A 12-year-old girl fleeing gangs in El Salvador arrives in Texas alone because her mother died during the journey. A Chinese family settles in the Midwest and enrolls their young children in school. Now, the world is responding to a new influx of refugees fleeing violence and oppression after the Taliban’s takeover of Afghanistan.
The United States is home to more than 44 million immigrants—from almost every country in the world—each with a diverse set of needs and experiences. Despite facing significant psychological challenges, including racism, acculturation, and trauma, immigrants access mental health care services at lower rates than people born in the United States (Derr, A. S., Psychiatric Services, Vol. 67, No. 3, 2016). This is partly due to structural barriers, such as cost and insurance coverage, but also because of a dearth of providers versed in the linguistic, cultural, and policy hurdles these populations face.
Psychologists do not need to match their patients’ nationality or experiences in order to help. They do, however, need to understand the geopolitical, cultural, and legal realities these communities are navigating.
“The most important thing that any clinician who’s working with immigrants can do is listen to the stories of individuals,” said psychologist Laura Minero, PhD, a postdoctoral fellow at the University of California, Los Angeles, and a Deferred Action for Childhood Arrivals (DACA) recipient.
Developing expertise in cultural competence, trauma-informed care, narrative therapy, and other strategies can position practitioners for success in working with the largest immigrant population in the world.
The immigrant experience
Immigrants arrive in the United States with a vast diversity of religious, linguistic, educational, and ethnic backgrounds. They also come to this country for a variety of reasons—some are seeking work, some fleeing violence, and others reuniting with family members. More than half come from Latin America and another quarter from Asia (Facts on U.S. Immigrants, Pew Research Center, 2018). Even immigrants from the same country often differ greatly in their legal statuses, levels of familial support, and personal experiences.
For that reason, understanding the context of immigration is essential for psychologists who seek to help these populations. For example, migrants leaving Central America’s Northern Triangle region (El Salvador, Guatemala, and Honduras), which the United Nations calls one of the most dangerous parts of the world, are often running for their lives, said Charissa Pizarro, PsyD, a clinical psychologist who works with undocumented immigrants.
These individuals often face gang violence and threats, domestic violence, and sexual violence in their home countries. During the perilous journey to the United States, they may have endured extreme weather and terrain, starvation, thirst, and manipulation or sexual assault by the smugglers they pay to facilitate the trip. Depression, anxiety, and posttraumatic stress disorder are common mental health issues among migrants who have experienced such trauma (Garcini, L. M., et al., Journal of Consulting and Clinical Psychology, Vol. 85, No. 10, 2017; Rojas-Flores, L., et al., Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 9, No. 3, 2017).
Upon reaching the United States, immigrants and refugees from around the world face additional hurdles in navigating the immigration system, finding a job, and overcoming language and cultural barriers. At this stage, many immigrants of color also face bias and discrimination because of their race, which can affect their mental health (Garcini, L. M., Psychology of Violence, Vol. 8, No. 6, 2018).
“Racism is finally being recognized as a public health issue, but it’s also important to connect that to the immigrant experience,” Minero said. “A lot of the challenges that immigrants experience are actually due to racism.”
For others, such as families who are more established and have enrolled their children in school, acculturation and ethnic identity may be the primary concerns, said Dina Birman, PhD, a professor of psychology at the University of Miami who studies the way immigrants and refugees adjust to life in the United States.
Despite these myriad challenges, immigrants are incredibly resilient. Research on the “healthy immigrant paradox” even suggests that upon arrival, immigrants have better mental health than nonimmigrants. But once they settle in, mental health tends to decline—making support from psychologists central to the sustained well-being of these communities (Rivera, B., et al., Administration and Policy in Mental Health and Mental Health Services Research, Vol. 43, 2016; Coll, C. G., & Marks, A. K. [Eds.], The Immigrant Paradox in Children and Adolescents, APA Books, 2012).
Preparing to help
Before clinicians begin working with immigrants and refugees, they should understand the context of immigration in the United States, both today and historically. The U.S. government has repeatedly used immigration policy as a tool to deny citizenship to people of color, including through the Naturalization Act of 1790 and the Chinese Exclusion Act of 1882, said Germán Cadenas, PhD, an assistant professor of counseling psychology at Lehigh University in Bethlehem, Pennsylvania, who studies the psychology of undocumented immigrants.
“For the past few years, we’ve also seen a period of very aggressive anti-immigrant policies that have restricted the options for people to access employment, housing, education, and social support in this country,” he said, citing family separations, attacks on the DACA program, and the travel ban against people from several Muslim-majority countries.
Cadenas recommends that psychologists connect with advocacy groups such as Informed Immigrant, the Coalition for Humane Immigrant Rights, and Immigrants Rising for policy updates and explanations of some of the more complex issues that impact immigrants and refugees.
Next, psychologists must identify and dispel any biases and misconceptions they may have about immigrants. For example, providers may assume that migrants from Central America are not well educated, but education levels vary just as they do among nonimmigrants (O’Connor, A., et al., “ Central American Immigrants in the United States,” Migration Policy Institute, 2019). Another common assumption is that youth of Asian origin are well adjusted and require less mental health support than other students, said Cixin Wang, PhD, an associate professor of school psychology at the University of Maryland. As a result, these students are less likely than their Latinx peers to receive referrals to school-based mental health care providers, even after controlling for a number of factors, including externalizing problems and academic performance (Guo, S., et al., School Mental Health, Vol. 6, 2014).
Misconceptions about culture or encouraging patients to assimilate without care for cultural heritage can directly harm patients, said Rehman Abdulrehman, PhD, a clinical psychologist and assistant professor at the University of Manitoba who works with refugees from the Middle East. “Practitioners doing cross-cultural work who don’t pay attention to biases may inadvertently reward a patient who gives up their cultural practices, thereby reinforcing that individual’s internalized racism,” he said.
Developing knowledge about a patient’s culture and country of origin is also a key part of providing effective care. Speaking the same language can make a big difference—but it is not always necessary if a patient is bilingual or an interpreter is available. Other cultural nuances, such as conventions around eye contact or the desire to appease the clinician, can also influence rapport and the patient’s comfort level in treatment (Sue, D. W., et al., Counseling the Culturally Diverse: Theory and Practice, Wiley, 2019). For example, women from the Maasai society in East Africa are taught not to look men in the eye and to let men speak first during social interactions. Therapists should understand such gender norms prior to treating individuals from these communities.
Cultural competence also requires that practitioners know how values can impact therapeutic work. For example, patients from Latin American cultures that practice familismo, or loyalty to the family, may wish to consult family members before making any major treatment decision, Pizarro said. Without knowledge of the practice, a clinician might view such behavior as codependent.
Finally, psychologists should be familiar with the barriers to accessing care that many immigrants and refugees face—and consider delivering services in nontraditional settings to reach these groups. Those barriers include everything from busy schedules, cost, and lack of transportation to mental health stigma and fear that information they share with a psychologist might be mishandled, said psychologist Luz Garcini, PhD, an assistant professor at the University of Texas Health Science Center at San Antonio who conducts research on trauma among Latinx immigrants. Reaching immigrants in the places they already frequent—schools, community centers, places of worship, and even social media venues such as Facebook Live or Instagram Live—can help bridge that gap.
Honing clinical skills
Given the high rates of trauma among immigrant populations, a key tenet of immigration psychology is to approach treatment in a trauma-informed way (Miller, K. K., et al., Children, Vol. 6, No. 8, 2019). When conducting an intake interview or psychological assessment, the patient should know they are in control and can stop the interview or choose not to answer certain questions, Cadenas said.
The tone should be conversational and organic rather than interrogative. He also recommends that clinicians focus on creating a sense of safety and building trust, even if that means they cannot obtain all the desired information during an intake interview. Therapists may choose to share their own connection to immigration, if relevant, to indicate that they are a safe person to speak to, but Cadenas never asks patients to disclose their immigration status.
Providers should assess for trauma that may have occurred before, during, and after migration, especially with patients coming from high-conflict areas, including parts of Latin America, Africa, and the Middle East. Premigratory losses and exposures can include disruptions in work, school, or family life, such as a family who flees threats of sexual violence from a local gang, said Elena Reyes, PhD, a professor of clinical psychology and regional director for Florida State University’s College of Medicine in southwest Florida. Migratory trauma might include further threats, starvation, and physical or sexual assault. In the United States, postmigration detentions, family separations, and racist attacks can cause further harm.
As in all populations, trauma may manifest in different ways for immigrants, Garcini said, depending on cultural and personal views on mental health. Psychologists should pay close attention to somatic symptoms. Those may include pain, such as stomachaches, headaches, or back pain; dietary changes, including overeating or a loss of appetite; problems with sleep; or bedwetting and regressive behaviors in children.
Clinicians should also explore patients’ acculturation levels and attitudes, said Reyes. For example, a family’s culture may dictate that girls come home after school to help cook and clean. But in the United States, participating in sports, clubs, and other extracurricular activities can improve students’ college prospects.
“When parents understand these expectations, children and adolescents can engage in developmentally appropriate activities that will help them in the acculturation process,” Reyes said.
In tandem with acculturation efforts, providers should help immigrants maintain pride in their own identity, culture, and practices, said Minero. Research suggests that a strong ethnic identity can improve mental health among immigrant populations, including by reducing acculturative stress and depression (Balidemaj, A., & Small, M., International Journal of Social Psychiatry, Vol. 65, No. 7–8, 2019).
Psychoeducation is a big part of navigating issues with acculturation, trauma, and immigration status. At the integrated care practice where Reyes works, providers teach parents communication skills, such as age-appropriate ways to discuss the family’s immigration status with children and what to expect and do if a parent is deported. Garcini and her colleagues created psychoeducation booklets for children and families in detention centers, with information on somatic symptoms that may indicate mental health problems, advice for articulating emotions, and ways to handle family reunification.
Practitioners working with children should also consider the developmental disruptions that occurred during migration, said Reyes. For example, young children who left school to migrate may struggle to form healthy relationships with their peers. Providers can then work with families to reach the developmental milestones missed because of the immigration process.
Children from mixed-status families, where one or both parents are undocumented and one or more children are U.S. citizens, are another vulnerable group, Pizarro said. They experience high rates of psychological distress—such as depression, anxiety, and fear—and may face problems with behavior and relationships at home and at school (Gulbas, L. E., et al., Child: Care, Health and Development, Vol. 42, No. 2, 2016).
One highly effective way to serve children is through school-based programs, because barriers such as cost, transportation, and stigma are removed or reduced, said Wang, who helped create a three-tiered model of mental health care for immigrant youth (Journal of Immigrant and Minority Health, Vol. 23, 2021):
- Tier-one interventions: school-wide programs such as bullying prevention and classroom-based instruction in social-emotional learning skills that consider immigrant students’ unique needs (recognizing feelings of stress, culturally congruent coping strategies, etc.).
- Tier-two interventions: tailored small-group interventions for children who continue to struggle, such as a culturally informed psychoeducation program for children and families.
- Tier-three interventions: evidence-based individualized care that addresses persistent concerns such as trauma history, language issues, or other factors that may interfere with adjustment.
In terms of therapeutic modalities that are effective for immigrant patients, clinicians recommend strengths-based approaches and narrative therapy (Peltonen, K., & Kangaslampi, S., European Journal of Psychotraumatology, Vol. 10, No. 1, 2019; Ramirez, N., & Monk, G., Journal of Systemic Therapies, Vol. 36, No. 2, 2017). In narrative therapy, the patient deconstructs their experiences, roles, and choices through a conversation with their provider or a written story. In some cases, the narrative can be relayed through art, music, or film.
“During this process, it’s important for the patient to know that they’re the expert of their own story,” Cadenas said.
Cognitive behavioral therapy (CBT) and trauma-focused CBT are also good options, especially if talking about mental health is not common among the population being treated, Abdulrehman said. Clinicians can help patients practice monitoring their thoughts and behaviors and teach them about cognitive restructuring, emotion regulation, and other techniques (Friedberg, R. D., et al., “ Cognitive-Behavioral Therapy for Immigrant Youth: The Essentials.” In S. Patel & D. Reicherter [Eds.], Psychotherapy for Immigrant Youth, Springer International, 2016).
“Behavioral prescriptions can allow people to begin to address the problems they’re facing as a health issue rather than as a mental illness,” he said.
Paths to citizenship
In addition to treating immigrants in clinics, schools, and community settings, psychologists play a key role in the path to permanent residence and citizenship by conducting forensic evaluations that are reviewed by immigration courts.
“Immigration court is totally different than state and federal courts because the government is the judge, the prosecutor, and the appellate court,” said Robert Meyers, JD, PsyD, a New York–based clinical psychologist who conducts forensic evaluations.
Despite the one-sided nature of these proceedings, research indicates that immigrants’ cases tend to be more successful when they include a psychological evaluation (McLawsen, G., et al., Bender’s Immigration Bulletin, Vol. 16, No. 10, 2011). Forensic psychologists may conduct evaluations for a variety of cases, including asylum, human trafficking, and U visas, which provide protection for victims of certain crimes. Their work typically involves assessing the extent of psychological harm and, in asylum cases, whether it stems from persecution the patient endured.
Claudette Antuña, PsyD, who has conducted more than 800 forensic evaluations of immigrants in Washington state through the Northwest Immigrant Rights Project, uses a battery of tests that includes the Trauma Symptom Inventory-2, the Millon Clinical Multiaxial Inventory-IV, and the Personality Assessment Inventory, among others. She also provides basic psychoeducation in court, for instance explaining to judges that people who have faced trauma may appear calm rather than distressed.
For psychologists interested in pursuing training to conduct forensic evaluations for immigrants, Antuña recommends exploring the Harvard Program in Refugee Trauma and workshops offered by the organization Physicians for Human Rights. Antuña and Garcini also helped create guidelines for conducting psychological evaluations in immigration proceedings that the National Latinx Psychological Association will publish later this year.
In immigration courts, private practice, schools, and communities, psychologists are using their expertise to support the country’s growing immigrant population. Gaining additional knowledge and experience with cultural competency, trauma-informed care, and immigration policy can further amplify their impact.
