Caring for Families Separated by Changing Immigration Policies and Enforcement: A Cultural Psychiatry Perspective

Although the forced separation of families at the U.S.-Mexico border and the mental health impact on separated children has received recent media attention, the ongoing plight of families within the United States being forcibly separated and the mental health consequences have been largely neglected. The mental health community can play an important role in addressing the psychological and psychiatric needs of children and families undergoing forced separation within the United States. In the wake of changing immigration enforcement and new policies under the current administration, the number of immigration-related arrests has increased by 43%, and the number of arrests of noncriminal immigration violators has increased by 300% (1). In addition, temporary protected status (TPS) for legal residence, which was established in 1990 for persons fleeing natural disasters and political conflicts, has been revoked for 200,000 Salvadorans, 60,000 Hondurans, 2,500 Nicaraguans, and 46,000 Haitians. Protection is also ending for TPS recipients from South Sudan and Nepal. Thousands of Liberians, who were granted TPS in the 1990s during widespread warfare in East Africa and who were subsequently transitioned to deferred enforced departure (DED) status in 2007, have also had their residential status revoked. The administration plans to terminate residential protection for 90% of all TPS and DED recipients by 2019. In addition, the hundreds of thousands of young people formerly protected by the Deferred Action for Childhood Arrivals (DACA) program have lost their status and are now at risk of deportation.

For many families, these changing practices and policies place relatives at risk of forced separation. This is especially the case in mixed-status families that may include a parent with TPS, another parent without legal residential status, and children who may be either DACA recipients or U.S. citizens. Among Salvadoran families with TPS, 192,000 U.S.-born children could legally remain after their parents are deported. In these mixed-status contexts, families face painful decisions about whether to leave their children in the United States when other family members are deported. TPS is being revoked for the countries with the highest homicide rates in the world: Honduras, El Salvador, and Haiti rank first, third, and 12th globally, with murder rates in Honduras and El Salvador 600% greater than the global average (2). Therefore, many adults being deported may prefer that their children or other family members stay behind in the United States.

We are deeply concerned about this forced separation and its impact on the mental health of families, especially the short- and long-term consequences for children. The American Psychiatric Association’s (APA, May 30, 2018) statement about mental health consequences of forced separation at the border is equally applicable to families in the United States who are now being torn apart: “Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder (PTSD). The evidence is clear that this level of trauma also results in serious medical and health consequences for these children and their caregivers.”

Separation from caretakers shatters children’s emotional security and may elicit symptoms associated with stress-related disorders, such as the perception of a foreshortened future and an increased risk of suicide (3,4). In a study of 500 children whose relatives were detained in immigration raids, common acute symptoms included loss of appetite, nightmares, anxiety, anger, withdrawal, speech delay, and behavioral and academic decline (5). In this sample, some of the symptoms abated, but anger, aggression, and withdrawal did not improve over time. A vicious cycle can develop wherein older children who have a detained or deported family member are at risk of substance abuse and disruptive behavioral disorders, which increases risk of engagement with law enforcement and subsequent immigration detention and deportation (3). For caregivers, there may be a sense of hopelessness, demoralization, anxiety, and depression, which may decrease their emotional availability, further jeopardizing children’s sense of safety.

In a study of Latino parents of adolescents affected by the current administration’s policies and practices regarding permanent residency status, TPS, and undocumented status, parents with high levels of psychological distress were five times more likely than parents with low psychological distress to not seek medical care; four times more likely to warn their children to stay away from authority figures; and twice as likely to avoid asking police for help when needed (6). In the study, parents who had been stopped, questioned, or harassed by authorities were eight times more likely than others to have high psychological distress. Similar studies report that families fearing separation are at increased risk of major economic, health, and social difficulties because they are less likely to continue enrollment in Medicaid; the Women, Infants, and Children supplemental nutrition program; food stamp programs; and other social services (7). Although some states and organizations have attempted to address the needs of these families, the advice is often generic and can lead to false assurances among children. For example, in March 2017, the Connecticut governor’s office released the Family Preparedness Plan: Preparing Your Family for Immigration Enforcement (8), recommending that adults discuss potential deportation and separation: “Talk to your children about your plan: Without worrying them, assure your children that they will be taken care of if for some reason you are unable to care for them, even for a short period of time. Let them know who will care for them until you can.”

This recommendation introduces a paradoxical statement: the separation is presented as a plan of the parents when in fact it is experienced as an external imposition. It addresses neither the difficulty in communicating the risk of separation with children nor the mental health implications of forced separation for the family. In contrast, the Center for Law and Social Policy finds that many families affected by the current circumstances resist such empty platitudes to their children: “I don’t feel comfortable saying it’s going to be okay,” explained one caregiver (7).

As health practitioners, we need to address the psychological needs of families experiencing or at risk of forced separation. The following considerations are intended to help mental health care professionals fulfill this role.