Stress & Trauma Toolkit
for Treating Hispanics in a Changing Political and Social Environment
Clinical Vignette
Doña Carmen, middle-aged
Doña Carmen, a middle-aged woman from South America who has lived in the U.S. for more than 20 years, has been in treatment for depression. She describes herself as “stable” with the ability to engage in her preferred daily activities. She identifies psychotherapy and antidepressant medication as being important to her recovery. Beginning in summer 2016, Doña Carmen’s therapist noticed an increase in symptoms: depressed mood, restlessness, and a growing obsession of being watched by certain clinic staff members whom she had known for a decade.
A psychiatric evaluation reveals the onset of new psychotic symptoms. Doña Carmen is mistrustful and paranoid. She thinks the U.S. government is out to get her and that her therapist and certain staff members are in a plot to harm her. She now refuses to see her therapist. In conversation with her psychiatrist, Doña Carmen shares that she is worried about her fate since the government announced policy changes related to certain immigrant groups. She believes her safety in this country is no longer assured and has repeatedly stated, “I just don’t know who I can trust anymore.”
Factors that Put Hispanics at Risk for Mental Health Problems
Acculturation difficulties: These include language barriers, trauma history, cultural stigma against seeking mental health care, and lack of health insurance, particularly among people whose immigration status is undocumented.
Social determinants of mental health:As a group, Hispanic Americans are more likely to experience unstable housing, underemployment, unemployment, and poverty, all of which are associated with poorer physical and mental health.
Unfavorable government policies: Policies that promote mistrust and separate families challenge core Hispanic cultural values of familism (shared understanding and responsibility to identify a solution) and the Hispanic concept of confianza (trust in the experience, knowledge, and mission of each partner). Perceived anti-immigrant rhetoric and legislation, including efforts to rescind the Deferred Action for Childhood Arrivals (DACA) program , have affected health care utilization among vulnerable communities that feel targeted and persecuted by the government.
Reluctance to access mental health services: Given the multiple risk factors already experienced among Hispanic immigrants, refusal to access needed care due to fear and efforts to remain “invisible” may only lead to worsened health outcomes.
Racism, racial bias, and discrimination: Negative social factors such as racism, racial bias, and discrimination contribute to poor physical and mental health, including depression, anxiety, or suicidal thoughts, among other health concerns.
Racial profiling: Data have shown that Hispanics are disproportionately stopped and searched by law enforcement. Exposure to unfair law enforcement reduces trust in the government and increases the risk of health issues. Data has also shown that anti-immigration policies, which can sometimes result in racial profiling, exacerbate perceived discrimination among Hispanics--including U.S.-born Hispanics.
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Suggested Assessment and Treatment Recommendations
- Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
- Consider cultural and structural issues: Include consideration of cultural and structural issues in the psychiatric evaluation. Identify the social determinants of mental health such as poverty, transportation difficulties, lack of insurance, lifestyle options and choices, unemployment, and domestic violence, among others. These risk factors should be considered when creating a treatment plan for Hispanic patients. Promoting services capable of effectively addressing these issues can help improve treatment outcomes.
- Facilitate access to mental health services: Consider screening for mental health disorders in places where people are most likely to visit for health problems such as primary care clinics, women’s clinics, and pediatric clinics. Providing patients with a mental health consultation at convenient locations can ease cultural stigma against mental health care and facilitate treatment.
- Promote understanding of cultural differences in the clinical presentation of mental illness: Providers must consider the different cultural presentations of mental illness in Hispanics, as they may express depression, anxiety, trauma, and psychosis with somatic symptoms. Given these common clinical presentations, primary care providers are most likely to interact with these patients. Therefore, both mental health providers and primary care providers should receive cultural competency and sensitivity training.
- Increase provider partnerships: Developing partnerships with community and professional organizations may provide patients with more care offerings while increasing participation in the health care system.
- Promote interventions tailored to the populations: Service agencies should actively avoid barriers, such as waiting lists, while facilitating access to language-appropriate offerings. Service agencies should also incorporate population-specific, evidence-based recommendations and evaluate outcomes including consumer satisfaction and recovery-oriented services.
- Engage the family: Families are vital building blocks of the Hispanic community; therefore, incorporate patients’ families in the therapeutic process as much as possible.
- Community and religious engagement: Emphasize available community resources and engage with faith communities, when appropriate, to help create a supportive network.
- Support the creation of local leadership groups: Such groups may facilitate referrals to appropriate professionals and increase the availability of effective behavioral health services in Spanish. Leadership groups may also help strengthen partnerships with community-based resources such as advocacy organizations, attorneys, schools, and faith-based organizations.
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References
- Almeida J, Biello K, Pedraza F, Suzanne W, Viruell-Fuentes E. The association between anti-immigrant policies and perceived discrimination among Latinos in the US: A multilevel analysis. SSM - Population Health 2016 (2): 897–903.
- Associated Press. More than 165 workers detained after agents raid Portland food plant. Seattle Times, June 13, 2007.
- Barkil-Oteo A, Abdallah W, Mourra S, Jefee-Bahloul H. Trauma and resiliency: A tale of a Syrian refugee. Am J Psychiatry 2018; 175:8-12.
- Diaz E, Añez LM, Silva M, Paris M, Davidson L. Using the Cultural Formulation Interview to Build Culturally Sensitive Services. Psychiatr Serv 2017; 68:112-114.
- Escovar EL, Craske M, Roy-Byrne P, Steing MB, Sullivan G, Sherbourne CD, Bystritsky A, Chavira DA. Cultural influences on mental health symptoms in a primary care sample of Latinx patients. J Anxiety Disord April 2018; 55:39-47.
- Goldman N, Pebley AE, Chung C. The consequences of migration to the United States for short-term changes in the health of Mexican immigrants. Demography, August 2014; 51(4):1159-1173.
- Davidson L , O'Connell M, Tondera J, Tyron T, Kangas K. The top ten concerns about recovery encountered in mental health system transformation. Psychiatr Serv 2006; 57:640-645.
- Oh H, Stickley A, Koyanagi A, Yau R, DeVylder J. Discrimination and suicidality among racial and ethnic minorities in the United States. J Affect Disord 2019; 245:517-523.
- Page KR, Polk S. Chilling effect? Post-election health care use by undocumented and mixed-status families. New Engl J Med 2017; 376:e20(1-3).
- Paris M, Silva MA, Diaz E, Bedregal LE, Cole RA, Añez-Nava L. “The Connecticut Latino behavioral health system: A culturally informed community-academic collaboration.” Psychol Serv 2016, May; 13(2):140-147.
- Rothera E. Review of Carrigan, William D.; Webb, Clive, Forgotten Dead: Mob Violence against Mexicans in the United States, 1848-1928. H-SHGAPE, H-Net Reviews. July, 2014.
- Santos HP, Nephew B, Bhattacharya A, Tan X, Smith L, Alyamani RAS, Martin EM, Perreira K, Fry RC, Murgatroyd C. Discrimination exposure and DNA methylation of stress-related genes in Latina mothers. Psychoneuroendocrinology. 2018; 98:131-138.
- Silva MA, Paris M, Añez LM.. CAMINO: Integrating context in the mental health assessment of immigrant Latinos. Professional Psychology: Research and Practice, 2017; 48(6):453-460.
- Talamantes E, Aguilar-Gaxiola S. Perspective: POTUS Trump’s executive orders – implications for immigrants and health care. Ethn Dis 2017; 27:121-124.
- U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_16_5YR_DP05&src=pt Accessed November 27, 2018.
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