Culture is an important factor in shaping of identity . Cultural dynamics may play a significant role in appearance of emotional and behavioral problems of an immigrant-adolescent's life.

When individuals migrate from one country to another, it is likely that their cultural and ethnic identity will be influenced from new experiences (Mann 2006). Ethnic minorities including immigrants and refugees can favour either the dominant culture, or their own minority culture, or both or neither. Various terms, like acculturation, assimilation, alternation, multicultural and fusion models, have been used to describe the psycho-social interactions within the trans-cultural process (Floyd  2003, Gül et al 2008,  Machleidt and Calliess 2005).

Acculturation is defined as socio-cultural adjustment and acquisition of dominant cultural norms by members of a non-dominant group. Acculturative stress refers to the psychological, somatic, and social difficulties that may accompany acculturation processes. It was suggested that acculturative stress is a fundamental psychological force in acculturative processes (Berry 2003, Hovey et al 2006).

Acculturation is by no means a stress free process. Mental health problems could be exacerbated by the acculturation stress, leading to a possible conflict with the traditional culture of their ethnic group (Kosic et al 2006, Ward & Kennedy 1994).

Many studies concerning mental health among ethnic minorities have used the concept of acculturation, in particular Berry's acculturation model (Berry 2003), to investigate the relationship among acculturation strategies, acculturation stress, personal self-esteem, and collective self-esteem.

Biculturalism means that an individual was able to gain competence within two cultures without losing his or her cultural identity (La Framboise et al 1993, Vamsi et al 2007, Shuang 2007). Bicultural identity is sometimes disguised to avoid the negative discriminations in a host community, whereby intolerance and prejudices against other cultures prevailed. Being bicultural may also be perceived by the immigrants as a handicap in the acculturation process. This negative perception creates an enormous social acculturation stress for immigrants to challenge (Ekşi & Sığınmacı 2002, Navas et al 2007). 

A positive relationship between cultural values and mental health problems was reported (Lahti et al 2003, Munir & Beardslee 2001). In certain ethnic populations, maintenance of greater cultural values were found to be associated with: decreased self-esteem, an increased state and trait anxiety, and depression; whereas, language and ethnic identity had a minimal influence on the mental health (Hovey  et al 2006, Mossakowski 2001).

A survey over psychological adaptation of Turkish adolescents was carried out in Sweden and Norway. It was shown to be the predictors of good adaptation were Turkish identity and integration, whereas poor adaptation was related to marginalization and perceived discrimination (Virta et al 2004, Vedder and Virta 2005).

Turkish experiences in Germany

Turks have been living in Germany for over 45 years.  The history of the first Turkish immigrants in Germany was marked by the desire to return to the country in which they were born one day. However, time flies; before long they found themselves settled, married and with children, in Germany. Their children attended to German schools. They learned the language. Families bought properties, set up own businesses and employed more people. Before long they have formed the biggest group in the foreign population, with approx. 25 percent. From the total population of 2.4 million Turks, the number of the naturalised persons, up to date, is estimated at around 500,000 in Germany (Migrationsbericht 2006).

Turkish families are the most vulnerable groups compared to others. They are under cultural, financial and psychosocial stress to some extend.  Overall, Turks belong twice/thrice more often to the ?working poor? category than German or  South European workers, partly due to lower qualification and education levels. Turks are also significantly more at risk of being unemployed and requiring social welfare than the latter.

It falls short to meet the cultural and social expectations of the entire family. This leads to a tense and undesirable milieu for the children and young adolescents for the social integration to host German community.

It is estimated that the young Turks of the second and third generation make up ca. 60 percent of the Turkish society in Germany. Half of this population were born and grew up here. Unlike the first generation, the younger generation distinguishes itself relatively by improved training and education, a higher professional position and better linguistic levels.

Nowadays marriages between Turks and Germans are no rarity. As the examples indicate, many youngsters from today's Turkish generations are no longer fixed exclusively on the Turkish culture and lifestyles. Thereby they are expected to be better integrated into the German society and, as a result, motivation to return to the homeland of their parents is lower.

Nevertheless, not every Turkish adolescent manages well the splits between the German and the Turkish culture.  The conflicts have originated from the immigration situation, as for example, to be torn between two cultures under acculturation stress (Yağdıran et al 2001, Murad et al 2004, Schmelling-Kludas et al 2003, Gül et al 2008, Gün and Bayraktar 2008).

Little is known scientifically about bicultural adjustment of the younger generation of Turks in European countries. Due to the diverse cultural backgrounds and perceptions of psychiatric disorders, access, diagnosis, and treatment are especially challenging within the immigrant population (Uluşahin et al 1994, Bhugra 2006).

With the emergence of the concept of bicultural identity, several acculturation inventories and scales were developed mainly in the West. The acculturation scale which was used in this study was originally prepared for the purposes of investigating the personal and collective self-esteem of Latin-American immigrants in the United States. This model distinguishes several domains of acculturation: language spoken most of the time, language thought, ethnic identity, birthplace and the degree of adjustment to the host community (Coronado et al. 2005).

Little research has examined Turkish identity, cultural values, and Turkish language maintenance as predictors of mental health in young people with Turkish origin, living in Germany. By using an acculturation scale, the research presented examined to what extent the individuals with Turkish background identified with German culture and with their culture of origin, in the context of mental health. 

This study adopts an acculturation framework to examine the dominant language, cultural identity, birth place, self-perceptions, and socio-cultural adaptation of young Turkish people, in connection with mental disorders diagnosed in outpatients setting. The acculturation scale was administered in Turkish or German languages according to patients' preference or rather their competence in either language.

Patients: This study includes the data gathered, between June 2007 and May 2008, by using the acculturation questionnaire and the routine psychiatric examination from the patients with an ICD-10 code inside of the Capital-F. The test and psychiatric exploration were carried out simultaneously but separately by a qualified psychiatrist in an authorised out-patient setting (psychiatric practice) under national health insurance scheme in Germany.

According to the patients' self-assessment the data collected were grouped as being acculturated and integrated against being marginalised and separated. Then population statistics were made by using descriptive statistics to evaluate the results. The results were presented in the Table I.

Diagnostic methods

1. Acculturation Scale

A five-question acculturation scale adopted from Coronado et al (2005) in USA was used to study acculturation and the bicultural identity of young Turkish people (between 18 to 30 years old), who had ties with Turkish culture. The questionnaire were prepared in German and Turkish languages and a choice was given to patients to choose Turkish or German languages to complete the tests during psychiatric examination.

2. Psychiatric process

The psychiatric examination of patients included in this study were carried out under the official guidelines of relevant authorities in Germany and the diagnosis were made according to ICD-10 (WHO, German version ?Internationale Klassifikation psychischer Störungen, Kapitel V, Klinisch-diagnostische Leitlinien?). Information over the age, gender, employment, vocational training, acculturation stress, adaptation, adjustment and family dynamics was supplemented from psychiatric exploration.

3. Statistics

The descriptive statistics were employed to calculate statistical means and standard deviation. Furthermore, a statistical comparison was made by using the x² (chi-square) test in two population samples. To do this the Quick Method was used to calculate probability testing in null hypothesis for the data in Group I and in Group II. (Swinscow 1978). 

4. Exclusion criteria: Patients with an organic disease and with an diagnostic code outside Capital-F in the ICD-10.

Age and gender distribution of the patients included in this study are as follows: 122 male patients (55.45%, mean age: 24,34, s.d. ±3,87) and 98 female patients (44,55%, mean age: 21,88,  s.d. ±  2,96)  in total 220 patients (mean age: 23,4, s.d. ± 3,49) out of consecutive 1148 patients (19,16%) at the range of 18 to30 years old were included to this study (19,16%).

The results indicate that among 220 patients included to this study,  154 (70%) patients, (88 male- 57,14%, mean age:22,1 sd. ± 3,26 and 66 female- 42,85%, mean age: 21,73  sd. ± 1,19) were found to be relatively good adjusted (group 1), and of 66 (30%) patients (44 male- 66,6%, mean age:26,3 sd. ±3,39 and  22 female- 33,3%, mean age:25,88  sd. ± 3,41) were found to be relatively poor adjusted (group 2) to the host community (Table I).

The results show that there were significant differences in the two groups (p< 0.001, x²- Testing). Subjects with both Turkish and German cultures have identified themselves as integrated to the German life. These individuals were depicted in the first group with better integration. A majority of the subjects in this group have the ability to use both languages as speaking and thinking languages, whereas, Turkish is the dominant language in the second group. The subjects in the second group pointed out close ties with mainly Turkish language and culture (p< 0.001).

Our findings show that ?birth place' also plays an important role in the acculturation process; more people (65%) were born, in the first group, in Germany, whereas the majority of subjects (82%) were born in Turkey, in the second group (p< 0,001). The findings over description of ?cultural identity' show similarly a significant difference in two groups (p<0.02).

The findings over the ?Employment' and ?vocational training' extrapolated from the anamnesis indicate that these were important additional two predictors facilitating the acculturation process (p< 0.001).

The results presented in Table II showed etiologically two distinct patterns of co-morbidity.  Endogenous depression and the depression caused by the conflicts in the family-milieu are significantly more common in the group with better integration. Unlike, the depression triggered by the psycho-social maladjustment is clearly more prevalent in the group with poor integration (p< 0.01).

The obsessive-compulsive disorders were found exclusively in the first group, while the dysthymia appears to be only in the second group with poor integration. The figures of anxiety disorders, psychosis and substance misuse show no big difference between the two groups.

The results indicate that the majority of young participants born in Germany equally identified with both cultures; suggesting that bicultural identity is a coping resource for young Turks living in Germany. Further, it fails to prove a strong link between Turkish identity and better mental health. The predictors of good adaptation were shown to be: bilingualism, bicultural identity and Germany as country of birth, whereas poor adaptation was related to: dominance of ethnic culture and language, and being born outside of Germany.

The present research provides firm evidence for a bicultural identity through assessments of several domains of acculturation: language spoken most of the time, language of thought, ethnic identity, birthplace and the degree of adjustment to the host community. By the good integration for the people with Turkish background is meant to live side by side with German people without any intimidation, fear or any kind of prejudice arising from issues on culture, ethnicity or race.

The risk of any co-occurring psychiatric disorder was higher among individuals with high levels of total acculturation stress and family-specific acculturation stress. These findings were generally accounted for by associations between affective disorders and high scores on these indicators of acculturation stress.  Nevertheless, the degree of acculturation-related family stress is positively associated with co-occurring substance and psychiatric disorders, particularly affective disorders. Intervention in family strain related to the acculturation process may diminish the development of co-morbid mental disorders.

Some studies have shown that the outcome of many diseases, like many psychiatric conditions, vary across cultures (Gong 2007). Culture of origin and strength of ethnic identity have been reported to account for a significant proportion in perceived physical and mental health. Some studies support the need for considering ethnic identity as well as country of origin in providing care for clients (Cleveland & Laroche 2007).

In agreement with previous studies, (Beiser & Hou 2006, Gong 2007), our results show that dominant language, birth place, employment status and bicultural identity are the most important determining factors in emerging psychological stress in the acculturation process. The findings further indicate that bicultural identity has no role in the development of endogen depression. Psycho-social maladjustment depression is more prevalent with ethnic identity.

Despite the fact that Turks have lived in Germany for over four decades, (Migrationsbericht 2006), the gap in socio-cultural life remains large. Still today, many young Turks feel torn between both worlds. So naturally, the splits between the German and the Turkish culture were not managed successfully by every Turkish adolescent (Ilkilic 2002). This inner conflict feeling often finds its expression in the metaphor: ?sitting between two chairs ?, on one hand, the traditional world of the parents with stronger own cultural values, on the other hand, Germans' liberal life which invites a greater sense of individuality, freedom and permissiveness. This puts (especially) young Turks under enormous psychological pressure (Zielke-Nadkarni 2003, Virta 2004, Pette et al 2004, Vedder  and Virta 2005). Nevertheless, a vital step in bridging this gap would be an equal partnership in the new socio-cultural life, i.e. moving away from assumptions of the linear model of cultural acquisition and assimilation.

Many young Turks, from the second or third generations, project a life-style different from the image of their parents, from the earlier generations. They have become ?conscientious people compromising with two cultures?. Compared to the first generation of Turks, which existed almost exclusively as untrained manual workers, the generation of today present a more promising picture:  It emerges that the Turks are represented in nearly all middle layers of the social pyramid. Turkish society has considerably established itself heterogeneously from employees to employer, from police officers to lawyers, from doctors to MPs, in the German society.

However, the reciprocal influences on cultural identities leading to some degree of bicultural identity, is a rather recent concept in the whole community (Ward 2006). Despite these role models, the question remains wide open: To what extent is the host community ready to see itself as a multi-cultural, unbiased, multi-ethnic society? 

Future studies on the acculturation of Turks living in Germany should distinguish several spheres of acculturation: political, economic, social, family and religion. Furthermore, extensive research should be carried out to assess the ways in which cultural factors contribute both to resilience, and to an increased vulnerability to psychiatric problems.