Stress & Trauma Toolkit

for Treating Hispanics in a Changing Political and Social Environment

Anti-Hispanic sentiment has been present throughout American history, and it has resulted in historical trauma for Hispanic populations. Overt and covert racism directed at Hispanic Americans has resulted in not only verbal insults, but also acts of violence and structural racism. Recent events, such as immigration raids on food processing plants, have had devastating impacts on the wellbeing of Hispanics because they incite fear and erode public trust in institutions designed to care for the public, including fear of deportation for legal immigrants.

Although Hispanics are the largest ethnic minority group living in the United States, anti-Hispanic discrimination is still prevalent—and on the rise, especially with the controversies surrounding undocumented immigrants from Latino countries. Stereotyping of Hispanics in the current sociopolitical climate continues to affect Hispanics negatively. Discrimination is a contributing factor in social inequality and health disparities and is associated with adverse mental health outcomes in Hispanics. Discriminatory experiences for Hispanics are specifically associated with an increase in emotional stress, social isolation, and symptoms of depression and anxiety. Additionally, research suggests that everyday discrimination increases the probability of Hispanics reporting suicidal thoughts and behaviors.

The Hispanic American population consists of a diverse range of ethnicities, cultures, and experiences that require and benefit from a knowledgeable and thoughtful practice of psychiatry. Significant gaps already exist between patient demand for mental health services and the availability of appropriate resources for Hispanics, particularly for those with limited English-language proficiency. Language barriers and lack of culturally appropriate mental health services also keep many Hispanics with mental illness from seeking services.

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

  1. Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Engage the family: Families are vital building blocks of the Hispanic community; therefore, incorporate patients’ families in the therapeutic process as much as possible.
  8. Community and religious engagement: Emphasize available community resources and engage with faith communities, when appropriate, to help create a supportive network.
  9. 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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Resources

American Psychiatric Association Mental Health Facts for Hispanics. 2017. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-Hispanic-Latino.pdf

American Psychiatric Association Best Practice Highlights for Treating Diverse Patient Populations: Working with Latino/a Patients. https://www.psychiatry.org/psychiatrists/cultural-competency/treating-diverse-patient-populations/working-with-latino-patients/working-with-latino-patients

National Alliance on Mental Illness Latino Multicultural Action Center. https://www.nami.org/find-support/diverse-communities/latino-mental-health Offers guidance to consumers who may have mental health issues themselves or may be concerned about a family member.

Substance Abuse and Mental Health Services Administration (SAMHSA). https://www.samhsa.gov/behavioral-health-equity/hispanic-latino Provides data and reports related to mental health services needs in the Latino community and offers resources (some in Spanish) targeted towards the Hispanic community.

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References

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Authors

  • Jorien Breur, M.D.
  • Nubia Chong, M.D.
  • Esperanza Diaz, M.D.
  • Tatiana Falcone, M.D.
  • Liz Garcia, M.D.
  • Barbara Robles-Ramamurthy, M.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.