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The patient was an 18-year-old undocumented male immigrant from Mexico referred for consultation to a community-based psychology outpatient clinic after presenting to urgent care for symptoms of a severe Ataque de Nervios or panic-like symptoms with no organic etiology. The patient was brought to the United States (U.S.) at the age of two by his undocumented parents and has never returned to Mexico. Until his recent deportation, his father was the primary provider for their family. Hence, the patient is now working multiple jobs to provide for the family, including his ill mother and his two younger U.S. born siblings. His mother did not speak English; thus, the patient is her language broker and culture navigator. The patient is a stellar graduating high-school senior and part of the Deferred Action for Childhood Arrivals (DACA) program. He is interested in going to college; however, given the limited financial and employment opportunities available to DACA recipients, he does not think he would be able to attend college. As a result, he is feeling anxious, worried, depressed, and hopeless.
Moreover, since his father’s deportation, the patient has had a substantial increase in intrapersonal and interpersonal stressors including experiencing variations in self-perception and internalization of the undocumented stereotype. For instance, this included feeling inferior to others, regarding himself as a hindrance to the community, and feeling undeserving of social and economic opportunity. As a result, this had led to decreased self-esteem, a sense of being burdensome, and feelings of guilt/shame. He is also having trouble coping with a self-imposed pressure on his inability to repay a debt of gratitude primarily towards his parents and other family members who have made sacrifices for his future in the U.S. Despite his academic success in high school, the patient often feels sad and disappointed at the limited educational and employment opportunities available to him and his inability to help his family advance in the social ladder. He also reported constant fear and worry about deportation and severe symptoms of anxiety including inability to concentrate at school, trouble sleeping at night, and multiple unexplained somatic symptoms that have increased in frequency and severity since his father’s deportation. Additionally, he reported a recent increase in fear and avoidance of public places and distrust in others, which he described as disabling. His symptoms are significantly impairing his academic performance, work capacity, and social relationships, and he mentioned feeling at-risk for drinking to cope with distress.
To emphasize the influence of context and culture on the patient’s symptom presentation, an adapted version of the Cultural Formulation Interview (CFI) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) was used in diagnosis (1). A diagnosis of Other Specified Anxiety Disorder was made with Nervios and Ataque de Nervios as specifiers. Moreover, it was recognized that the patient was facing multiple and chronic psychosocial and environmental stressors requiring clinical attention including disruption of family by separation, social exclusion, target of (perceived) adverse discrimination, academic and occupational problems, low income, limited access to healthcare, and legal difficulties associated with undocumented status. Although the patient attended a few therapy sessions, he was ambivalent about mental health treatment because of stigma, lack of time and limited transportation. As a result, he terminated treatment prematurely and mentioned that is was more convenient for him to receive the support that was provided by his church community.
Undocumented immigration is a controversial issue at the forefront of the U.S. political agenda. Among the more than 11 million undocumented immigrants residing in the U.S., over a million are acculturated undocumented youth that were brought to the U.S. as children by their parents, and who meet the requirements of the Development Relief and Education for Alien Minors (DREAM) Act (2). Under this act, these young immigrants, often referred to as DREAMers, are given a time-limited conditional permit to remain in the U.S. and pursue an education, with the caveat of facing constant institutional and societal exclusion and rejection due to their undocumented status (3 – 5).
DREAMers are at-risk for psychological distress and diminished quality of life given the many complex stressors that they face, which are often experienced over a long time, under harsh living conditions, and without access to adequate mental health services (3). Dreamers are often marginalized and discriminated against. This restricts their existence such that they become isolated from the larger educational and work communities, while also experiencing separation from deported family members and an inability to travel internationally to visit them. Moreover, they live in constant fear of deportation and experience a sense of voicelessness, invisibility, and “loss of rights” due to their conflicting undocumented status (4 – 9).
Unfortunately, prevention and treatment interventions aimed to address the mental health needs of DREAMers are limited and efforts are needed to provide access to contextually and culturally sensitive interventions that reduce risk and increase resilience in this population. A key first step to address in the development and implementation of mental health services for these at-risk youth is to reduce cultural and contextual barriers that prevent access to and use of needed mental health services. This includes increasing information and psychoeducation in order to reduce mental health stigma, to highlight stress as a risk factor to the mental health of DREAMers, to improve treatment adherence including devising strategies for engagement and retention, and to disseminate information about treatment effectiveness of mental disorders and distress, including the combined use of medication and therapy. It is also important to facilitate access to affordable mental health services through collaboration with non-traditional sources of delivery available to DREAMers (e.g., religious institutions, school counseling centers, human rights and advocacy agencies, community centers), as well as to develop strategies aimed to improve the trust relationship between the community and the mental health service agencies to facilitate safe disclosure.
In terms of clinical implications, the following recommendations may be valuable in the development of culturally and contextually sensitive mental health interventions for DREAMers. First, endorsing the use of therapeutic techniques that facilitate the integration of context in therapy (e.g., life narrative, values-based interventions) and supporting the building of therapeutic alliances based on genuineness, empathy, and unconditional acceptance of the DREAMer’s background and situation, would facilitate validation of the DREAMers’ experience, which is important for the healing process (10). Also, facilitating the development of adaptive coping strategies within a culture and context-sensitive framework (e.g., authenticate values and build cultural pride, validate aspirations and longterms goals, promote self-care that is consistent with the immigrant’s values (e.g., familismo, collectivism, spirituality) is important for instilling hope amid uncertainty and to foster resilience in the face of adversity. Equally important is the ability to facilitate the establishment of additional social support systems, including organized support aimed at reducing feelings of isolation and useful for promoting altruism and engagement, which is consistent with collectivistic attitudes often endorsed by DREAMers (10). Moreover, it is also essential to facilitate the recognition and expression of cultural concepts of distress (e.g. Nervios, Ataque de Nervios, Susto), which requires the development of appropriate assessment measures and building of a network of professionals knowledgeable in the aforementioned concepts. Finally, it is important to emphasize that the undocumented experience not only impacts the individual him/herself, but also the larger family system and social network surrounding the DREAMer. Thus, incorporating family and group therapy in interventions aimed to address the mental health needs of DREAMers could be particularly beneficial.
Debates on programs and policies pertaining to DREAMers are complex and multifaceted, and divisiveness on opinion and action is long-standing. Nevertheless, revisiting policies to devise solutions grounded in evidence and developing new alternatives to facilitate access to and the provision of culturally and contextually sensitive mental health services for these at-risk youth is critical to protect their mental health and their basic human rights.
Funding was provided to Luz Garcini by the Ford Fellowship and UC MEXUS Award and to Juan Peña by the Minority Biomedical Research Support Initiative for Maximizing Student Development (Grant # 5R25GM058906-16) and the Training and Mentoring Program at the Institute for Behavioral and Community Health (Grant # 5R25MD006853-05). In writing of this manuscript, Juan Peña was also supported by the National Science Foundation Graduate Research Fellowship Program (Grant #DGE-1418062)
Disclosures: The authors of this manuscript have no conflict of interests to disclose.