Mental Health Struggles among Norwegian International Adoptees

Abstract This article explores mental health struggles experienced by international adoptees. A series of 26 qualitative retrospective interviews with international adoptees in Norway, aged 21–34 at the time of interview, shows how a considerable number of these adoptees experienced profound mental health issues, particularly depressive symptoms. The findings suggest that struggles relating to mental health are strongly associated with the challenge of constructing a sense of identity, the lack of a sense of belonging, and grieving for adoption-related losses. The adoptees with these struggles also tended to lack narrative agency—the ability and opportunity to change and influence one’s own life course. This research has implications for policy and practice in the sense that adoptees’ self-reports of mental health struggles, and their link to adoption-specific issues of identity and belonging, demonstrate the need for post-adoption services tailored to supporting adoptees in the construction of a secure sense of identity and belonging. Post-adoption support can help to reduce the risk of rumination over adoption-related questions in solitude and, as such, contribute to protecting the mental health of adoptees.


Introduction
There is a persistent concern that international adoptees struggle with mental health problems (Keyes et al., 2008), and with drug and alcohol abuse (Askeland et al., 2017).The emergence (and persistence) of mental health problems among international adoptees has been linked to adverse pre-adoptive conditions such as neglect and abuse (Cederblad et al., 1999), and to post-adoption difficulties such as issues of identity and belonging, and a lack of connection to one's origins (Grotevant et al., 2017).A particular connection is drawn between mental health problems and a preoccupation with identity exploration (Cederblad et al., 1999;Grotevant et al., 2017).Findings from some studies focusing on international adoptees indicate that those who struggle with identity issues during adolescence are more likely to suffer from internalizing mental health problems such as depression and anxiety in young adulthood (Grotevant et al., 2017).Unknown aspects of their past may make it particularly challenging for adoptees to construct a coherent life story, and this may have longer-term implications for their identity and wellbeing (Grotevant, 1997;Yngvesson & Mahoney, 2000).As such, incoherence in the life stories of adoptees poses a risk to their mental health (Grotevant, 1997;Koskinen & Böök, 2019;Yngvesson & Mahoney, 2000).
While the mental health of international adoptees has been explored in several studies (Hjern et al., 2002;Juffer & van Ijzendoorn, 2005), and its interwovenness with identity construction has been established (Cederblad et al., 1999;Grotevant et al., 2017), the lived experiences of adoptees and their mental health struggles remain under-researched.The role of narrative agency in this area has also not been explored so widely, as the previous research about the connection between identity and mental health has been strongly (and rightly) rooted in explanations of a perceived inherent incoherence in the life stories and identities of adoptees (Yngvesson & Mahoney, 2000).As such, the current study aims to complement earlier research on adoption and mental health, by exploring the lived experiences of adoptees, and the role and relevance of the concept of narrative agency within their life stories.The initial study this article is based on was broadly aimed at studying the lived experiences of international adoptees in Norway, and as such issues pertaining to the mental health of adoptees became a major theme by opportunity only.
Specifically, the objectives of this article are threefold: firstly, to explore international adoptees' accounts of their own lived experiences of mental health problems; secondly, to illustrate the connection between mental health problems and incoherence in the adoptees' stories of identity, belonging, and origins; and thirdly, to explore the role and relevance of the concept of narrative agency for the mental health of adoptees, by examining and illustrating the role narrative agency may play in contributing toward an increase in the sense of narrative coherence and consistency in adoptees' life stories.
In the remaining sections, this article firstly engages with the theoretical framework of the research, exploring how narrative identity theory might be a useful framework for studying the mental health of international adoptees, and particularly focusing on the salient concepts of narrative agency and coherence.Secondly, the section on methodological and ethical considerations illustrates how the life story approach was applied.Thirdly, the results section presents excerpts from the empirical material obtained, seeking to illustrate the lived experience of international adoptees with mental health problems.Fourthly, the discussion and policy implications section seeks to present the key findings extracted from the empirical material presented, and to discuss these in relation to the theoretical concepts of narrative agency and coherence.This section will also include concluding remarks and policy recommendations.

Theoretical framework
Narrative identity theory is a useful approach for understanding the connection between unresolved identity issues and the mental health of international adoptees because narrative identity has been found to be important to psychological wellbeing (Grotevant et al., 2017;McAdams & McLean, 2013).McAdams and McLean (2013) define "narrative identity" as "a person's internalized and evolving life story, integrating the reconstructed past and imagined future to provide life with some degree of unity and purpose" (p.233).This definition is based on the idea that people create an identity through constructing life stories over time, connecting the past, present, and future to provide themselves with a sense of unity, purpose, and meaning, ultimately creating "a coherent account of identity over time " (p. 233).
McAdams (1985) suggested that constructing and internalizing a life story contributes to providing answers to the key identity questions, as set out by the early identity theorist Erikson (1963).These questions are: Who am I? How did I come to be?And where is my life going?To McAdams and McLean (2013), it is thus through narrative identity that "people convey to themselves and to others who they are now, how they came to be, and where they think their lives may be going in the future" (p.233).In this sense, it can be argued that by narrating life stories, "we construct a sense of identity and belonging, and establish how we relate to one another" (Baldwin, 2005(Baldwin, , p. 1022)).
Narrative identity theory suggests a link between mental health and the one's ability to construct a life story, as it is believed that narrating personal stories can protect and preserve a sense of psychological wellbeing.Adler (2012) for example, has highlighted that the psychological benefits are linked with narrative identity, in that it provides the self with a sense of purpose, meaning and unity across time.Further to this, Adler (2012) argued that personal life stories also serve the purpose of giving individuals an opportunity to make sense of their lived experiences.
The concepts of narrative agency and coherence constitute overarching features of life stories and are salient to mental health and a sense of well-being (Adler, 2012).While narrative coherence relates to the ability to link past, present, and future (episodic events) and integrates these into a larger connected life story (narrative) that provides the individual with a sense of meaning (McAdams, 1993), narrative agency refers to "the ability and opportunity to author one's own narrative" (Baldwin, 2005(Baldwin, , p. 1024)).While coherence in life stories is found to contribute toward a healthy construction of identity and feelings of belonging (Kraus, 2007), incoherence in life stories has been linked to psychological distress (Grotevant, 1997).For international adoptees, this concept of incoherence in life stories is a crucial and determining factor in their mental health and sense of identity and wellbeing.
Lichtenstein and Baruch (1996) noted that searching for consistency is an important aspect of adoptees' self-narrative and sense of identity.However, achieving such consistency, they argue, involves a great deal of complexity, due to the many "nested narratives (or narratives within narratives)" (p.92) that adoptees must integrate into their overall life story.Examples of such "nested narratives" pertain to their birth, placement, and adoption stories.These stories may be contrasting in their emotional (and factual) content, in the sense that the adoption story, as often told by the adoptive parents, is filled with aspects of love, happiness, and the forming of a family and attachment between family members, whereas the birth and placement stories may be associated with abandonment, relinquishment, and loss of family members (Lichtenstein & Baruch, 1996).
The knowledge of one's past and biological bloodline is understood to be an important aspect of forming one's identity (Lawler, 2008).For many adoptees, being adopted from overseas, therefore, adds further complexity to identity construction (Triseliotis et al., 1997) as vital information about their biographies and biological connections may be lost or incomplete (Triseliotis et al., 1997).Thus, for adoptees, consistency and coherence in their life stories are often further compromised because aspects may be unknown (Yngvesson & Mahoney, 2000).The incorporation of missing pieces of information-such as adoption status and reasons for relinquishment-also has implications for the stories that adoptees are able to construct for themselves and others (Koskinen & Böök, 2019).Yngvesson and Mahoney (2000) had suggested that a sense of anxiety or lack of certitude may be felt by adoptees whose life stories are incoherent due to missing aspects of their past.
The above section on narrative coherence has illustrated that the ability to construct and maintain a sense of consistency and coherence in identity narratives is seen as vital to a person's wellbeing, and that for many adoptees, this ability is compromised (Baldwin, 2005;Carless & Douglas, 2008;Grotevant, 1997;Yngvesson & Mahoney, 2000).As adopted individuals incorporate information into their own senses of self, and explore different aspects of adoption, they may ruminate over a number of adoption-related topics, such as loss of biological ties and connections.This is because dwelling on and dealing with losses relating to a pre-adoptive past may cause adoptees to experience a grieving reaction.Several adoption scholars (Brodzinsky, 2011;Leon, 2002;Pearson et al., 2007) have noted that a sense of loss can be inherent in adoptees who lack information about their past, struggle with their sense of belonging and identity, or feel (in)different toward their adoptive families.Furthermore, it is a common assumption among researchers and clinicians that the loss of biological family plays a crucial role in the adoptee experience itself, which also has implications for adoptees' sense of having a clear identity.For instance, Brodzinsky (2011) has argued that unresolved feelings of loss can have severe implications for the wellbeing of the adoptee.
Adoption and identity-related rumination have also been linked to the concept of narrative agency (Baldwin, 2005).Important features of agency relate "to the individual's autonomy, achievement, mastery, and ability to influence the course of his or her life" (Adler, 2012, p. 368), which are vital features of a person's wellbeing (Adler, 2012).A lack of narrative agency, on the other hand, may cause rumination and a sense of inability to take charge of one's life; as such, a lack of narrative agency reduces adoptees' ability to construct coherence in their narratives and identities.It is in this sense that Adler (2012) argues that agency is, therefore "strongly connected to the individual's sense of meaning and purpose" (p.368).In line with this, several studies have demonstrated that agency is strongly connected to mental health and wellbeing.
In a mental health context, the absence of the opportunity to construct the one's own story might have implications for how a person creates meaning and coherence in their life (Carless & Douglas, 2008).Those who experience mental health problems may, according to Baldwin (2005), be regarded as having lost "both narrative integrity, on account of loss of coherence and consistency, and narrative agency, because of a loss of the ability to author their own narratives" (p.579).In order to restore and construct narrative coherence and consistency, it is therefore necessary to find methods for adoptees to narrativize their lives in a way that is meaningful and makes sense to them (Baldwin, 2005).Carless and Douglas (2008) noted that meaning and coherence should not be understood as "inherent features of narratives" but rather as themes that are created and developed "through the act of telling stories" (p.579); it has been suggested that increasing agency within narratives can play a crucial part in healing from negative experiences and establishing a stable, coherent narrative identity (Baldwin, 2005).Agency describes a sense of being in control and the ability to make self-determined decisions; these are associated with decreases in mental health problems and an enhanced sense of well-being (McAdams & McLean, 2013).Baldwin (2005) had argued that enhancing narrative integrity and agency can contribute to facilitating the construction of positive and meaningful life stories.
Enhancing integrity, agency, and coherence in life stories can be achieved by supporting someone to construct stories of their past that are based on fragmented or missing information, or that hold difficult emotions (Lichtenstein & Baruch, 1996).This is approached with the aim of helping someone make sense of how they came to be who they are, and of securing their sense of certitude in their own identity and belonging; there is an emphasis on support aimed at joining smaller, nested narratives together, to create a "meaningful whole" (p.91).According to Baldwin (2005), it is necessary to find ways and means to accommodate the different stories into an overall larger story of a life.Baldwin suggests that although various approaches can be drawn on in order to enhance agency (and coherence) in life stories, the life (hi)story approach can facilitate narrative integrity and agency and thus promote coherence and continuity in a person's overall life story.This is because the life (hi)story approach emphasizes appreciation of the uniqueness of the individual through its focus on the individual's present story and its contextual backgrounds.
Narrative agency may involve both the reconstruction and joining of stories, so that life stories and smaller, nested, narratives become related primarily to meaning, rather than being based on factual and fragmented information and chronology.In this sense, the reconstruction and the piecing together of the smaller stories into a cohesive whole can help toward making sense of the individual's "chaos of suffering and loss" (Montello, 1997, p. 194).

Methodological and ethical considerations
The empirical basis for this article is a series of retrospective qualitative interviews carried out for the purpose of a PhD study into the lived experiences of internationally adopted individuals in Norway.A total of 26 interviews were conducted with young adult international adoptees, aged 21-34.Of these, 7 were male and 19 were female.The age at adoption varied, with the youngest being only six weeks and the eldest nearly ten years of age.Some of the adoptees were adopted together with one or more of their biological siblings.Out of the 26 participants, there were 24 individual households represented, meaning that there were two sets of siblings represented in the study.The individual stories of siblings are included and their experiences are considered unique, as the siblings reported different experiences both prior to and after adoption, due to age and their role within their sibling group, their previous living arrangements in their country of origin, and their age and maturity after the adoption had taken place.
The participants originated mainly from Asian, Latin American, and South American countries including China, India, Thailand, Sri Lanka, Colombia, Guatemala, Costa Rica, Brazil, and Peru.They had all been adopted by ethnically white Norwegian couples, meaning that the adoptions were also across ethnic, racial, and cultural lines.The interviews were mostly carried out in the bigger cities of Norway, but the participants had grown up in various parts of the country, including both rural and urban areas.
The interviews were based on a life story approach, which emphasizes letting the participants speak about what is important to them (Hesse-Biber & Leavy, 2006).A few questions were predetermined for discussion, and important themes were followed up as they arose during conversations.The participants were asked about their childhood and adolescence, and their general experiences with being adopted.Examples of questions asked were: Can you recall some very early childhood memories?What was it like growing up adopted?Did you talk much about the adoption in your family growing up?How was it being a teenager?Is there anything that you feel it is important for me as a researcher to know about the experience of being adopted?What advice would you give someone who's considering adopting a child from abroad?Because of the open approach to interviews, adoptees were given the opportunity to talk freely about what they considered the important aspects of their lives.This presented the adoptees with a unique opportunity to share their life stories.
A methodological strength of the open-ended life story interviews was that they allowed adoptees to elaborate on issues that were important to them.To date, very few studies have aimed to capture the views and perceptions of adoptees themselves.The approach the current study has taken complements the existing body of literature on psychological outcomes for international adoptees, which predominantly consists of large quantitative studies based on clinical or national register data.An important aspect of the current study is that many of the adoptees shared highly personal and sensitive pieces of information, which was uncommon in the quantitative research; for this reason, paying careful attention to the protection of their well-being was a crucial aspect of the ethical framework for this study, as the research participants risked interference with their emotional lives when sharing such personal information (Patel, 2005).
After the interviews, any potential harm to wellbeing was therefore discussed with the participants.They were encouraged to make contact should they feel they wanted to omit certain parts of the interview, fully withdraw from the study, or further discuss issues raised during the interview.They were also encouraged to make contact should their mental health status be negatively affected due to participation in the research, or if they needed help accessing counseling or other health services concerning issues revisited during the interviews (Daley, 2012;Dickson-Swift et al., 2006;Lee & Renzetti, 1990;Patel, 2005).

Background of researcher
Prior to undertaking the research on which this article is based, I had little experience with conducting research on sensitive topics.Therefore, when the sensitivity of the topic was revealed in the initial stages of interviewing, it became evident that proceeding with the interviews required me to enhance my knowledge and skills in conducting sensitive research.Literature on conducting interviews involving strong participant emotions (e.g., Booth & Booth, 1994;Dickson-Swift et al., 2006;Liamputtong, 2007;Melville & Hincks, 2016) and practical guidelines originally aimed at research involving subjects struggling with loss and grief due to bereavement (e.g., Jorm et al., 2007;Omerov et al., 2014) became valuable sources to draw on.In addition to this, ample time was spent developing a strong ethical framework, based on a feminist ethic of care, to best meet the caring needs of the research participants.

Positionality
Several aspects of my identity and professional background may have influenced the ways in which participants shared their lived experiences with me during interviews.We shared attributes such as belonging to the same age category and growing up in Norway, which provided a sense of shared understanding of the social, cultural and political climate of Norwegian society during the time when the adoptees grew up.However, there were also important differences in our roles and identities: firstly, I could be considered an outsider, as I am not transracially adopted, and grew up with both my biological parents and in relative proximity to the majority of my extended biological family; further to this, my race did not differ from those in my family or local community, and I belonged to the majority ethnic identity in terms of my racial and ethnic heritage.While many of the adoptees in the study had been raised in middle class homes, several of them struggled to maintain the socio-economic lifestyle into which they were adopted due to unemployment, educational struggles, and/or mental health problems.For me, proceeding to higher education and employment in academia served to maintain the middle class position into which I was born.For these reasons, I was unable to personally relate to many of the experiences the adoptees shared with me.
Beyond these aspects relating to my identity, a mix of my personality and professional background (particularly acquired skills learned from the field of feminist methodological approaches) may have influenced the stories generated and co-created in interviews with the participants in this study, especially in terms of the depth of the interviews, their emotional content, and the related struggles participants shared with me during them.Whilst being genuinely interested in their stories, and therefore being a keen and friendly listener, my professional background working with disadvantaged youths and my professional research training within the social sciences, particularly feminist methodology, may have influenced the ways in which participants came to feel comfortable sharing personal and emotive experiences with me.While the extent to which these factors influenced the empirical data obtained from interviews cannot be fully known, it is important to reflect upon the potential effects aspects of my identity, personality, and professional training and experience may have had on the research.Further reflections on this topic and my experience of conducting these interviews will be discussed in a forthcoming article.
Pseudonyms were used to preserve the anonymity of the research participants.No background information was given about their country of origin in relation to the empirical data excerpts, because providing such information might risk revealing information about their identity.The interviews were tape-recorded, transcribed, and anonymized in accordance with national ethical guidelines, and the interview data were thereafter categorized into themes and analyzed.A wide range of themes was discussed during the interviews and the analysis below was guided by the themes most frequently raised and discussed by adoptees.Reflexive thematic analysis was applied to the process of analyzing interview data, and the specific analytic approach including coding and deciding on themes was inspired by the framework outlined by Braun and Clarke (2006, 2013, 2019, 2021), of which the key aim is to look for commonalities within the empirical material, as opposed to uniqueness of experiences (Braun & Clarke, 2006).Examples of initial codes were "depression," "anxiety," and "confusion;" these later became clustered together to form the major theme, "types of mental health problems/internalizing mental health problems including depression, anxiety and confusion."Smaller themes within the major theme were termed "depression, " "anxiety, " and "confusion." Each of these themes had a list of symptoms (smaller codes)-"clinical depression, " "light depression, " "feeling depressed and/or sense of flat, low, empty mood"-and a list of experiences related to the theme, such as "experiences of depression," including a table containing participant quotes/research notes linked to them.
The aims and objectives set out for the study were to explore experiences of being internationally adopted; thus, the study did not particularly emphasize mental health.However, adoptees were encouraged to talk about significant aspects of their lives.Mental health problems, identity, origins, belonging, and a sense of loss and grief were highlighted by a considerable number of adoptees as significant and prominent aspects.The major themes are included in the analysis below and are illustrated by excerpts from the interviews.The analysis seeks to illustrate the issues related to mental health experienced by young adult adoptees, and the potential links between these issues and the psychological stresses caused by adoption; however, it does not to any extent aim to evaluate whether the adoptees had clinical psychological health issues.

Types of mental health issues experienced by adoptees
Many of the adoptees in the study reported struggling during their young adulthood with issues related to mental health; they believed these struggles had started in their adolescence.The types of mental health problems adoptees faced were mainly internalizing problems such as depression, loneliness, sadness, fear of rejection, and confusion, rather than externalizing problems like anger, behavioral problems, and attention disorders.These findings are consistent with arguments from previous research, which indicate that for young adult international adoptees, mental health challenges tend to fall into the category of internalizing rather than externalizing problems (Tieman et al., 2005).The findings presented and discussed below illustrate the adoptees' own experiences and perceptions of mental health issues.

Depression
Feeling low and experiencing depressive symptoms were among the issues highlighted by adoptees.Alexander (25) struggles with his mental health, and particularly with depression.He talked about anger and frustration after years of searching for his birth family, and he felt ashamed that they did not want to know him when he finally managed to track them down in his early 20s.Alexander discussed his battle with (clinical) depression: I have been going through phases of severe depression since my adolescence.It is not because I was bullied or anything like that.Right now, I am ok, but it is chronic so it returns quite regularly and when it is bad it can be really bad.I am on medication for it and have received counselling but the counselling sort of just makes it worse.I am not able to work so I am on benefits, which is quite sad as I am only 25.It is also quite embarrassing as I really don't want to be the guy who doesn't go to work, you know?So, in a way, it affects the way I feel about myself, too.
Alexander's condition profoundly impacts his wellbeing; it interferes with his ability to function in everyday life and leaves him unemployed as he struggles to cope with and overcome depression.Alexander would like to work, but is unable to, and therefore he receives unemployment benefits.For Alexander, this affects his self-esteem.This demonstrates the complexities of the mental health and wellbeing-related issues that some adoptees face.
In adoption literature, theoretical explanations of depression-related symptoms are often, at least to some extent, believed to be expressions of the loss, grief, and accompanied mourning experienced by adoptees (Silverstein & Kaplan, 1982).These symptoms are often accompanied by a sense of loneliness, which several participants mentioned as a persistent and prominent issue during both adolescence and adulthood.The prevalence and longevity of the feeling of loneliness indicate the extent of the impact it has on adoptees' mental wellbeing.Ida (adopted at six weeks) talked about how loneliness, for her, is connected to sadness and the feeling that others cannot fully understand her pain: It was kind of like very strong emotions all the time.It was-it was a lot of sad stuff.Quite a lot of loneliness.A lot of loneliness.One of the things that was difficult was being alone in it all.I had no other adopted friends, so I sort of didn't have anybody to share that experience with.That's what was the hardest part of it all.I could talk about how I was feeling to my best friend, but it wasn't like she would understand how I felt.That is what was the hardest part…Having to keep all these feelings to myself.You know what I mean?
To Ida, feeling alone with her thoughts and sadness are particularly painful and overwhelming, and have an inevitable impact on her mental wellbeing.Adoptees' feelings of loneliness and sense that others cannot directly understand their situation can be linked to loss-related struggles.As such, loneliness can be a form of loss and grief.Brodzinsky (2011) observed that adoptees who are struggling with adoption-related loss are at risk of feeling "othered," as they feel that there is no one else around them who really understands what they are going through.

Loss and grief
Another related emotion that recurred in the informants' stories was grief.Although expressed and interpreted in a variety of ways, this was mentioned by many of the adoptees.For example, Susanna (31) spoke about how she struggles with an overwhelming sense of grief: What I feel today is grief.This grief appears in all kinds of situations.There's nothing in life that gives me any joy or pleasure because what I should have achieved by now, given my age, I just couldn't achieve because of all the challenges I have had to go through.I struggle to maintain friendships because of my mood disorder, and I have not been able to succeed in education or keep a job, even though I want to.So, sadly, I am unemployed.I can't keep a relationship as I push people away, and I feel grief over not having started a family.The greatest sense of grief for me is grieving the loss of so many things in life.There isn't really much more to say than that.I have kind of started to come to terms with just feeling overwhelmed by grief.
Susanna's grief is connected to her feeling of loss due to adoption-related challenges and makes her unable to feel joy or pleasure, which indicates that the grief is also connected to depressive symptoms.She describes how her mental health problems interfere with her daily functioning and wellbeing, affecting aspects of her life such as relationships, and her ability to acquire education, take up employment, and enjoy family life.She feels grief over her expectations of what she should have achieved at her present stage in life and links her pain to the previous adoption-related hardships.The excerpt from the interview with Susanna is also illustrative of how she lacks narrative agency, in the sense that she is unable to resolve, process or reconstruct past traumatic events relating to her adoption, which is the root cause of her struggle with grief.Because of Susanna's lack of narrative agency, or inability to change her situation, she states that she is trying to accept her situation, which in turn perpetuates her grief, as her deep-rooted suffering remains unresolved.
Susanna explicitly shares that a major aspect of her sense of grief is the losses relating to her adoption.According to Silverstein and Kaplan (1982), loss can be a complex aspect of the adoption experience.They argued that an explanation for this may be the fact that loss, for adoptees, has no closure; the losses in the adoptees' lives appear not only as single occurrences, but also as a process of both identifiable and less identifiable losses, thereby making loss an evolving process.Adoption involves loss, and that requires some form of mourning process for adoptees (Silverstein & Kaplan, 1982).It can be difficult, however, to recognize feelings of loss and grief, because such feelings can be complicated and difficult to resolve (Brodzinsky, 2011); as such, it is challenging to identify exactly how feelings of loss and grief are experienced by adoptees.
Loss and grief, however, were important themes that recurred in many of the interviews.The participants indicated that these issues were related to the lack of knowledge of their origins.The interview with Niels (33) below illustrates how separation from origins can cause emotional pain: I feel a sense of loss and grief when I think about the fact that I was taken away from my origins.
Niels' profound feeling of disconnection from his origins has left him with a feeling of loss and grief as he struggles to accept that he has been separated from his origins.This is one example of how loss and grief were expressed by adoptees in the study.Aspects of adoption, such as being separated from biological parents, or lack of knowledge about one's origins, can manifest in feelings of loss (Brodzinsky, 2011), which are also often related to the loss of cultural connections and a lack of biological information (Pearson et al., 2007).Dwelling on and dealing with losses relating to their pre-adoptive past may also lead adoptees to experience grieving reactions.For international adoptees, during adolescence and young adulthood, "the process of grief becomes more complex and abstract than in childhood; they grieve not only the loss of birth parents and origins, but also part of themselves" (Tieman et al., 2005, p. 678).

Psychosis
In addition to the above-illustrated challenges, the adoptees struggled with such issues as depression, loneliness, and grief.Several of the adoptees also experienced more severe mental health problems, such as psychosis, requiring psychiatric care and hospitalization.The excerpts below illustrate this.
Thomas ( 27) explains that he has bottled up emotions that at some point became too difficult to handle: I have previously been admitted to psychiatric care in order to process difficult experiences from the past relating to experiences of bullying and racial discrimination.

Elisabeth (33) also mentions experiences with psychosis:
I have been psychotic, in and out of psychiatric care, because of everything that's happened.It is an overwhelming experience.
Elisabeth attributes her mental health challenges to her pre-adoptive experiences: I had some baggage from before I was adopted that I don't think anybody thought of, really, because I did not speak Norwegian when I first came here, so nobody really understood what I had gone through.It was mostly related to looking after younger siblings.I also protected my younger siblings from domestic violence before being moved to the orphanage, living our first years with an alcoholic father.Some of the participants, such as Thomas, needed help to overcome difficulties relating to experiences from their adolescence, while others, like Elisabeth, had been experiencing more critical psychiatric problems, such as diagnoses of disorders including psychosis.Both Thomas and Elisabeth associated their experiences of being hospitalized for mental health struggles with adoption-related trauma, unresolved issues, and emotions about the past.Their unprocessed and unresolved experiences of trauma manifested in severe mental health problems.

Suicidal ideation
Some participants also disclosed experiences of suicidal ideation and behavior.They cited a range of emotions as reasons for attempting to commit suicide: I have suffered from depression and suicide ideation for years.I can also admit that I have attempted suicide on multiple occasions because I just didn't want to live.A lot of it has to do with attempted and failed relationships with my biological family.(Alexander,25) For Alexander, suicide attempts were linked to depression, and he explains that depression is the reason for his recurring suicidal thoughts and attempts.For Susanna, however, suicide attempts were a cry for help, and not necessarily linked to a desire not to live: About the suicide ideation and attempts?It wasn't that I wanted to do it, really.But when it comes to attempting suicide, it was more a desperate cry for help, and I was thinking, "Is this really what I need to do in order to get help?"And then it's not like you can tell this to people either-that this is the reason why you attempt suicide.And then it was more like negotiating issues with myself.Should I do it again or not?For now, the conclusion is that I try and get by, day by day, and hope for fewer rainy days.I hope I can stand this and eventually get through it.Mina (28), however, was overwhelmed with emotions, which made her feel confused, angry, and frustrated, and turned her to suicide in a desperate attempt to combat her painful emotions.Adopted as an infant, Mina has struggled with questions of identity and belonging throughout her adolescence, and around the same time as her suicide attempt, she was also diagnosed with bipolar disorder.A particular difficulty Mina experienced was family gatherings, as such events caused intense feelings that she did not belong: When I was 17, I was very confused, and one night I just wanted to put an end to it all, even if I didn't.We were at a family gathering and I just couldn't face meeting people, so I went out and hid and was very close to ending it all.I remember my mum being terrified, and yes, perhaps it was a bad idea, but it was just that I was so frustrated, angry, and confused.Today, even after so many years -I'm 28 now -I still quite often feel like I just don't want to live, and really, I hope I will survive but for now, I have promised myself only to try my best to stay in this life.
The above excerpts, taken from interviews with participants discussing suicidal ideation and suicide attempts, illustrate the severity of the emotional pain and mental struggles faced by adoptees.The reasons given for the suicidal ideations and attempts were varied: Alexander attributed his depression to attempted and failed relationships with his biological family; Elisabeth termed it a cry for help, as she struggled to process past traumatic events relating to her adoption; and Mina believed her suicide attempt was prompted by emotional pain, rooted in confusion, frustration, and anger.
Several of the adoptees in the study discussed similar issues relating to suicide ideation and suicide attempts.The adoptees' explanations for why their struggles were so severe that they saw no other solution than putting an end to their lives indicate that they felt they were unable to cope with their situation.Struggling with past events and the inability to resolve such issues are often the result of a lack of a solid sense of self and personal agency.The adoptees were overwhelmed by loneliness, which underlines the traumatic experiences they had as a result of their lack of connection to their origins, and other unresolved adoption-related issues they faced.

Identity, belonging, and disconnection from origins
Many of the adoptees discussed how they struggled with unresolved issues of identity, belonging, and lack of knowledge about origins during both adolescence and young adulthood, and how the struggle impacted their mental health and wellbeing.The adoptees emphasized that the lack of knowledge was particularly problematic, noting that it contributed to the confusion surrounding their own identity, as well as to the persistence of their emotional pain; this is illustrative of the link between incoherence in life stories and mental health.Participants' lack of knowledge about their past also impacted their narrative agency, as many found themselves preoccupied with turning over unanswered identity questions in their minds.As such, they were unable to resolve their identity issues and reconstruct a meaningful story of their past.The interview excerpts below illustrate the salience of these unresolved issues for identity, belonging, and lack of knowledge; they also demonstrate their connection to adoptees' origins and past, in terms of the emergence and persistence of mental health problems.
Excerpts from the interview with Mina illustrate how she grappled with issues of missing information about her past, and questions about her identity: About the pain related to the adoption, it is like there's a key to a chest of drawers that's missing, and it is like I will never be able to open these drawers.It is the first 6-8 weeks of my life that are gone, and it still severely impacts me.
Although only a few weeks of her life were missing, Mina highlighted how this impacted her mental health and wellbeing.Despite being adopted as an infant, it was her lack of knowledge about the beginning of her identity narrative, including the biological and cultural anchoring of her identity, that Mina had difficulty coping with.The severe impact this had on her psychological functioning is illustrative of her inability to construct a coherent identity for herself without the missing pieces of her past.The inability to (re)construct a meaningful narrative, owing to the missing information, is also indicative of the narrative agency that Mina lacked, making her unable to reconstruct coherence in her identity narrative in a way that made sense to her.She was also unable to relate this narrative to her present and anticipated future, which suggests that this major aspect of her suffering was also related to her lack of narrative agency.This is further illustrated by the fact that Mina continued to elaborate on how questions of identity have led her to contemplate the past, and how these missing aspects of her identity also represented the psychological problems with which she grappled: There are some questions that I have always struggled with, like who is my mother and who am I? I think I was about 17 when these thoughts started to appear and one day I just couldn't manage to go to school.I was just sitting in my bed, staring at the wall and just didn't have the energy or will to do anything.That's the first memory I have of the sort of problems that I struggle with, and since [then] I have been diagnosed with this bipolar disorder.
Mina stated that she began to think about her identity a lot when she was in her late teens, pointing out that these issues eventually resulted in the development of depressive symptoms.She was later diagnosed with bipolar disorder, involving periods of (hypo)mania and depression.For some, the question of identity evolves gradually, and it is not something that they can come to terms with overnight.For example, for Mina, it was an ongoing process during childhood that eventually developed into something she could not handle.Mina's recollections of being unable to go to school and lacking the energy and will to go about her normal day-to-day activities are also reflections of the overwhelming impact that identity-related issues can have on some adoptees, as they struggle to process their situation.
Ida, on the other hand, described how her depression was linked to questions over her origins and identity: I think the depression was due to all the difficulties I had to deal with on my own growing up.Had I known my story earlier -the reason why I was given up for adoption and what my mother looked like, I think things would have been different for me.I think I would have had a better childhood -a childhood where I sort of wouldn't have had to go through so many emotions.
To Ida, depression was linked to not having any (or sufficient) information about the beginning of her life, and the reason she was relinquished by her biological mother.She mentioned that she had undergone bouts of depression since early childhood as a result.Ida thought her depression was ultimately rooted in difficulties she faced constructing a coherent and consistent identity narrative, as she was uncertain about her identity.
From the excerpts above, it is clear that many of the adoptees attributed their mental health struggles to their lack of knowledge about their pre-adoption circumstances, such as the reason for relinquishment, and their lack of connection to, and knowledge of, their birth parents.Unresolved questions of this kind led many of them to agonize over these issues, which led to them being emotionally consumed by them.The above excerpts from the interviews with Mina and Ida are illustrative of the connection between dwelling on identity and depression for adoptees.
Like Ida, Niels has felt very low at various points in his life, due to unanswered questions about his past and identity.Although the issues were most critical during his adolescence, these questions persisted; as such, he still finds it difficult to deal with them in adulthood: There were a lot of thoughts during my childhood and adolescence, but to be honest it has become more problematic recently.I kind of thought that it was over, that it is the kind of something you struggle with as a teenager, and I guess everyone has some kind of identity issues during their adolescence, but for me, it's just gotten worse.It's kind of like you don't know where you belong.There are just so many thoughts all the time and sometimes it sorts of wears me out, in a way.Niels' experience of questioning his identity and sense of belonging, and the confusion that the experience engendered, made him emotionally "worn out".During both adolescence and adulthood, he found himself struggling with an overwhelming amount of daunting and emotionally draining thoughts.This is illustrative of adoptees' lack of narrative agency, in the sense that they were unable to navigate through the chaos of thoughts they were experiencing.When I asked Niels about what could have possibly helped him feel less confused about his thoughts and develop a stronger sense of identity and belonging, he gave the following answer: Definitely wish to know more about my origins.I am sometimes quite jealous of adoptees who know about their past.They sort of have the information they need and don't have to wonder about things so much.I think those who have a bit of information don't struggle as much as I did, and they probably don't get obsessed with their past like I did either.If they know, they don't need to be unsure, you know?Niels said it would have been life-changing for him to have known more about his origins, so he could establish a secure sense of identity and a stronger sense of belonging; this illustrates the impact such missing information has on adoptees' mental health and wellbeing.

Discussion and policy implications
The above excerpts illustrate how mental health issues are experienced by young adult international adoptees in Norway, and how their mental health problems may be linked to struggles with identity, belonging, and a lack of connection with their pre-adoptive past and origins.The mental health issues adoptees reported as having the most profound emotional impact were related to depression, such as persistently feeling low, and feeling a strong sense of loss and grief.There was a clear link between depressive symptoms and unresolved identity issues.These findings confirm earlier research findings such as Grotevant et al. (2017).Several of the participants also reported suicidal ideations and suicide attempts, raising concerns over the severity of psychopathology in some international adoptees.
The fact that many of the adoptees attributed their mental health problems to their lack of knowledge about their past and connection to their origins and birth families illustrates the influence that this lack of knowledge has on the mental health of international adoptees.A key concern is that the "gaps" or "holes" in the adoptees' knowledge compromise their ability to construct their identities and their evolving life stories coherently and consistently (Yngvesson & Mahoney, 2000).The lack of knowledge about their past is, therefore, a major reason why adoptees struggle with constructing a meaningful pre-adoption narrative for themselves, which in turn has implications for their mental health: they are unable to connect their earlier experiences in life with their evolving sense of identity and life story.The findings of this article are also in line with the arguments set out in the previous research into mental health and identity (Baldwin, 2005;Grotevant, 1997;Yngvesson & Mahoney, 2000), confirming the link between unresolved identity issues and depressive symptoms.This article's findings also support the conclusions of Koskinen and Böök (2019), that the adoptees' sense of coherence is strongly connected to knowledge of their biological family; the risk of developing depressive symptoms appears to be linked to a lack of knowledge about their past and origins.
In addition to unresolved identity issues, mental health problems were found to be rooted in traumatic past events that adoptees struggled to deal with.These issues impacted their ability to construct meaning and purpose in life, ultimately affecting (inter alia) their general wellbeing, mental health, social relationships, and ability to participate in employment.For many of the adoptees, resolving adoption-and identity-related issues thus constituted the core of their mental health problems, leading to the emergence, persistence, and prominence of the issues adoptees faced.
Many of the adoptees raised the issue of having to deal with their unresolved issues in solitude; this, in turn, engendered rumination, and a sense of being overwhelmed by their thoughts and by their inability to resolve and process their questions.McAdams and McLean (2013) had suggested that exploring negative events comes with a certain risk; dwelling on past events may lead to decreased levels of wellbeing, and not to the individual being able to narrate or articulate "a satisfactory ending" to their stories (McAdams & McLean, 2013).This is in line with the reports from the adoptees; for many of them, it was just this inability to construct satisfactory answers to their adoption-and identity-related questions that caused challenges to their mental health, and many reported that reflecting on the past events and unresolved questions decreased their sense of wellbeing.Such experiences are illustrative of the issues adoptees face with constructing coherence and consistency in their identities and life stories, and of their lack of narrative agency; they are unable to create meaning and purpose in their life stories due to these missing aspects from their pasts.The excerpts from the interviews also demonstrate the lack of resources that adoptees could draw on in order to construct a coherent sense of identity for themselves.
The complexity of the issues that adoptees often grapple with in isolation leads to a lonely, daunting, and overwhelming experience.Reflecting on these issues has led to profound mental health issues for many of the adoptees included in the study.Currently, there are no post-adoption services available for adoptees and their families that are aimed at supporting adoptees' search for belonging and the construction of identity.Their past traumas, their experience of missing or fragmented information about the past, and their mourning over adoption-related losses, all engender a struggle in navigating everyday life as young adults.
Thus, adoptees and their families need specialist support that is often not available from regular health care and social welfare providers (Baden et al., 2013).Arguably, the lack of such provisions is a factor that compromises the mental health of international adoptees in Norway.In interviews, many adoptees expressed their experiences of being passed around the healthcare system in search of the right type of support; they found little understanding of their specific adoption-related struggles.Given the large number of children who have been adopted to Norway via intercountry adoption programs, and the existing evidence concerning the potential challenges they may experience in relation to international adoption, adoptees should be able to access similar services to those available to foster children and their families upon arrival in Norway.This includes follow-up visits and possible early interventions to prevent potential future issues relating to identity and mental health.If international adoption to Norway is to uphold its legitimacy, children and their families need to receive specialist, long-term, therapeutic support designed to meet the needs of their specific circumstances.As life stories and narrative identities are constructed through conversations, specially trained mental health professionals can support adoptees in the endeavor of establishing certitude in their existing life stories-or reconstructing and joining together smaller, nested narratives-so that they gain a new coherence and consistency, which is vital to gaining a sense of meaning and purpose in life.Arguably, the current lack of post-adoption support constitutes a failure to protect the best interests of adopted children, which is the core principle legitimizing the institution of international adoption.Provision of, and access to, appropriate post-adoption support may be successful in preventing the emergence, persistence, and profundity of the mental health problems currently experienced by international adoptees in Norway.

Limitations to the current study and further research
A key limitation of this study is that its initial design did not account for the exploration of adoptees' mental health challenges, and the call for participants to take part in the study, therefore, did not specify this as a focus of the research.This would have had an impact on the participants recruited for the research, as the study did not specifically aim to recruit adoptees with experiences of mental health issues.Future studies should focus on mental health in international adoptees, including protective factors for international adoptees' mental health, exploring aspects that may contribute to facilitating identity formation, construction and preservation of narrative coherence in their life stories, and a sense of narrative agency.Future research could explore the role and relevance of racial and ethnic identity in relation to the mental health of transracially adopted individuals.Other important areas for research are suicide and suicidal behavior in international adoptees, and the adoptees' and their families' specific experiences with mental health services.