Moncrieffe, M. V. (2023, November 1). Specialized care for immigrants experiencing trauma is vital. Psychologists are breaking down the mental health barriers. Monitor on Psychology, 54(8). https://www.apa.org/monitor/2023/11/immigrant-mental-health
Last year, more than 2 million people attempted to enter the United States, bringing the total number of immigrants to a record high of 46 million, according to recent estimates from the U.S. Census Bureau. Some sought refuge from conflicts, violence, and political unrest, while others wanted the security of a functional economy. The Southwest border experienced the largest ever surge in numbers. In 2022, more than a million individuals became authorized permanent residents in the United States. Most new permanent U.S. residents originate from 20 countries and five continents, with the largest numbers of people coming from Mexico.
Psychologists specializing in working with these communities say that immigrants, asylum seekers, and refugees are living with extreme stress, consistent vulnerability, and life-long health consequences as a result of barriers that limit their ability to receive psychological care. A 2022 study of children and families living in the United States who have experienced migration-related trauma found significant barriers to receiving mental health care, including mental health stigma, distrust of service systems, and cultural and linguistic differences (Miller, A. B., Psychological Trauma, Oct 27, 2022).
Psychology as a field has not historically considered the structural inequities and cyclical trauma in immigrant communities (Rami, F., et al., American Psychologist, Vol. 78, No. 2, 2023). Some psychologists are changing this by providing specialized care for different types of immigrant trauma, training new providers to deliver culturally and contextually competent care, and embedding themselves into the immigrant communities they serve.
Following are four examples of psychologists working closely with different historically marginalized immigrant populations:
As the daughter of a Mexican-born mother, psychologist Jeannine Cicco Barker, PsyD, focuses her Philadelphia-based practice on supporting immigrant and marginalized communities. After gaining experience in providing psychological assessments to these communities, Cicco Barker now provides therapy, outreach, and advocacy to often hard-to-reach populations or individuals who must remain hidden or face deportation.
Every immigrant story is unique and often complex, said Cicco Barker. Her special insight into this population was gained by working with organizations like Physicians for Human Rights Asylum Network and by providing volunteer psychological services for the CARA/Dilley Pro Bono Project at the Family Detention Center in Dilley, Texas. These roles support Cicco Barker’s ability to serve communities she is committed to immigrants, refugees, and asylum seekers.
Providing these services at the border and in detention centers is just one example of how psychologists can help this vulnerable population, said Cicco Barker. She asserted: “It is not very easy to do.” But, an accessible and pragmatic approach for psychologists to help is offering immigration evaluations or offering pro-bono/low-cost therapy to immigrants and asylum seekers, she said.
Often that work involves finding ways to provide specific care for every member of the family. “A lot of the time children of immigrants are often supporting their families in unexpected ways, from taking care of younger siblings to translating for parents,” she said. Cicco Barker sees some of her personal experiences mirrored in those of these first-generation Americans, and this prepares her to provide appropriate care and services. Changing demographics in the United States are making a slow impact on diversity in psychology, which remains dominated by White clinicians, representing almost 81% of those in practice. “I look at our field—it lacks diversity and as a result, our services are not equitable and accessible,” she said.
The pandemic changed the way that many psychologists provide care, including Cicco Barker, who is registered with PSYPACT and can see patients from 39 states via telehealth services. Technology—and the laws enabling it—is broadening her scope to reach patients across the country and that means more access for individuals and communities in need, including historically marginalized immigrants.
The number of psychologists skilled and able to provide care embedded in cultural awareness and sensitivity to Asian Americans is limited, with 3.28% of psychologists identifying as Asian. This is important because after Mexico, the largest numbers of authorized immigrants settling in the United States are coming from India and China. Living between cultures is a challenge faced by all immigrants, and navigating those complexities is how psychologist Valerie Yeo, PsyD, is providing care for Asian American communities. Strong family ties, sometimes differing immigration status within these families, and high expectations of success in these communities often result in hidden challenges for Yeo’s patients.
Yeo is one of the few private practitioners in Portland, Oregon, providing care to first- and second-generation Americans, many of whom are of Asian descent. Fear continues to occupy the minds of new and even established immigrants, particularly in Asian communities, said Yeo. In 2020, there was a 70% increase in attacks on individuals of Asian descent, according to the FBI Hate Crime statistics. It was social unrest, said Yeo, that originally made her decide to devote her practice to working with immigrants. “I was thinking about ways that I could use my degree to effect more concrete change,” she said.
Yeo provides support and psychological evaluations for patients applying to be permanent residents, for waivers of removal from the U.S. or citizenship. These application processes are often long and time-consuming, said Yeo. Working with immigrant populations means that psychologists must know where individuals and families can access the community experts and the resources they need to guide them through this process, said Yeo. “With immigrant clients, we are working with people who by and large aren’t White, English might not be their first language, and they may have been through all sorts of trauma. We’re also often working with interpreters, so it is not just language but also cultural differences,” she said.
To make sure she doesn’t bring biases into the clinical setting, Yeo continuously works to understand the communities that she serves. “I have multiple marginalized identities myself,” said Yeo. “As psychologists, we cannot say that we are ‘culturally affirming’ if we are not also working to dismantle systemic oppression in our own selves and within our communities,” said Yeo. The next step for clinicians is to consider their approach in relation to this broader context, asserts Yeo. “If we do not do the work to think about what we are bringing [to the sessions], then we can do a lot of harm to our clients,” she said.
With 6 years of experience providing psychological evaluations, Yeo now trains psychologists and other mental health providers in this process through the nonprofit organization IMPACT based in Portland, Oregon. IMPACT provides services to individuals and families trying to gain stability. Immigrant families often have the added complexity of varying legal statuses between undocumented parents and their children born in the United States.
For psychologists new to providing services to immigrant and undocumented clients, this means exploring each patient’s journey. “Without knowing the sociopolitical context of people’s experiences, it can be easy to pathologize or essentialize someone’s presentation, especially if it does not conform to Western-centric ideas of health or wellness,” said Yeo.
As well as providing services and care to patients, she also works to broaden the psychological literacy of other professionals working with immigrants such as attorneys. She represents her patients when they are being evaluated during immigration proceedings, and the goal of the evaluations is to assess the client’s mental health and well-being. “My role in these evaluations is essentially to tell someone’s story and to provide some education—especially about trauma—for people in the court system and to attorneys who might not otherwise know this information,” she said.
While psychological care is losing its stigma for many Americans, many immigrant populations struggle to acknowledge mental health challenges. In addition, working with immigrants often involves multiple layers of effort from administrative to practical on the part of the provider, Yeo says. “It does create a little more case management around finding services that are going to be a good fit. A lot of these folks are not coming from a Eurocentric environment, so I always try to be careful that I am making referrals to places and providers who have that understanding, and have done their own work around how to provide care with cultural humility and awareness,” said Yeo.
Some psychologists believe the work to strengthen the profession to address the needs of immigrants must begin in the classroom by training the new generation of scientist-practitioners. Researchers like Luz Garcini, PhD, an assistant professor of psychology in psychological sciences and director of community health at the Kinder Institute for Urban Research at Rice University, are doing just that.
Research has shown that despite the challenges of the immigration experience, the influx of foreign-born individuals has increased life expectancy in the United States (Hendi, A. S., & Ho, J. Y., SSM – Population Health, Vol. 15, 2021). But Garcini suggests that this may well be a false narrative. Her research indicates that there is a major psychological and physical cost in making the journey to the United States. “In the short term the United States is a place for immigrants with the greatest resilience, those whose bodies can withstand the most abuse, and those who have no choice but to stay as a survival mechanism,” she said.
Data is limited and there is a need for research to guide effective interventions, advocacy, and policy to reduce risk and prevent further harm, said Garcini. “There is little information about what happens over time and the detrimental effects of living under chronic stress and oppressive circumstances.” Addressing the lack of longitudinal data is the next crucial step for researchers.
The burden of disease faced by this immigrant population and its toll on the well-being of unauthorized and often essential workers is unknown, said Garcini, but is “something that we must urgently explore.” Garcini and her collaborators are currently using biomarkers to document how toxic stressors and trauma can get under the skin over time to increase health risk among marginalized Latinx immigrants, with the goal of informing public health and migration policies.
Garcini and her team have been collaborating with immigrant communities to address significant gaps in the research literature. This means going out into the community to meet immigrants where they are, said Garcini, who, along with a team of psychologists, has now launched the Latinx Immigrant Health Alliance (LIHA), a group of Latinx scholars who collaborate to advance research, policy, and effective interventions to improve immigrant health and inform effective policy.
There are also growing networks and directories featuring psychologists whose goals are to provide care for immigrant and marginalized populations. One thing these providers have noted about working with immigrants at various stages of their journey is that sliding scale fees are essential. Clinicians can partner with nonprofits, such as the Open Path Collective and the Loveland Foundation, which fund mental health care at steeply reduced rates for patients with lower incomes.
Oswaldo Moreno, PhD, an associate professor of psychology at Virginia Commonwealth University (VCU), and a first-generation American, directs the La Esperenza Research Lab, where his team researches health care and mental health disparities. They employ qualitative and quantitative methodologies that include community engagement, as well as community-participatory and school-based research. “My goal is to be able to uplift the voices of the communities,” said Moreno, whose patients include Latinx and Spanish-speaking individuals and families.
Moreno’s work takes place not only on the campus but also in the neighborhoods of Richmond, Virginia, where he codirects and co-supervises the VCU Multicultural Clinic, providing mental health services for immigrant and Spanish-speaking communities. He said he tries to follow the example his parents set as immigrants to the United States. “They had a fifth-grade education, but they instilled in us the idea of getting an education, as well as values like giving back to the community, passed on from generation to generation. I really value working with people,” said Moreno. “Providing adequate, culturally responsible services,” said Moreno, is at the core of his work, and those differ from patient to patient. “One size does not fit all,” he said.
According to Moreno, the essential component in providing care for immigrant communities is context. “A lot of my work looks at systemic policies at the regional, state, and national levels,” he said. He adds that the lived experiences of immigrant families have been politicized, creating more challenges to an already vulnerable community. “If we look at the Western views of psychotherapy, many look at just the individual level, but the reality is that [our] policies and systems are making the lived experience quite stressful. So, it goes broader than just the community and the individual; it’s not just about health disparities—it’s about structural health inequalities,” he said.
COVID-19 brought to light many of these structural issues when jobs held largely by immigrants and those of lower socioeconomic levels were recognized as essential, even as the lack of provisions for their safety (and treatment in the event they contracted COVID-19) telegraphed that the workers themselves were expendable. Due to this, as well as anti-immigrant rhetoric, policies, and sentiment, many immigrants “feel like they are being pushed out,” which creates further emotional entanglement at the end of an often difficult journey, said Moreno. Immigrants often suffer “a lack of belonging,” he said. “This is a human rights issue and our role as psychologists is to be able to care for all communities.”
