviour.

• Public health
• emigration
• substance abuse
• suicidal behaviour
• hermeneutics
• men

Introduction

When we were working on an earlier study of young men with substance abuse and suicidal behaviour (Biong & Ravndal, 2007), some alarm bells rang when there was a steep increase in Oslo in mortality from overdoses in male immigrants from non-western countries (Municipality of Oslo, 2005). From 2002 to 2004, the prevalence increased from 3% to 14%. An earlier nationwide epidemiological study revealed a statistically significant association between an intention to die and the number of life-threatening overdoses (Rossow & Lauritzen, 1999). The risk of suicide in this group may therefore be underestimated (Steentoft, Simonsen, Kringsholm, Dragsholt, Worm, Hansen, Müller, Toft & Kaa, 2000; Nordentoft, 2007). International research has identified geographical mobility, age and gender as vital factors in suicide mortality (Burrows, Vaez & Laflamme, 2007; Kwan & Ip, 2007; Mäki & Martikainen, 2007). However, the picture is not unambiguous, as for example Sundaram, Qin and Zollner (2006) found suicide risk to be significantly lower amongst Asian-born persons immigrating to Denmark.

Suicidal behaviour is still mostly studied using quantitative methods. Hence, it could be argued that there is a need for more analysis of subjective experiences. The meaning young immigrant men give to their experiences of disrupted life, substance abuse and suicidal behaviour seems to be absent in the literature, as shown in extensive literature reviews done by Johansson (1997), Skogman (2006) and Nordentoft (2007). The lack of qualitative studies indicates a need to look beyond simplistic, linear, risk-factor models to subjective experiences and contexts.

Emigration is the process of leaving one's own country in order to settle permanently in another. Several studies have shown that non-western immigrants experience poorer than average health in Scandinavian countries (Povlsen, 2008). One possible reason for this may be the discrimination experienced by many people with non-western backgrounds in, for example, the labour and the housing markets. Individual lifestyle may also play a part (Hogstedt, Lundgren, Moberg, Petterson & Ågren, 2004). Post-traumatic stress disorder has specifically been related to extreme negative life events before, during and after emigration. This condition heavily impairs the social and psychological functioning of the individual (Richman, 1998).

Health and well-being

The concept of health may be defined in different ways based on ontological assumptions and view of man (Tengland, 2007). Since acculturation, that is behavioural and psychological changes that occur as a result of contact between people belonging to different cultures (Povlsen, 2008), may be part of the process of adaptation to new conditions, health in the present study is seen as the balance between the individual's goals, the individual's repertoire and the environment in which the individual acts (Pörn, 1993). Inspired by Pörn, we understand health to be the ability to define and re-define goals, and to achieve them by means of balancing repertoire according to the environment. A holistic view of health means that health could be improved by increasing one's repertoire (capacity and/or ability), revise one's goals and/or influence the environment in order to make actions easier. Further, Pörn's perspective allows an individual to enjoy health even if one has a diagnosed disease.

The World Health Organisation (WHO) defines well-being as how individuals can realize their own potential, cope with the normal stressors of life, work productively and fruitfully, and be able to contribute to their community. According to the WHO (2005a, b), public mental health policy is crucial to achieving such aims. Policies on labour, urban planning and socioeconomic issues are regarded as having an important impact on mental health and the risk of mental health problems. Therefore, a healthy policy requires intersectional linkages and it should incorporate multisectorial and multidisciplinary approaches (Ingleby, 2005; Kickbusch, 2007). A more philosophical conceptualization of human well-being is presented by Sarvimäki (2006) and this has informed our point of departure when trying to describe alternative ways of well-being. Based on Heidegger's ideas of Being, well-being could be understood as comprising a sense of familiarity and authenticity in the everyday unfolding of life, as well as orientating towards the future and realizing one's potential. According to Sarvimäki (2006), confronting anxiety and death also forms part of this orientation.

Stress and coping

A basic assumption in this study is that emigration is a stressful process in life. According to Lazarus and Folkman (1984), psychological stress is a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being. Stress and coping emphasizes a transactional approach between stressful life events and emotional outcomes, and is said to be mediated by two processes: Cognitive appraisal and coping. Cognitive appraisal is defined as the two-fold process by which people first evaluate or give meaning to the relevance of the stressful event (harm, threat or challenge) and then assess whether coping options exist for altering the stressor. Coping is defined as constantly changing cognitive and behavioural efforts to manage external and/or internal stressors, and conceptualized as a discrete response to a specific event. The response might be differentiated in two main ways; problem-focused coping and emotion-focused coping. Problem-focused coping is goal-directed, as it includes active strategies to solve or manage problems. Emotion-focused coping uses strategies directed at an internal restructuring of emotions associated with specific problems.

By taking a hermeneutic and phenomenological paradigm as our point of departure, we claim an epistemological possibility to improve our knowledge and deepen our understanding of complex social phenomena. Therefore, the aim of this descriptive and exploratory study was to illuminate and interpret the lived experiences of emigration, substance abuse and suicidal behaviour in young non-western men in Scandinavia. Two research questions were formulated: (1) How is meaning constructed in the narratives? (2) What impact do these experiences have on health, well-being and coping?

Method

Epistemological consideration and design

Drawing on the tradition of phenomenology, Ricoeur's interpretation theory (1976) holds the notion that gaining knowledge and understanding about lived experiences cannot pass directly from one person to another, but is to be constructed through the hierarchical interpretation of text. Such an interpretation of life as text integrates explanation and understanding in a dialectic movement rooted in the properties of the text. This movement, the hermeneutic circle, is described as a process, involving first an intuitive guessing of the meaning of the whole, followed by an explanation of the parts and then again a move to a comprehensive understanding of the whole of the text. We found such a phenomenological hermeneutic approach useful when we wanted to analyse and understand how the meaning was constructed in personal narratives.

Narrative theory holds that the most basic way to create meaning out of human experiences is to narrate them and to listen to others (Polkinghorne, 1988). This is especially so if the narrative is about life events which have involved a disruption between ideal and reality, the self and society (Riessman, 1993). We regard emigration, substance abuse and suicidal behaviour as such disruptive activities (Eastmond, 2007). When ontologically subjective phenomena are intersubjectively communicated and are tested using qualitative methodology (Barbosa da Silva & Wahlberg, 1994), such scientifically based knowledge may prove important if it contributes to new perceptions and to the development of services offered to male immigrants, especially when they face existential challenges. The knowledge gained from this study may help to widen the understanding of clinicians, researchers and others about emigration, substance abuse and suicidal behaviour, and the impact on health, well-being and coping.

Participants

Sampling was carried out in cooperation with different treatment centres or, in one case, by word of mouth. On the basis of epidemiological data of premature death in combination with immigration, substance abuse and suicidal behaviour, several substance abuse treatment centres were asked for permission and for help to recruit men between 20 and 40 years of age. To ensure that participants would be able to reflect on and articulate about the subject matter, one inclusion criterion was that they were not currently under the influence of illegal substances. Another was that they had reported previous suicidal behaviour. After several months, four men, Fahrad, Mahmood, Mohammad and Pax (fictive names), aged between 30 and 40, agreed to participate. Since male immigrants form a very small group in the treatment centres, the participants are presented briefly to ensure confidentiality.

The participants grew up in North Africa, the Middle East or South-Asia. All were the eldest son in the family. Between the ages of 14 and 17, they had been forced to migrate due to war or conflicts with the authorities. All except one said that his father had made the decision to leave. The father had the position of assessing the situation for the family, and seemed to have the economic or social resources to facilitate the son's emigration. At the time of departure, the country of destination, with one exception, was not decided.

One participant left his country with his parents and younger siblings, and had family in Scandinavia. The others left alone and experienced one to five years of hardship and poverty on their way through Europe. This transitional period ended when they arrived in Scandinavia. Here they sought asylum and were placed in different kinds of institutions. At the time of interviewing, the participants had been in Scandinavia for 15 to 20 years. Two had a formal education but were in vocational training, one was working in a family-run business and one was engaged in further studies.

Their experiences of substance abuse and suicidal behaviour, with the exception of one participant, had started after immigration. Their substance abuse had developed over time, ultimately ending with poly-drug dependency with periods of daily injections of heroin. None of them had an intimate relationship at the time they were interviewed. One had been married to a Norwegian woman and had children, but was divorced and met his children on a regular basis. Two were receiving inpatient treatment, one was receiving outpatient treatment and one was on medication-assisted rehabilitation. The suicidal behaviour started between the ages of 20 and 35. For three of the participants the last suicide attempt had occurred more than four years ago. One participant had attempted suicide on two occasions during the last year before the interview.

Data collection

The data were collected using in-depth interviews (Mishler, 1986). The interviews took place where the participants wanted, most often where they were living, and during a stable period. The interviews were unstructured by asking the interviewee to associate freely on the basis of an opening question: “Can you please tell me the story of how you came to Scandinavia, what it was like to arrive, and, if possible also tell me how you became addicted to drugs?” The ethical committee assessed whether asking about suicidal behaviour could harm the participants, because of moral, social or religious factors associated with suicidal behaviour in their countries of origin. As a consequence, this was not explicitly asked about in the opening question.

To facilitate a supportive context, in which the participants could feel free to relate and narrate, the researcher (SB) made special efforts prior to the interviews and during the sessions. In the days before the interviews, the appointment was confirmed with the participant. At the session, the interviewee and the researcher engaged in small talk before the interview and had a de-briefing at the end. One interview was carried out in prison. In this position, the researcher had a sense of having the status not only of a nurse doing public health research, but also of a representative for the official authority. The aim of the study and the role of a researcher were therefore specifically re-confirmed.

The interviews took the form of a conversation, in other words, the interviewer did not act like an expert, and in line with Denzin and Lincoln (2003), encouraged the participants to narrate as freely as possible. The interviewer asked questions aimed at further narration, such as, “What happened next?” “Can you remember any more details” or “How do you reflect on this?” Active, respectful and sensitive listening is a prerequisite for creating a context for narration (Alma & Smaling, 2006). During the interviews, all participants told about their experience with suicidal behaviour without the interviewer asking directly. The interviews lasted between one-and-a-half and two hours, and were tape-recorded then transcribed verbatim by the first author. Associations and experiences from both the dialogue and the non-verbal communication that took place during the interviews were noted in order to ensure that these initial impressions could also help with later interpretations.

The part of the study that was conducted in Norway was approved in advance by the Regional Committee for Medical Research Ethics, Eastern Norway Regional Health Authority (Dnr. 05023). One interview was reported, planned and carried out in accordance with the current regulations for research ethics in the relevant Scandinavian country (e-mail November 25 2005). The participants were given both written and verbal information before agreeing to participate. Mainly in cooperation with the treatment centres, individual psychosocial follow-up was planned and offered after the interview if needed.

Data analysis

Lindseth and Norberg's phenomenological hermeneutic method (Lindseth & Norberg, 2004) was used to analyse the text. This empirical method is inspired by Ricoeur's philosophical ideas on interpretation (Ricoeur, 1976), and emphasizes the dialectic movement between understanding and explanation, and between the text as a whole and its parts. The task is to get at the meaning of the studied phenomena. Lindseth and Norberg's method (2004) consists of three different, but interwoven, steps: Naïve reading, structural analysis and comprehensive understanding. Naïve reading is regarded as a first conjecture of the text, and it is supposed to guide and provide the direction for the following structural analysis. Several kinds of structural analyses can be used to explain the text by identifying and formulating themes. As we collected and analyzed biographical narrative material, Labov's (1982) definition of a personal narrative guided our process of identifying the narrative content of the text.

Thirty-eight personal narratives on emigration, substance abuse and suicidal behaviour were identified in the text. They were reflected on against the background of the naïve understanding and then set in relation to each other and condensed into fourteen sub-themes according to their content. The goal is to keep sub-themes as distinct and mutually exclusive as possible while keeping the number of them manageable. The concepts we used to describe the sub-themes were expressed in everyday language. Assisted by the co-author the sub-themes were reflected on, examined and interpreted into higher-level content of meaning forming three themes. This internal verification process was done by continually going back and forth between the naïve understanding, the personal narratives and the sub-themes until all were captured and formulated in different themes. A theme was defined as a thread of similar meaning that penetrated one or several sub-themes.

The process of interpreting the text as a whole meant that we again tried to come close to the text and to re-contextualize it (Lindseth & Norberg, 2004). In order to keep a clear stance between our findings and the discussion, we chose not to include illuminating literature as part of this step. Through reflecting on the three themes in relation to the research questions and the authors’ pre-understanding, we formulated the main theme of the study. This represented a comprehensive understanding of the meaning of the studied phenomena, to which all data are related.

Findings

The main theme, living in a maze, was formulated as a comprehensive and metaphorical understanding of the young men's lived experience of emigration, substance abuse and suicidal behaviour. Living in a maze influenced the participants' health, well-being and coping in several ways. The themes “getting in a tight spot”, “being in a fog” and “being in a burning bed” described the diversity of lived experiences. The three themes were supported by the sub-themes and by the naïve reading (Table I).

Table I.  Examples from the structural analysis.

Unit of meaning (Personal narrative)	Condensation (Sub-theme)	Theme	Main theme
“I … left home when I was 15. I could not stand my father, we argued all the time. … I thought: No! … I just went.”	Becoming an adolescent concerns the conflicting relationship to one's father.	Getting in a tight spot.	Living in a maze.
“My culture gives me quite specific obligations. … I have become useless. … I could do my family a favour by getting rid of myself.”	An emigrating young man using illicit drugs concerns being different and useless.	Getting in a tight spot.
“With heroin I got more and more distanced from society. … You are not part of reality any more. … Death is just one step ahead.”	Becoming addicted to heroin concerns loosing touch with reality.	Being in a fog.
“I longed for safety, but got another defeat. … It was an exhausting fight with my family and I really struggled with wanting to die. … I tried to commit suicide. … The bed caught fire. I could have died. I just sat there, feeling nothing.”	Becoming defeated in family conflicts, while longing for safety, concerns adjusting by suicidal behaviour.	Being in the burning bed.

Naïve reading

The participants started to narrate about life just prior to when they emigrated and how the decision to leave their country came about. At the core of the descriptions were the participants’ perceptions of insecurity. Some narrations were about how they had felt different from others in their childhood, because they were the only or eldest son, and had felt insecure because of their social position. War, civil war, political fighting, conflicts with authorities or cultural expectations from one's family were stressful events experienced as insecurity. After emigration, being and feeling alone led to insecurity when one had to face new demands, which led to a wide range of decisions that had to be taken in life.

After immigration, they felt increasingly insecure in their new environment and with a sense that one did not belong. They were unsure about their identity and ended up in new conflicts. Lack of belonging was experienced as not being reassured and valued in social relationships, feeling distanced from others, and loosing their sense of trust. In this position, they began to use drugs, or the use increased. Drugs were described as being a doorway to relaxation, escaping from the pressure and insecurity of daily life, stopping them thinking about problems and creating some good feelings. Recreational use of drugs led to dependency, with daily use of heroin, ultimately creating a sense of being outside reality.

The following narrations were about suicidal ideation and attempts. The social death they experienced was transferred into thoughts of the possibilities of seeking a physical death. It seemed to be of little importance whether they lived or not. Suicidal behaviour was described as one step further on the path of dehumanization one was already on. Killing oneself was thought of and described as a window one could approach, open and jump out of. The window functioned as a border, from where it was possible to escape from life when life was perceived as unbearable.

Lack of belonging and unclear identity seemed to be the cause of conflicts in the new society. They again felt different from others and they were labelled as different. Having psychosocial problems added to this labelling. Fighting their feeling of being rejected and defending their culture of origin (even if they might not feel part of it any longer) became part of the conflict. This fighting was exhausting in the long run and was described as falling between two stools. There were conflicts between the norms and expectations of their family of origin and their identity performance. This was described as being no longer able to live up to cultural demands. The expectations of their family could be altered by the years of separation, and this made them vulnerable when their dreams of how family life could be were not fulfilled.

The escalation of insecurity in the forms of lack of belonging, identity problems and external conflicts led the participants to contemplate alternatives to their current situation. Suicidal ideations, but also planning, varying in intention and duration, were central in these reflections. Living with acting out suicide attempts, in the form of car accidents, overdoses of drugs or prescribed medication, or cutting themselves were often expressions of negative future expectations. Sometimes the participants said they had been seeking death. Yet, they told they had felt frightened when being so close to death.

Being rescued from dying was sometimes experienced as a turning point, and was followed by a reduction in substance abuse or a search for help. Help and treatment were described as getting the addiction under control, and finally as a positive reorientation in the relationship between themselves and their family. A preliminary interpretation on this level was that emigration, substance abuse and suicidal behaviour in the participants could be related to the person's insecurity in life. The sense of being a failure, both according to the expectations of the society of origin and in the new context, and being isolated and left without hope for the future, led towards the final action.

Structural analysis

In the initial part of the structural analysis, the 38 personal narratives on emigration, substance abuse and suicidal behaviour were condensed into 14 sub-themes.

Six of them, “fighting”, “relationship to one's father”, “not being seen”, “being different and useless”, “conflicting values” and “hope”, referred mainly to the domain of managing experiences of the emigration process. Four of them, “to oppose”, “to feel like a wreck”, “fleeing from burdens” and “loosing touch with reality” concerned an understanding of the process in which recreational use of drugs developed into dependency and existential crisis. The last four, “could not go on existing”, “loosing self-worth”, “being useless”, and “adjusting” focused on the motivation for suicidal behaviour.

Furthermore, meaning was constructed across the above sub-themes, and ultimately condensed into three themes involving the meaning of (a) getting in a tight spot, (b) being in a fog, and (c) the burning bed. In the following, the presentation of the findings will be structured according to the meanings assigned to the sub-themes by the researchers, and thus be held as interpretive filters through which subjective experience is conveyed. For practical reasons we chose the most relevant quotes to explain the themes.

The meaning of getting in a tight spot

The constructed meaning of getting in a tight spot concerned the domain of managing the practical problems associated with emigration. The reason for emigrating was most often external conflicts. To get in a tight spot was then experienced as a feeling of insecurity, based on conflicts and opposition between the young boy and, for example, the school system, the police or the nuclear family. Sometimes the practical problems of emigration then had to be solved by the boy himself, as illustrated by Mohammad:

I lived in a poor family, and left home when I was 15. I could not stand my father, we argued all the time. He said: ‘One day you will have responsibility.’ I thought: No! As the first child, I had a lot of responsibility. I thought that I was old enough to manage on my own, so I left my father. I just went.

Conflicts based on expectations of him as the oldest son seemed to give rise to conflicting identities and evoked ambivalent feelings about himself and the future. Deciding to leave his father was a practical solution to structural and emotional distress. Patterns of relationships in childhood and adolescence pointed to some differences in the participants’ experience with and management of the father figure: “I had a better childhood than many others. I knew my father hit me out of love. If you do not hit your son, you are not a proper father”, one of the participants reported. Tensions in family relationships at an early age added to the sense of insecurity and they were later perceived as a source of anger and protest. The protest meant opposing authorities in different ways, often leading to lack of belonging and further conflicts.

Being called up for military service, or actually being involved in war, was reported as an extreme experience of getting in a tight spot. Mahmood, who at one point in his military service could not handle the psychological stress and shot at one of his officers, narrated how he was then taken to a military prison and tortured. Being hospitalized due to the devastating consequences of torture, gave his father the possibility to act and arrange for him to leave:

My father paid a large sum to the night staff and I was kidnapped to get out of the hospital. I hid in a flat for several months. Then my father paid a man to smuggle me abroad. After one year of travelling I came to Norway. I was a total wreck, both psychologically and physically. I wanted to end it all.

His earlier trauma added to the problems of practical adaptation to his new environment. Not speaking the language, feeling isolated, and the physical and mental sequelae of his wartime experiences, brought him into a further tight spot. His perceived insecurity and hopelessness was managed by increasing use of drugs and by the thoughts of the possibility of choosing death as a way out from his tight spot. Then suicidal ideation and planning rapidly emerged, “I thought of death as the best solution”. His reflections were soon followed by a suicide attempt by seriously cutting himself and being admitted to hospital. After hospitalization, he was put on antidepressant medication, and referred for psychological follow up in the community and for specialized psychosocial treatment for refugees. He tried to manage his crises himself by increasing his use of different drugs. The fact that the treatment did not focus on his uncontrolled addiction added to his perceived insecurity: “I never felt secure, as the most important part of my problem was missing. I could not handle the force of the drugs.”

Mahmood's family was shocked by his first suicide attempt, and tried to help. However, this gave rise to another tight spot, that of family expectations. Becoming addicted to drugs was in conflict with his status and role:

My culture gives me quite specific obligations. I cannot live up to any of these expectations. I became a shame to my family. I have become useless. I hate myself so much. I could do my family a favour by getting rid of myself. That would hurt them only once.

An increased sense of unclear identity and low self-worth, coupled with his trying to manage conflicting forces, led to reflections about how long he could go on living. Then, practical challenges in his daily life were perceived of as impossible to overcome. A suicide attempt by having a car accident while intoxicated with prescribed medication, was then carried out with the intention of “ending my life”.

The meaning of being in a fog

The constructed meaning of being in a fog, related to how the participants comprehended their experiences, whereby recreational use of drugs developed into dependency. Dependency was followed by existential crisis in the trajectory towards suicide ideation and attempts. Fahrad made us puzzled when recalling his earlier thoughts of wanting to become a person using drugs: “I wanted to be a drug addict. I could feel this inside me. It would be like having no responsibility in life, being free of all kinds of social bonds.” Pax added some other dimensions: “Drugs are part of a personality I would like to be. I would like to be a rebel and belong to a minority. I will be different.” Living with substance abuse in societies where the use of illicit drugs is regarded as a crime, such an understanding could impair moral choices and easily lead to conflicts.

With the exception of Mahmood, the participants began to use drugs after their arrival in Scandinavia. Using drugs was first a way of trying to cope with their lack of belonging and their unclear identity in daily life, but also with the conflicts with the new society, as Fahrad told about:

The use of opiates was like folding up my body, putting it in a drawer, and getting rid of the burden of carrying it around. I did not get the acknowledgment I needed. Those of us who come here struggle with our identity and the conflict between the values we come with and the values we see in the new society. It is a battle.

The drugs functioned not only to relax the body and to escape from different problems. Drugs also became a doorway to communicate with others. The initial effects created some pleasant feelings and cognitions. However, as the process of addiction developed, a downward journey took over from the initial positive phase, and the whole range of negative consequences of drugs caught up with him and added to the problems of managing and understanding his life. Fahrad described the experience of this downward process as his head becoming foggy. He could no longer see any clear way ahead:

With heroin I got more and more distanced from society. You have no relationship to society anymore. I could sit and observe people around me, everything appeared so meaningless. You even become an observer towards yourself as well. You are not part of reality any more, you are an observer. It is like being an un-soul, and then the wish for death develops. This existence is as close to death as it is possible to come. Death is just one step ahead.

The participant seemed to be preoccupied with a wish to be released from the burdens of living with his lack of belonging and unclear identity. Taking dope with friends for both pleasure and self-medication, and later having death as a possibility, was constructed as a sort of cognitive freedom. Reflections on death escalated when he became distanced from reality, like a sort of social, psychological and spiritual death. This position hampered his cognition of himself and of reality. To Fahrad, understanding his substance abuse as having a fluctuating and permeable border between living and dying later resulted in several suicide attempts, in which the one in which his bed caught fire, was the most lethal.

The meaning of the burning bed

The constructed meaning of the burning bed concerned how different experiences of insecurity provided the motivation for suicidal actions. Choosing between different actions means the process leading to the action that was given priority. Some actions were based on managing problems that stemmed from the participants’ experiences of emigration, others on how life and death, freedom or responsibility, were comprehended. Fahrad, who had high expectations of affiliation with his reunited family in Scandinavia, was very disappointed when he found out that his nuclear family had a very traditional and conservative value system:

I longed for safety, but got another defeat. I withdrew more and more, rejected everyone around me, had no sense of belonging. It was an exhausting fight with my family and I really struggled with wanting to die. One day, when I was alone at my parents’ home, I tried to commit suicide by taking several Rohypnol tablets and heroin. The bed caught fire. My father came and rescued me. He saved my life. I could have died. I just sat there, feeling nothing.

Fahrad's motivation to commit suicide seemed mainly to be his sense of being defeated in a family conflict. This related to his hope that his empty life would be better after the family reunion. When this did not happened, and he could not see any way out of the frozen situation, his suicidal ideation was transferred to actions. Being rescued by accident seemed in the first place to motivate him to decide to reduce his drug abuse.

Mahmood, reflecting on his father's involvement in his escape and survival from torture, recalled how this motivated him to go on living: “I owe him my life, he became the border between living and dying. That is the reason why I want to get something out of my life.” Guided by this motivation, he decided to seek treatment actively. Motivation could be hampered by practical problems, like not speaking Norwegian and not knowing how the health and social systems worked. This delayed treatment for Mahmood and was a source of increased insecurity.

Mohammad narrated how motivation to attempt suicide was based on his feeling that he had lost everything in life: “When you loose everything, then anything can happen. You get so psychologically exhausted, I could not take any more, then the thought of suicide came.” At this time, one of Mohammad's closest friends died from an overdose of heroin. This motivated him to steer his life in a more positive direction: “I told myself I had to return to society and find my life again.” From this position, he managed to get more control of his substance abuse, reduce his suicidal ideation and apply for help. It was a turning point for him.

Comprehensive understanding

One of the participants illustrated his experiences of emigration, substance abuse and suicidal behaviour as living in a maze. In symbolic language, this could also be a metaphor for the comprehensive understanding, integrating the naïve reading, the structural analysis and the authors pre-understanding.

Entering the maze started before emigration, and embedded their experiences of insecurity. Because of difficult circumstances, they were unclear about the direction their existence should take. Opposing authorities, either in society at large or in the family, was part of a feeling of being different from others. These differences emerged at an early age, as the only or eldest son, taking secular and radical choices in a traditional, religious or conservative context. The obstacles this created in the maze were partly managed by practical means in the form of emigration. Emigrating was an act of trying to regain security or freedom, finding a way out of the maze, and hoping for new possibilities in life.

Emigration created both possibilities and obstacles to find a way out of the maze. The possibilities were trying to get an education, paid work or health services. Obstacles were problems of getting permission to stay in the new country and social isolation.

To be different was then understood mainly in two ways. Both understandings hindered finding the path in the maze. The first hindrance was the problems of adapting to the new environment. The second hindrance was the tension between their traditional values and the values of the new society. This questioned their identity and their role towards their father. Not living up to the cultural demands made on them because of their upbringing, was experienced as being specially complicated emotionally, and sometimes created shame. Such conflicts gave rise to an unclear view of themselves and the future, and resulted in escalating substance abuse and later suicidal behaviour.

Not being able to find their way out of the maze, the participants developed a sense of being defeated and not caring whether they lived or died. Long-term and serious substance abuse was experienced as being as close to death as it is possible to come, as physical death was just one step further from living in the maze. This motivated the young men to contemplate or attempt suicide.

They reached a turning point towards getting out of the maze when they reflected on the consequences of their substance abuse and suicide attempts. External factors, such as being recognised as addicted to drugs, being imprisoned and getting the possibility to apply for treatment while in custody, contributed to new hope for the future. The turning point allowed them to revise their thoughts about themselves and their relationship to their family and to society. From this position, they managed to make new and different choices for the future: “I must get out of this”. They found a path leading out of the maze.

Discussion

The aim of this descriptive and exploratory study was to illuminate and interpret the lived experiences of emigration, substance abuse and suicidal behaviour in young non-western men in Scandinavia. By adopting a phenomenological hermeneutic analysis, the findings were that, for these participants, the meaning of their lived experiences was a deep insecurity in life, composed of a mixture of lack of belonging, unclear identity and external conflicts. As a whole, this was interpreted as living in a maze, affecting one's health, well-being and coping in a profound way.

Health

Emigration, a complex social process over time, alters one's goals in life. This process has implications for one's ability to define and reach goals. The decision to emigrate was a goal in itself, but it also meant that the participants needed to formulate new goals as immigrants in a new country. This process represented a journey other than the geographical journey. From an anthropological perspective, experiences of transitions between structural positions tend to impose a situation of liminality on the individual (Turner, 1973). Between a more orderly and predictable past, one suffer from ambiguity when facing an unpredictable future. Turner (1973) holds the notion that the structural invisibility of liminal personae has a two-fold character; they are at once no longer classified and yet not classified. Mahmood literally pictured the consequences of structural invisibility: “We are Norwegians, but are not accepted, not in Norway, and not in our country of origin.”

Altered goals due to changes in status and roles within the social hierarchy, and forced moving from a traditional society to a western, post-modern society at important stages in life with regard to personal development, resulted in insecurity. The participants came to Scandinavia when these countries were in an economic recession (Botten, Elvbakken & Kildal, 2003). A combination of a growing market orientation and more emphasis on individualism and the individual's duty actively to take care of himself, might have led to a high level of tension when the participants tried to identify and ease their problems in an unknown environment. Environmental conditions, such as the legislative framework, the labour market, accommodation, policies and attitudes towards immigrants, and access to health care, added to this. However, comradeship with other individuals experiencing liminality formed an important part of their repertoire and actions. Substance abuse then represented a search for social inclusion. Later, suicidal behaviour was an action for confronting death when liminality seemed unbearable.

Emigration was risky and dangerous, and impaired the participants’ repertoire. Emigrating was initially perceived as an action to solve serious problems and provide opportunities for positive changes and a hopeful orientation towards the future. Nevertheless, the impaired repertoire in the new environment left the participants in situations where previous experiences and resources were no longer sufficient to help them to achieve their goals.

When the participants failed to develop skills regarded as important by members of Scandinavian society, this led to negative moods and sensations. Previous research has shown that the conditions in the receiving country alter the immigrant's health more than negative life-experiences before emigration (Sundquist, Bayard-Burfield, Johansson & Johansson, 2000).

Social isolation in the form of living alone and unemployment, and low self-worth have been shown to be risk factors for suicide (Nordentoft, Breum, Munck, Nordestgaard, Hunding & Laursen Bjaeldager, 1993; Yoder, 1999; Qin, Agerbo & Mortensen, 2003). The mutual dynamics of belonging worked in the opposite direction, as the participants’ sense of low self-worth escalated their withdrawal from social life and thus led to further social isolation. To handle these negative dynamics, suicidal behaviour was used to alleviate their pain and existential void (Biong & Ravndal, 2007). However, one positive part of the repertoire was that the participants did not report misuse of alcohol. This is in line with Hjern and Allebeck's findings (2002) from a national Swedish cohort study, showing that patterns of alcohol abuse in the country of origin are strong determinants of alcohol-related disorders in first-generation immigrants.

Fahrad and Pax expressed an early sense of internal forces pushing them to use illicit drugs, which left us puzzled about how such repertoire may have contributed to their ill health. From a biomedical perspective, health could be linked to possible personal traits in opioid dependency, as recently shown by Kornor and Nordvik (2007). They found differences between the opioid-dependent group and the matched comparison group, suggesting that the personality traits of people with opioid dependence are different from their non-clinical peers.

Well-being

The participants’ well-being was challenged, not only because of their disruptive experience of geographical mobility, but also because of their personal development from child to adult. Adolescence is a vulnerable period, as it is a period of biological, cognitive, and social-relational transition. Traumatic experiences and tension between the generations may have left them with an unclear sense of self and an early sense of unfamiliarity (Lowe, 2003; Sarvimäki, 2006). Emigrating at this time may also have caused additional distress. Although emigration may have been well prepared or self-imposed, it is still likely to result in loss and cause problems in orienting towards the future. Securing favourable conditions during emigration as adolescent is therefore crucial, both for the well-being of young people and for public health policy and practice (Hogstedt et al., 2004).

Well-being is related to emigration as a kind of identity performance project. Emigrating as an adolescent often causes a sense of living between two cultures and as having one role in the family and another in the community, affecting one's identity and personal development (Povlsen, 2008). Metaphorically, this was described in this study as falling between two stools, indicating problems with developing an authentic sense of self, possibly inflicting on the suicidal process (Sarvimäki, 2006; Biong, Karlsson & Svensson, 2008). The experience of unclear identity was also associated with downward social mobility. Class was then a source of unfamiliarity in everyday life and with insecurity in orientating towards the future. Socioeconomic conditions have previously been shown to be related to suicide mortality in men (Burrows et al., 2007; Mäki & Martikainen, 2007). Carballo, Divino and Zeric (1998) argue that the way in which the immigration process can best be made a healthy and social success depends on the new country's ability to respond in a way that can lead to enhanced equity between immigrants and the general population.

Coping

Coping is highly contextual. However, Lazarus (1993) states that some people resist the negative effects of stress better than others do. From an early age, the participants had assessed whether anything could be done to change challenging situations. When they found this to be possible, for example, by fighting against dominating social structures or fleeing from overwhelming situations, problem-focused coping dominated. If their assessment was that nothing could be done, like when they could not handle the forces of the drugs, emotion-focused coping predominated. For their coping to be effective, it had to be changed over time and across different conditions. When Fahrad and Mahmood were arrested and sent to prison for several years, then they seriously started to contemplate their existence. They decided to seek treatment for their dependency and psychosocial problems. To Fahrad, this problem-focused coping was embedded in a specific context, as he could still recall how he felt treated as a subject by the judge in court. Mahmood could enjoy a more positive emotion-focused coping first when he engaged in dual treatment, addressing his dependency and his psychosocial problems at the same time. When dependency was not focused, this gave a strong sense of insecurity, as he then lived with the threat of uncontrollable internal forces. Medication alone was not experienced as sufficient.

The relationship between the participants and their environment was often a source of stress. Some public health researchers report that difficult social relationships and lack of social support seem to affect individuals’ adversely more than socioeconomic position (Volanen, Suominen, Lahelma, Koskenvuo & Silventoinen, 2006). The Finnish study was carried out with different groups and the research design was different, but we also found that health, well-being and coping were heavily related to the domain of social relationships.

Our findings support previous studies that substance use is related to suicidal behaviour both as problem-focused and emotional-focused coping and as a means of suicide ideation and suicide attempts (Rotheram-Borus, 1993; Molnar, Shade, Kral, Booth & Watters, 1998). Further, Neale (2000), and Kidd and Kral (2002), have shown substance abuse to be perceived of as a “slow suicide” by marginalized groups. This provides health and social professionals with several important opportunities to intervene.

Methodological aspects

Life as text, that is the researcher's interpretation and presentation of the stories, does not represent life as lived or experienced. Hence, our interpretation is not established truth, but verisimilitude (Bruner, 1986). Eastmond (2007) points to the fact that the voice of the participant is always interwoven with others, at least with the researcher's. This can create problems in deciding whose voice is heard. However, even with the challenges and limitations of narrative research, the stories of marginalized people are often not deemed relevant or credible, or not heard at all.

A number of measures were taken to ensure validity and transparency during and after the analysis. The researcher's pre-understanding is stated, and reflections are made about the context and the influence of the researcher. Efforts were made to identify data that were inconsistent or that challenged the comprehensive understanding. After the initial analysis, the first author and the supervisor (ER) discussed the developing explanations and interpretation of the findings on several occasions to determine whether the sub-themes and themes represented what they actually were supposed to. The presentation of the findings is as detailed and complete as possible, allowing the reader to view the material that supports the statements made.

Drawing on the ideas of Ricoeur (1991), we argue that the focus should be more on the kind of reflections and actions that the findings of the present study create in the reader when assessing transferability (Wiklund, Lindholm & Lindström, 2002). This notion represents a naturalistic and analytic way of generalization. The researcher or the clinician must make the final judgment about whether the descriptions and interpretations we have given in the present study are sufficiently analogous to be used as a precedent for cases she or he is engaged in.

Implications of the study

By adding to the descriptions of health, well-being and coping in a certain group of immigrants, this study should contribute to the refinement of transcultural skills and awareness in society. In particular, it should help health and social professionals to communicate in a more sensitive way. To develop tailor-made health promoting and preventive measures, the narratives of marginalized actors can provide important experience-based knowledge and illuminate the diversity of experiences involved in complex social phenomena. This may also help to avoid stereotypes of “sex”, “risk groups” or “immigrants” (Eastmond, 2007).

Problem-focused coping may have some important limitations due to possible lack of repertoire in an unknown environment. If this coping style fails, distancing oneself from distress by using drugs or by suicidal behaviour could be of importance. In times of distress, distancing enables a person to appraise an encounter as more benign. From this perspective, emotion-focused coping, for example, in the form of substance abuse, can be viewed as productive, at least in the short run, and should therefore not be met by negative judgements from health and social professionals. A phenomenological stance to lived experiences is of importance in every encounter with an aim of recognizing subjectivity.

In line with earlier studies, this study shed light on the fact that other areas than the health care sector play a vital part in how health, well-being and coping are perceived. For decision-makers the results point to the importance of policies that enhance a sense of security, belonging and identity performance in a group of immigrants. Reducing potential external conflicts between immigrants and local people is also important. This study may generate further ideas and hypotheses to be tested in later studies and for other groups.

Conclusions

To young men experiencing emigration, substance abuse and suicidal behaviour, the constructed meaning of their lived experiences was interpreted as living in a maze. This living was composed of insecurity in life with a mixture of lack of belonging, unclear identity and external conflicts.

Ill health in young men who had experienced emigration, substance abuse and suicidal behaviour involves impaired possibilities to define and re-define goals, and a sense of liminality in an unknown environment. Having been engaged in conflicts before emigrating seems to have a negative influence on well-being following immigration. Structural and emotional problems were perceived as threats to perceiving one's existence as meaningful. Substance abuse and suicidal behaviour were explicit expressions of not being well when living in a maze that was perceived as closed.

Different coping responses were used in different situations to enhance health and well-being. Problem-focused coping was used to solve practical problems, and emotional-focused coping was used to reduce the psychological stress linked to problems with moods and sensations. A combination was used as a motivation for substance abuse and suicidal behaviour.

Narratives can help to explore discontinuities in the lives of young male immigrants, who have used illicit drugs and have attempted suicide in their efforts to make sense of disruptive changes. To help individuals to find their way out of the maze, society in general, and health and social professionals in particular need to recognize subjectivity and look behind generalized notions of individual and social phenomena. In this way, these young men can revitalize their balance between goals, repertoire and environment in everyday life.

Acknowledgements

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.