Clinical Encounters With Immigrants: What Matters for U.S. Psychiatrists
Abstract
Approximately 3.2% of the global population consists of migrants. Today, unprecedented numbers of people are relocating to the United States; more than ever, psychiatrists are caring for immigrant patients. International migration is a multilayered issue that often has implications for the mental health of migrants. Thus, there is an increasing interest in understanding how the different factors associated with migration processes affect the mental health outcomes of immigrants. The authors group these factors into three categories: immigrant process, clinical encounter, and mental health services. When possible, the authors incorporate a gendered and life span perspective and suggest avenues for including what they know regarding the care of children, adults, and elderly psychiatric patients with immigrant backgrounds. This study pays special attention to the immigrant paradox literature, which explains why some immigrants are healthier when they start their journey, and why their mental health deteriorates as they live longer in the host societies. This study aims to provide psychiatrists with an understanding of what to ask, assess, and consider when caring for patients who are international migrants.
Since ancient times, mobility has been a marker of the human species. In 2013, 232 million people, or approximately 3.2% of the world’s population, were migrants (1). We define migrants as individuals who relocate from one nation state to another and for whom this relocation carries changes in social membership. The United States attracts approximately 20% of the migrants across the globe; in 2013, more than 41 million immigrants lived in the United States (2). Immigrants and their children combined represented roughly one-quarter of the U.S. population (2). Immigrants to the United States are more diverse than ever. People of Mexican origin make up 28% of the immigrant population in the United States, followed by Chinese (5.6%) and Indian (4.8%) individuals (3). Never before in U.S. history have we witnessed such volume and diversity among the country’s immigrants.
As described by Portes and Rumbaut (4), immigration is a bilateral process driven by the immigrants’ needs (e.g., to pursue economic opportunities, to improve their children’s access to education, or to escape from totalitarian governments) on the one hand, and the changing needs of employers and governments benefiting from immigrant labor (e.g., cheap labor, skilled workers) on the other. On the individual level, migration processes can be understood as an investment in one’s well-being (5), but sometimes this investment may not yield a good mental health return. For the host country, immigrants’ labor resources and investments may be welcome, while at the same time the new residents’ presence challenges established ideas about community and citizenship. Tensions between the needs and wishes of both individuals and host societies have implications for the mental health of immigrants. Unrealistic expectations of support on the migrants’ side or hostile conditions of reception may add stressors to the already challenging migration process, resulting in a diminished sense of well-being among newcomers. This in turn may exacerbate latent vulnerabilities for mental disorders. For instance, a greater incidence of nonaffective and affective psychoses has been documented among dark-skinned migrant groups in the United Kingdom (6) and Sweden (7).
We have begun to grasp the complexities and challenges involved in the process of immigration to the United States and how these affect mental health. However, disentangling this relationship is difficult in that the effects of immigration on mental health can only be understood taking into consideration the micro-, meso-, and macrolevel factors associated with this process. Complicating matters, our understanding of the relationship between immigration and mental health is challenged by the fact that immigrants and immigration conditions are intrinsically heterogeneous and constantly changing. Their diversity makes comparisons across groups difficult and poses challenges to the design, testing, and implementation of evidence-based practices to care for these patients. Amid the heterogeneity of immigrants, however, there are common issues that most must face, including their need to adjust to a new environment and their experience of loss of a shared sociocultural world.
This article offers some insights into what we know about the factors shaping the mental health outcomes of migrants and how these issues should be included in the clinical encounter with immigrant patients. We start by discussing key concepts describing the experiences of migrants to the United States, including those that capture their cultural incorporation. Then, we propose a model to understand immigration as a multilayered and complex phenomenon that has the potential to affect mental health. When necessary, we incorporate a life span and gendered perspective to discuss the interactions among these factors. We address issues of how to include the patient’s immigration experience in the clinical encounter and offer suggestions on what psychiatrists should ask, assess, and consider when caring for immigrants. We finish by discussing the immigrant paradox literature, which explains why some immigrants are healthier when they start their journey and why their mental health deteriorates as they live longer or in subsequent generations in the host societies.
The Cultural Integration of Immigrants and Implications for Clinical Practice
There are two dominant theoretical approaches to the study of the cultural integration of immigrants: one sees it as a linear process that involves the shedding of the heritage culture and the increasing endorsement of the host culture, whereas the other theorizes that it is a bidimensional process involving adoption of the host culture as well as maintenance of the heritage culture. Researchers in the first camp often refer to this pattern of cultural integration as assimilation and owe much of their approach to studies on the integration of 20th century European immigrants to the United States (8). Promoters of assimilation endorse cultural homogeneity and often use metrics, such as economic achievement or intermarriage rates, to explain that immigrants who manage to assimilate have better outcomes. The second theoretical approach to the study of immigrants’ cultural change refers to this process as acculturation. Acculturation has been widely studied by psychologists interested in the mental health of immigrants (9, 10). Scholars who see acculturation as a bidirectional process embrace cultural heterogeneity and promote practices that sustain the coexistence of people of different backgrounds. For them, the aim of the acculturative process is to reach biculturalism, which refers to the integration of cognitions, attitudes, and behaviors from the culture of origin and the dominant culture (11). Although this position has weak empirical support, this camp endorses the notion that individuals of immigrant backgrounds who become bicultural have better mental health outcomes (12).
The conceptualizations of the process of cultural change among immigrants have implications for psychiatrists in that they call for alternative models of addressing the patient’s culture in the delivery of clinical services. Promoters of assimilation stress the universality of Western understandings of mental disorders and of U.S. treatment models. Little attention is paid to the patient’s cultural models of symptom presentation, illness behaviors, treatment models, and help-seek behaviors. Translators may be included in the service delivery, but cultural differences between providers and patients are often ignored. Endorsers of acculturative theories call for multiculturalism and promote cultural competency. Culturally competent psychiatric services incorporate the patient’s ethnocultural beliefs, values, attitudes, and conventions (13). Culturally competent services seek to generate intercultural understanding between providers and consumers, avoid imposing the providers’ values and practices on the patients, and allow patients to respond to their mental health needs through culturally meaningful ways (14). Part of the challenge in implementing culturally competent services is that they place much of the cultural bridging responsibilities on the providers. Specifically, culturally competent services demand that clinicians understand what culture is, recognize the role that it plays in mental health, and include it in every aspect of service delivery. For instance, psychiatrists assessing culturally diverse patients must inquire about their level of acculturation, particularly in reference to mental health. When serving children of immigrant backgrounds, the clinician would evaluate whether there is an acculturation gap between the child and his or her caregivers, assess how it may affect treatment adherence, and plan treatment accordingly. More importantly, clinicians will stay away from stereotypical notions about culture, such as assuming that a similar background equals identical culture. Patients’ culture will be assessed, taking into consideration its dynamic nature and considering, for instance, the interaction of age, gender, class, education, religion, and so forth. Although it is complex, the delivery of culturally competent services is critical for immigrant patients. Meta-analyses have shown that culturally competent treatments are more effective than standard mental health services among ethnocultural minorities (15, 16).
Immigration and Mental Health
The relationship between immigration processes and mental health outcomes has been explored by a number of researchers (17–21). From that body of work, we identified variables that mental health providers should consider when serving immigrant patients. We added variables we ascertained as important in our research with immigrants. For purposes of clarity, we organized these variables within three categories: clinical encounter, immigrant experience, and mental health services. We close each section with suggestions about how clinicians can include these categories in their work.
Clinical Work With Immigrant Patients
Immigrants’ characteristics mold their migration trajectories, the type of stressors they face, and the resources they have to cope with these stressors. Among these variables are the immigrant’s age, gender, sexual orientation, and religion. Migration processes should be understood from a life span perspective, because age shapes the experience of immigrants. For instance, older adults may have a harder time adjusting to a new society, whereas children adapt faster than adults to changing cultural contexts. These different adjustment rates may affect immigrants’ mental health in various ways. Older adults may feel disempowered and incompetent navigating their new social context. By contrast, because children learn new languages quickly, they may become translators for their caregivers and they thus feel empowered. Early age of immigration, however, may not have positive effect on mental health for all groups. For instance, Vega and colleagues (22) found that among Latinos of Mexican descent, a younger age of entry and a longer residence in the United States are associated with a higher prevalence of psychiatric disorders.
Gender.
The effects of immigration stressors and contexts of reception on immigrants’ mental health should be framed within gender categories (23). For instance, Takeuchi and colleagues (24) found that among Asian immigrants, lacking English proficiency had a greater negative impact on the employment opportunities of men compared with women, increasing men’s risk for mental health problems.
The gender ideologies and practices of immigrants may be different from those of mainstream Americans. Female genital mutilation (FGM) provides a challenging example of the balancing act that psychiatrists must perform between patients’ cultural practices and their rights. In 2015, it was estimated that more than 500,000 girls and women were at risk for or had undergone FGM in the United States (25). FGM has been associated with adverse psychological effects (26). U.S. law prohibits practicing FGM on minors, as well as taking a minor to another country to perform the procedure. Although FGM has been studied more in the obstetrics-gynecology and anthropological literature (27–29), psychiatrists ought to include questions about it in the assessment of vulnerable clients and contact protective services if they are concerned about a girl’s risk of being mutilated.
Sexual orientation.
Many immigrants in the lesbian, gay, bisexual, and transgender community experience chronic discrimination in their countries of origin, from homophobia to threats to their life. Perceived discrimination is consistently associated with negative mental health outcomes (30).
Marital status.
Independently of immigration status, marital status and the health of marital relationships is often a focus of inquiry during psychiatric assessments and treatment. For many immigrants, marriage to a U.S. citizen offers the fastest, and often only, pathway for legal residency. Within the United States, many undocumented immigrants and those with temporary work visas enter marriages for immigration purposes. Marriage is also a pathway for people in less developed nations to legally migrate to the United States. Some individuals become “mail-order brides,” which is considered a form of human trafficking. There are documented risks associated with these marital practices, including domestic violence (31).
Ethnicity and race.
Several disparities in risk behaviors and mental disorders have been identified across ethnic groups of immigrants in the United States, such as high rates of suicide attempts among Latina adolescents (32). The interplay of race, as a social construct, and the mental health outcomes of immigrants is very complex. For instance, many immigrants have not been exposed to the U.S. binary white-black race ideologies before arriving in the country. On the basis of ascribed racial characteristics (e.g., their skin color), they may find themselves labeled as racial minorities. For these immigrants, racial discrimination can be puzzling. Discrimination has been identified as a risk factor for the mental health of Asian and Latino immigrants (33). At the same time, black immigrants of Caribbean and African origin may also struggle with their new acquired racial minority status in the United States. Their increased exposure to discrimination because of their skin color puts them at risk for mental disorders (34).
Religion.
In general, religious participation is considered a protective factor for the mental health of individuals. Many religious organizations have important roles in keeping the culture of origin alive for immigrant communities (e.g., by hosting ethnic schools). Ethnic school attendance has been identified as a protective factor in the development of youth of immigrant backgrounds (35). The protective function of religion on mental health does not apply equally across groups of immigrants. For instance, Muslim immigrants faced increased discrimination after the events of September 11, 2001. Islamophobia has been associated with increased psychological distress, reduced levels of happiness, and worse health status among Arab Americans (36).
English proficiency.
The immigrant’s native language is an integral part of his or her identity and helps to ground his or her understanding of the world, whereas learning English aids the immigrant’s cultural and social integration in the United States. English proficiency may act as a protective factor for depression and stress among immigrants. Speakers with foreign accents often face accent discrimination. Kim and colleagues (37) found that among Asian and Latino immigrants, those with limited English proficiency were less likely to access psychiatric services to address their mental health needs.
Culture and Mental Health
Psychiatrists serve a growing number of migrant patients (38), who sometimes present diverse modes of expression of emotional distress [e.g., the literature on “ataques de nervios” (39)], understanding of mental health and its treatment (40), and the relationship between providers and patients (41). These culturally based dimensions shape the definitions and lived experience of mental illness and services. Culture shapes developmental and behavioral expectations, along with parenting practices. In cultures with greater emphasis on obedience, the threshold for disruptive behaviors is lower than in those that value individual expression (42). Thus, the same behavior may be assessed as disruptive in one cultural context, whereas it may be encouraged in others. It is important that clinicians serving children of immigrant backgrounds become familiar with the caregiver’s parenting and developmental schemes. As in general child psychiatry practice, multiple informants need to be interviewed to gather a nuanced profile of the pediatric patient’s mental health. During the psychiatric assessment phase with immigrant children, the psychiatrist will interview informants from different cultural backgrounds. This practice helps to separate culturally based parental complaints about children’s behaviors from those that need to be addressed through psychiatric intervention.
Stigma.
Stigma concerning mental illness and treatment is a cultural dimension that hinders immigrants’ access to psychiatric services. Immigrants, who already confront discrimination because of their otherness, fear increased prejudice due to mental illness (43). Perceptions about psychiatric services vary across the globe, and immigrants carry their own cultural perspectives when they come to the United States. For example, immigrants from regions where psychiatric services have been used to aid political oppression may be reluctant to seek treatment. In many places across the globe, psychiatric services are practically unknown to the general population or are exclusively for the severely mentally ill who are treated in asylums.
On the provider side, working with immigrant patients may pose challenges that are different from those elicited by native clients. Cultural competency training mostly addresses what psychiatrists need to know about multicultural patients, but it rarely addresses what these patients require and elicit from the professionals caring for them. Practical challenges require adapting the clinical practice parameters to the immigrant patient’s cultural and linguistic needs. For instance, these patients may need translation assistance, thus requiring psychiatrists to allocate more time per appointment. Others may need appointment schedules that do not interfere with praying times. Cultural differences with patients may generate a range of emotional responses among clinicians. A client endorsing patriarchal values may decline services from a female provider, in turn upsetting that provider. Others may seek the psychiatrist’s help with issues that fall beyond the scope of mental health services, leaving providers overwhelmed or frustrated. Interactions with immigrant patients may also trigger a psychiatrist’s cultural or religious biases.
The Cultural Formulation model aids practitioners in rendering accurate psychiatric diagnoses and formulating treatment across cultural boundaries (44). Lewis-Fernández and colleagues (44) developed an interview combining five dimensions relevant to mental health services, including assessment of cultural identity, cultural explanations of mental illness, cultural factors related to the psychosocial context and impairment level, cultural aspects of the clinician–patient relationship, and the overall effect of culture on psychiatric diagnosis and care. The Cultural Formulations Interview is a standard component of culturally competent psychiatric care.
Implications for clinical practice.
The intersection of social and cultural characteristics shapes the immigrants’ experiences and their mental health. To fully understand the migration experience, clinicians ought to include life span and gendered perspectives and should be attuned to the compounded vulnerabilities that different subgroups face as they adjust to life in the United States. Cultural competence is critical for psychiatrists serving this population. Culturally competent services must include considerations about (a) the patient’s social and cultural characteristics and how these frame his or her migrant experiences and mental health and (b) the clinician’s response to immigrant clients. Psychiatrists can improve the accuracy of their diagnosis and develop better treatments for immigrants by using the Cultural Formulation method.
Immigration Process
The Decision to Emigrate
The context of departure shapes the decision, process, and nature of the exit of the country of origin (19). Country-of-origin sociopolitical characteristics have a great impact on the reasons and conditions of exit and arrival of migrants. When the decision to emigrate is driven by life-threatening risks, immigrants may arrive in the United States or other host country with a more compromised mental health status. For instance, anxiety prevalence and depression rates among refugees are almost double the rates among individuals who migrate for economic reasons (45). The cultural match between the immigrant’s country of origin and the United States may hinder or facilitate his or her incorporation into American society.
Migrants move to the United States for different reasons and under diverse conditions, and their migration decision is not always voluntary. Voluntary international migrants are those who relocate because of reasons under their control. Examples include individuals who decide to pursue new career opportunities in a different country or move to relocate with family members. Forced international migrants are those who need to relocate to a different country for decisions beyond their control. People may migrate to the United States because of war or because they belong to persecuted groups such as sexual or religious minorities. Coerced migrants, such as victims of human trafficking, constitute a third category of international migrants. Initially, these individuals may have sought to migrate, but the circumstances of their migration fell beyond their control. Finally, children and elderly persons are other groups who migrate internationally, but their control over the decisions regarding migration may be limited. Although the majority of children either migrate with or reunite with family members, increasing numbers do so on their own. Examples include children who migrate to the United States alone to attend school (46) or unaccompanied minors who cross international borders (47).
The Journey to the United States
The process by which immigrants move from one country to another may be direct or may occur in stages. Today, the duration and strenuousness of the voyage are determined in part by the immigrant’s level of education and economic resources. In general, poorer migrants with less education take longer to complete the trip from their country of origin to their destination, and sometimes their journey takes them through several countries before they arrive in the United States. One example entails Chinese immigrants who arrive in the United States by crossing the border with Mexico (48). Sometimes this process can take months and even years. As border crossings became more difficult because of increased surveillance, the risks that unauthorized immigrants take and the price they pay have also increased. Unauthorized migrants often enter the country under extremely stressful circumstances and are regularly victimized by traffickers. For instance, Amnesty International (49) reported that six of ten girls and women crossing the Mexican border are sexually assaulted or raped. In addition, many immigrants arrive in the United States owing large sums of money to the “coyotes” or “snakeheads” who helped them migrate. The well-being of the immigrant’s family depends on his or her ability to honor these debts. Traumatic migration experiences are not unique to undocumented migrants, because some authorized immigrants often arrive in America after stressful periods in refugee camps or during civil wars, or they endure traumatic separations from their loved ones before initiating their journey to the United States.
Family members often migrate to the United States in stages, a process that has been referred to as “serial migration” (50). The separation of parents and children can be quite extended (51). The family configurations and dynamics must adjust to this transnational experience in which members are physically absent but emotionally present. In these families, contact between biological parents and children may be regular or sporadic, but in general, parents lack the ability to provide supervision to the children left behind. Parents separated from their children and unable to reunite because of their immigration status may experience guilt, worry, sadness, and powerlessness. In many cases, children with migrant parents, who are left under the care of relatives or friends, endure emotional hardship as well as physical and sexual abuse. In others, the emotional ties that bind parents and children fade, and new ones are forged with the temporary caregivers. Whatever the case, family reunifications can be very challenging (52).
Starting a Life in the United States
Immigrants from rural backgrounds encounter multiple barriers in their process of adaptation to the United States. Some of these barriers are rooted in the country’s immigration policy, which has prioritized the legal incorporation of educated and urban migrants while neglecting agricultural and less educated workers and their families. Farm workers and their families face many stressors related to the physical environment (e.g., exposure to pesticides) and the economic difficulties and uncertainties associated with farming (e.g., lack of work during droughts). In addition, children of rural immigrant families are often recruited into farm work at an early age and have limited access to educational opportunities. When immigrants from rural backgrounds choose to settle in postindustrial urban areas, they may encounter serious obstacles in their adaptation due to their lack of education and urban social capital. These stressors can pose detrimental effects on the mental health of this group of immigrants.
Immigrants face different contexts of incorporation relevant to their mental health. Although the importance of immigrants for the U.S. economy is undoubted, the country’s approach to the incorporation of immigrants has varied over time. These variations resulted from changing geopolitical, economic, and social factors that influenced domestic and foreign policies. Governmental policies are important in determining the incorporation patterns of arriving immigrants (53) because immigrants encountering exclusionary policies endure greater structural and economic restrictions as well as a general disadvantage. For instance, immigrants arriving in the United States from Muslim countries face greater discrimination than those from Western European countries, which may affect their sense of well-being and acculturation.
Legal status is a common concern for immigrants in the United States. The term legal or documented applies to individuals who have acquired legal rights and protections through birth in the United States (resulting in full citizenship) or through federal immigration (54). Authorized immigration to the United States happens through obtaining a visa (e.g., employment, student, or work visas), refugee status, resident alien status, or naturalization. The term undocumented (we use undocumented and unauthorized interchangeably in this article) refers to immigrants who are in the United States without federal government authorization, also known as illegal (54). Immigrant families are often “mixed-status” family units in which some members, often children born in the country, are U.S. citizens, whereas others are undocumented immigrants or have some legal status that could ultimately allow them to access U.S. citizenship (i.e., refugee, legal resident) (55). Approximately four in ten second-generation Latino children have at least one undocumented immigrant parent and hence live in a mixed-status family (56). The growing number of deportations of unauthorized immigrants, many of them parents of U.S. citizen children who in many cases are left behind, requires that mental health professionals become prepared to work with this population (57). Research has shown that undocumented Latino immigrants’ fear of deportation heightens their risk of experiencing negative emotional states, particularly anger (58).
Once they are in the United States, newly arrived immigrants must compete with others, including U.S. workers, for jobs. Legal immigrants, including those with professional visas or those admitted for family reunification processes, may be able to access the formal wage market. As part of the process of reception and placement, adult refugees are given employment assistance, thus easing their transition into the workforce. Undocumented immigrants depend greatly on their social networks to obtain employment and often do so in the informal economy. Depending on their educational background and skills, command of the English language, professional credentials, and social capital, immigrants’ insertion in the market may be more or less challenging. Professional immigrants with work visas or those who lack legal authorization to work may be more vulnerable to exploitation and abuse by employers, because their opportunities to obtain employment are limited. Many immigrants must insert themselves into the labor economy by taking jobs that may, even with better pay, carry less social recognition than the jobs they performed in their country of origin. Medical doctors may start again as residents or even as health educators, and police officers may have to work as landscapers. This may pose special challenges for the well-being of immigrants whose sense of identity is closely tied to their professional role. Men who are used to being the sole providers for their families may learn that their low-wage work is not enough to support their spouses and children, threatening their self-esteem.
Family issues.
Because immigrant families in the lower socioeconomic status strata often cannot survive on one low-wage income in the United States, women may seek employment to help support the family. Women may find it easier than men to get jobs in the service economy. Their entry in the workforce, especially among immigrants from countries with lesser opportunities for education and employment for women, can change family and gender dynamics (59) and bring about serious interpersonal and marital stressors. Furthermore, as with many American women who juggle work and families, immigrant women may struggle with caring for their children and spouses while working. In more traditional and less acculturated immigrant homes, men may not be expected to help with child rearing and household tasks, thus further burdening women who work. Working, however, can also foster a sense of empowerment through building women’s social and human capital, thus facilitating their acculturation.
Just as adult immigrants need to insert themselves into the labor market, children have to negotiate the educational system. Supportive learning environments are not always available for immigrant children, and some of these children face discrimination and lack of opportunities at school. The effect of the school experience on academic outcomes is well documented. For instance, perceived discrimination at school has been linked with poorer academic outcomes among Mexican immigrant children (60). In addition, psychiatrists should be attuned to the behavioral manifestations of the children’s experience at school and beware of confusing such behavior with pathology. For example, some young children entering a school environment with no knowledge of English often go through a nonverbal period in their second language that should not be confused with selective mutism (61).
Elderly adults often immigrate to the United States as part of family reunification–either legally or as unauthorized immigrants. Sometimes they join the family to help care for younger children while the parents work outside the home. Although some elderly migrants could feel isolated if they left behind family and friends, others could feel empowered by their caregiver roles. Older adults may have a harder time adjusting to the new environments, learning the new language, and building social networks. Sometimes, their acculturation issues can be confused with cognitive decline (e.g., the case of an older adult who may get lost navigating his or her new neighborhood and may not know the language to ask for help).
Fellow immigrants and assimilation.
Another important aspect of the context of reception has to do with the proportion of coethnics among neighbors, coworkers, classmates, and so forth. Many immigrants with low socioeconomic status arrive in the country through personal networks and initially settle with family members or coethnics. Their opportunities for work are also organized within networks of coethnics, which in turn build reciprocity and support. These networks are critical for the well-being of immigrants (62, 63); they not only provide support, but they also help newcomers in the process of adjusting to the United States. As time passes, some immigrants become successful and move to areas with fewer coethnics, whereas others continue to struggle and face limited opportunities for social mobility. Research suggests that large numbers of immigrants downwardly assimilate, a phenomenon called segmented assimilation (64). This assimilation pattern exposes them to many risk factors for negative health and mental health outcomes such as poverty, a dearth of educational and occupational opportunities, inadequate health care, and discrimination.
Implications for Clinical Practice
Clinicians should collect a comprehensive narrative of the patient’s migration trajectory, including reasons for migration, conditions of exit and arrival, and exposure to stressful events before, during, and after migration. Psychiatrists could explore not only what prompted the migration but also whether the patient’s expectations for settlement in the United States were fulfilled. In addition, clinicians could ask how the process of migration affected the patient’s emotional well-being, his or her social network, and the quality of his or her relationships. Disruptions in social networks, along with changes in family dynamics, should be the focus of attention during services.
It is important to explore family immigration processes, as well as transnational family experiences and the meaning patients give to these experiences. Clinicians should explore the conditions of separation and—if separation has occurred—reunification. Special attention must be given to parents separated from minors and to children and teens reunited with their parents after a period of extended separations. Supportive services and culturally competent family therapy could ease the conflicts emerging during family separations and reunification and could reduce the mood and behavioral symptoms resulting from these conflicts.
Mental health professionals cannot ignore immigration law. Psychiatrists ought to be sensitive to the patient’s immigrant status and how it affects his or her mental health. In addition, some undocumented patients may fear that being diagnosed with a psychiatric disorder could carry negative effects on their future ability to secure legal immigrant status. Thus, psychiatrists need to stress issues of confidentiality in the delivery of mental health services. Clinicians serving this population could become aware of local nonprofit groups that provide legal counsel when needed and identify who may benefit from immigration assistance. For instance, undocumented women in abusive relationships may qualify for domestic violence asylum in the United States, and many domestic violence service agencies have immigration lawyers on staff. Psychiatrists may explore the legal status of all members of an immigrant family and, when needed, assist families in the process of separation due to deportation. Mental health professionals are increasingly acting as expert witnesses in immigration courts on behalf of developmentally disabled or mentally ill U.S. citizen children whose caregivers are in the process of being deported. Their advocacy aims at curbing the deportation process and securing opportunities for families to remain united so that children can receive the services they need.
Mental Health Services and Implications for Clinical Practice
Cultural and contextual variables affect immigrants’ help-seeking pathways. The choice of treatment provider is strongly influenced by culture, whereas the opportunities to meet those providers are shaped by contextual factors. For instance, some immigrants may approach ethnic healers (e.g., curanderos) or spiritual leaders (e.g., Imams) instead of seeking the assistance of a psychiatrist (65). Others who may be engaged in psychiatric treatment may complement those services with spiritual or folk practices (66).
On the contextual side, immigrants experience many barriers to accessing psychiatric services. Immigrants often have low levels of income and health literacy, and their work schedules preclude them from attending appointments. Compounded with these barriers, there is a shortage of mental health services and multicultural providers. Health insurance is not available for undocumented immigrants.
The age of the immigrants may also affect their access and use of mental health services, because psychiatrists are more likely to see immigrant children than adults. This is because immigrant children attend school; in this context, these children interact with teachers and others who are familiar with American ideologies of mental health. If the child is referred for services, the psychiatrists may meet caregivers who do not assess the child’s behaviors as pathological or may not understand the nature of psychiatric services.
Practitioners must be aware of the challenges faced by immigrant patients to access services and they must generate opportunities to reach these individuals outside traditional mental health settings. For instance, psychiatrists could partner with ethnic community centers or religious organizations to educate immigrants about mental health. Accessing services despite challenging barriers is a marker of resilience and positive prognosis among immigrant patients.
The Immigrant Paradox and Implications for Clinical Practice
The immigrant paradox describes a phenomenon in which newly arrived immigrants are more successful at navigating life and are healthier in their host societies compared with more assimilated individuals of immigrant backgrounds. This paradox has been described among Latinos (62), black Caribbeans (67), Africans (68), and Asian-American women (24). The premise of the paradox is that newly arrived immigrants show good adaptation in a number of outcomes, despite their poor socioeconomic profile and low educational background (69). For instance, Vega and colleagues (70) found that Mexican immigrants have approximately one-half the prevalence rate of psychiatric disorders compared with people of Mexican descent born in the United States. The positive outcomes among newly arrived immigrants have been detected in a myriad of mental health outcomes including psychosis, substance abuse, and depression (6, 71, 72).
The immigrant paradox highlights that the effects of international migration processes span multiple generations. Psychiatrists should pay special attention to immigrants who belong to groups more likely to undergo downward mobility after immigration and thus face the combined effects of discrimination due to their race, immigrant backgrounds, and their socioeconomic status. Preventive psychiatric interventions for immigrants ought to incorporate protective elements of the patients’ cultural background. Mental health professionals must explore the process of adaptation and mobility upon the immigrants’ arrival to the new country, including opportunities for upward mobility, cultural integration, and exposure to discrimination. Along with these, psychiatrists could focus on disentangling whether the presenting mental health problem is related to the immigration process or if it is adaptive to the contexts of reception.
Summary
Immigrants in the United States are as diverse as their mental health needs. Their vulnerabilities for mental disorders are compounded with diverse patterns of stressors related to the immigration process. Although much more needs to be learned about how differential risks relate to immigrants’ mental health outcomes, it is clear that these risks can be moderated by the contexts of reception. Psychiatrists delivering clinical services can make substantial contributions to the well-being of this vulnerable group as they and their children become part of America.
Footnotes
Support for work on this article was provided in part by training grant T32MH16242 from the National Institute of Mental Health.
The authors report no competing interests.
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