Stress & Trauma Toolkit

for Treating Undocumented Immigrants in a Changing Political and Social Environment

Immigration to United States began in the 17th century, and ever since, the country has been the destination for millions of people as they search for a better life. According to recent Pew Research data, there are approximately 11 million undocumented immigrants in the U.S. Of these, 5.6 million are of Mexican descent, 1.8 million are from Central America, and 1.5 million are from Asia. The U.S. civilian workforce includes 8 million unauthorized immigrants.

Ever since the passage of the Asian Exclusion Act in 1875, the U.S. government has made several attempts to exclude undocumented immigrants and prevent their access to citizenship. This includes the strategy of creating more stringent immigration policies for specific groups in response to political pressures. U.S. Immigrations and Customs Enforcement (ICE), the federal agency responsible for immigration enforcement that created in response to the September 11, 2001, terrorist attacks, exemplifies this approach.

Since the 2016 presidential campaign, debates about the construction of a wall across the U.S.-Mexico border and the status of the Deferred Action for Childhood Arrivals (DACA) program have been elevated to key issues in the current socio-political climate. Recent changes in policies have impacted several groups of undocumented immigrants. In January 2017, an executive order halted entry into the U.S. from primarily Muslim countries including Chad, Yemen, Sudan, Somalia, Iraq, Iran, and Libya. The U.S. Supreme Court upheld the order for five of the seven countries. In April 2018, an executive order affecting undocumented immigrants led to the forced separation of over 2,000 children at the border. The American Psychiatric Association released a press statement in May 2018 and adopted a formal position statement in December 2018 opposing separation of children from parents at the border because of the adverse mental health impacts of such policies.

Clinical Vignette

Carlos, 17 years old

Carlos is a 17-year-old undocumented Mexican American with no previous psychiatric history. He was sent to the school mental health clinic by his 11th grade teachers for a marked change in behaviors. While previously an honors student looking forward to attending college, Carlos reports that his grades have recently dropped due to “constant stress.” In addition to schoolwork, Carlos was previously involved in extracurricular activities and part-time employment to support his family. When probed about his future, Carlos feels that college is “no longer an option” because of the uncertainty surrounding the DACA program. Constant worries about deportation have made everyday activities like attending school and shopping for groceries challenging and fear-ridden for Carlos and his family. Read more

Mental Health Risk Factors

Trauma and stressors before, during, and after immigration: Undocumented immigrants often experience trauma at various stages of the migration process:

  • Before: Financial issues, sense of failure, escape from violence, poverty, political oppression, threats or disasters
  • During: Violence, environmental hazards, abandonment/separation, witnessing death
  • After: Limited resources given their status, intra- and interpersonal conflict, stress from adjusting to their new environment, exploitation, fear of deportation

Racism and Discrimination

  • Overt and subtle acts of racism and discrimination: These include experiences that can range from poor treatment and verbal and physical attacks to systematic marginalization and disparities in healthcare, academics, employment and other socially imposed barriers.
  • Racial profiling: Depending on race/ethnic background and appearance, undocumented immigrants are often profiled as gang members or other types of criminals. Profiling can lead to fear, anxiety, isolation, and a compromised sense of safety and identity.
  • Implicit/explicit bias and microaggressions: These incidents, whether intentional or not, can deeply affect individuals. A lifetime of cumulative microaggressions can lead to adverse mental health consequences.
  • Religious discrimination: Some undocumented immigrants face discrimination because of their religion. Studies show that there are detrimental mental health effects as a consequence of targeting and isolating religious minorities.

Treatment in school and the workplace: Research suggests that low-income, immigrant, and racial/ethnic minority children are disproportionately placed in low-ability groups early in their education, while adults experience discrimination and stigma in the workplace.

  • Stigma: Undocumented immigrants are often subjected to stigma at work, in school, and by society.
  • Shifting family structures and dynamics: Undocumented immigrants have varying family situations and mixed-status families are common. Some individuals are in the U.S. alone; others have large families, and some have children who are citizens. This can create strained family situations, including varying levels of inclusion, exclusion, acculturation, and desires for assimilation among family members. These shifting and potentially disparate priorities often lead to increased intergenerational conflicts.
  • Social isolation: Stigma often leads to social isolation and a decreased level of support in the community. Isolation can be a risk factor for mental health disorders.
  • Separation from family: Undocumented immigrants can be separated from family and children may be placed in foster homes or other custodial arrangements. Separation from family can be traumatic, especially for children, and can lead to mental health symptoms. In addition, studies have shown that young children entering foster families may avoid engaging with a new caregiver and, even if reunited with their parents, may respond to feelings of abandonment by rejecting them. This can create a self-perpetuating cycle that prevents nurturing and responsive care and ultimately exacerbate dysfunctional family dynamics.

Institutional racism and social determinants of mental health: Racism is a social determinant of mental health. Institutional racism aggravates other social determinants of mental health, including access to quality education, safe housing, gainful employment, appropriate health care, and a clean environment.

  • Low socioeconomic status (SES): Racial and ethnic minorities tend to have lower socioeconomic status, as determined by education, income, and occupation. Low SES has been significantly associated with stress related and induced mental illness. Undocumented immigrants have fewer opportunities for work given their immigration status.
  • Housing segregation and frequent moves: Given socioeconomic disparities, undocumented immigrants often live in poor neighborhoods, have fewer resources, and are more likely to move frequently. This instability affects access to consistent health care and access to quality education.

Fear and distrust

  • Distrust of the U.S. legal system: Studies show that undocumented immigrants have increased rates of fear and distrust of the U.S. legal system, causing decreased participation in civic life, including advocacy efforts. They also have a decreased likelihood of using the legal system even when they are victims of illegal activities. This distrust can extend to the health care system and act as a barrier to care.
  • Fear of deportation: Given the current political climate, undocumented immigrants live in widespread fear of deportation, which limits their use of health care and social services and prevents social integration.

Higher overall risk for mental health issues for some undocumented immigrants:

  • Undocumented immigrants who have had exposure to violent trauma are at high risk for depressive disorders, post-traumatic stress disorder (PTSD), and substance use disorders.
  • Unaccompanied minors have a higher number of traumatic exposures on average than minors who migrate accompanied by family, which increases their risk for mental health problems like PTSD.
  • Compared to U.S.-born Latinos, Latinos who are undocumented immigrants are more likely to have multiple psychosocial problems, including those related to employment, access to health care and the legal system. However, undocumented immigrant Latinos use fewer mental health services use than U.S.-born Latinos do.
  • Immigration-related stressors can increase suicidal ideation and risk due to the distress associated with cultural stress, social marginalization and intergenerational conflicts in addition to PTSD and other psychological disorders.

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Suggested Assessment and Treatment Recommendations

  1. Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  2. Consider protective factors: Studies have shown that the most important protective factor for undocumented immigrants’ mental health is whether they receive adequate social support. Other protective factors include pride in ethnicity, bilingualism and multilingualism, and spirituality.
    • Encourage and advocate for the unification of patients with their families.
    • Connect patients to resources. Emphasize the importance of social supports for the well-being and recovery of disenfranchised populations. Connections with resources can be just as important as receiving treatment.
    • Provide consistent and accessible follow up. Undocumented immigrants often distrust the health care system and may require more frequent and consistent follow-up to create a sense of trust. Collaborative decision- making and motivational interviewing can be helpful when culturally sensitive.
    • Spirituality and faith should be assessed and incorporated into treatment planing if the patient desires.
    • Minimize language barriers. Make an attempt to offer resources in patients’ native languages. Provide opportunities to learn English if patients show an interest.
    • Collaborate with community organizations that support undocumented immigrants in multiple facets of their lives, including family supports.
  3. Recognize culturally specific concepts of distress, normative cultural factors, and cultural humility: Be sensitive to culturally specific phenomena when treating patients, but also treat each patient as an individual and assess what their culture means to them. For example, in many Latino cultures, PTSD symptoms may be attributed to susto (“soul loss”), instead of being recognized as a mental illness. The Cambodian language has no word for depression or anxiety, so these patients may present with complaints of "khyal attacks" or "wind attacks," which are described as dizziness, shortness of breath, and palpitations. At the same time, not all individuals from Latino and Cambodian cultures, respectively, ascribe to these concepts.
  4. Encourage clinicians to examine their own implicit and explicit biases.
    • Suggest regular training that promotes reflective self-examination and awareness of implicit bias.
    • Evaluate, challenge, and address structural and practice-level factors that perpetuate explicit bias, discrimination, and inequalities for immigrant and other vulnerable populations.
  5. Consider the many external and internal factors that influence the course of a person’s life:
    • Use a “socio-cultural ecological framework” that considers the complex interplay between individual, relationship, community, cultural, and societal factors that influence mental health. Community-focused interventions that integrate school, community, physical and mental health care, and faith-based organization providers can increase access to care and provide social support.
    • Conduct psychiatric testing in a format that accommodates the individual’s culture and/or language or that applies to many cultures.
  6. Combat psychosocial stressors: Undocumented immigrants often experience a large variety and number of psychosocial stressors.
    • Assess needs using standard instruments or assessments such as the Brief Risk Overview survey, and take into consideration the possible effects of adverse childhood experiences.
    • Employ early assessment of psychosocial stressors, substance use, and barriers to care when treating undocumented immigrants.
    • Identify accessible social services and supports for addressing psychosocial stressors in the lives of undocumented patients.
    • Think about partnerships with organizations that offer trusted spaces within the specific community, including faith-based organizations, schools, or community centers.
    • Consider increased follow-up and connecting patients to services such as peer navigators, health coaches, college resources, or legal assistance. Resourceful thinking can help bridge cultural or language gaps, such as advocating for testing in a different language for a child in school or using innovative but accessible technology.
  7. Screen for trauma: Given the high risk for trauma among undocumented immigrants, consider screening for trauma and practicing trauma-informed care even if patients do not meet the criteria for PTSD.
    • Screen for trauma exposure and symptoms, anxiety, depression, substance use disorders, and sleep disorders. Whenever available, use screening measures developed for the population the patient identifies with.
    • Recognize the impact of violence on development and coping, and identify recovery from trauma as a primary goal. An empowerment model maximizes patient control, collaboration, and a safe environment. This model also emphasizes resilience, minimizes retraumatization, and practices cultural competency and cultural humility.
    • Consider early interventions for dual pathology of PTSD symptoms and alcohol or substance use disorder (AUD/SUD in immigrants with trauma history, particularly for Latino immigrants, who are at high risk for comorbid PTSD and AUD/SUD.
    • Since trauma-informed care involves both the individual treatment of a patient by a provider and the policies of systems-based practices, consider re-examining policies that may restrict access to social services and health care for the undocumented.
  8. Inform patients of their rights: Research indicates that fear of deportation is common among immigrants; when undocumented immigrants understand their rights, they can use that information to advocate for themselves, decrease their chances of being separated from loved ones, and protect their mental health. Some examples of this include connecting patients with legal aid or providing appropriate language information to notify them of their rights. Victims of crime may be eligible for changes in immigration status if they help law enforcement investigate the crime.
  9. Use narrative therapy and cognitive restructuring: Allowing patients to tell their stories and recreate their narrative often helps immigrants process and prevent symptoms of depression, anxiety, and PTSD. Narratives allow people to access their story in a less damaging and more therapeutic way. These strategies are known to help with issues related to identity and stress.
  10. Encourage self-advocacy and empower patients: Inform undocumented patients of the legal rights that they have. Provide links to legal and social services that can assist patients in learning how to practice self-advocacy and to access resources they need for themselves and their families.

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Resources

APA Cultural Formulation Interview https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview.pdf

APA Module on Trauma-informed Care https://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=398

Immi offers resources to undocumented immigrants including a tool to help determine a path to documented status, information on immigration relief, links to organizations providing legal aid. www.immi.org

References

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Authors

  • Divya Chhabra, M.D.
  • Lisa Fortuna, M.D.
  • Pamela Montano, 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.