Lisa R. Fortuna, MD, MPH

The effects of minority and undocumented immigrant status combined with poverty pose a set of unique psychiatric risk factors. Restrictive legislation and policy measures have limited access to health care and other basic human services for undocumented immigrants and their children. Despite the need for mental health support, undocumented immigrants underutilize mental health services as well as other social services and supports. Undocumented status results in an invisible class of people who suffer from significant challenges combined with limited access to services that can assist them.

Most undocumented immigrants come to this country for economic opportunities or to reconnect with a family member who is a US resident or citizen. Many endure traumatic experiences while emigrating that put them at psychological risk.

Once in the US, undocumented immigrants face multiple psychosocial stressors. Experiences of discrimination are associated with increased risk of depression and anxiety.

 In a study of Hispanic immigrant patients at a mental health program in New York City, undocumented patients had a significantly greater number of psychosocial stressors than legal residents and US-born citizens.

 They were more likely to have psychosocial problems related to occupation and access to health care and the legal system. They also had a lower mean number of total mental health appointments in which to address stressors.

The mental health of undocumented immigrants is a family issue. Approximately 5.5 million children in this country have at least one parent who is undocumented. About 1 million of these children are also undocumented, while about 4.5 million are US-born citizens; approximately 9.5 million people live in “mixed status” families that include American citizen children and undocumented immigrant parents.

Undocumented children and US-born children of undocumented parents are at risk for long-term detrimental effects on their social development, sense of belonging, educational achievement, economic well-being, and mobility. Fear and vigilance are key issues in the home lives of undocumented immigrants: parents are significantly less likely to engage with teachers or be active in school or to access health services. Parents’ fears of deportation lead to lower levels of enrollment of their US-born children in public programs for which the children are legally eligible. These include child care subsidies, public preschool, and food stamps.

Many undocumented immigrant children and youths are subject to racial profiling and ongoing discrimination. They are exposed to gangs, immigration raids in their communities, arbitrary stopping of family members to check their documentation status, being forcibly taken or separated from their families, returning home to find their families have been taken away, placement in detention camps or in the child welfare system, and deportation. These experiences lead to anxiety, fear, depression, anger, social isolation, and lack of a sense of belonging.

The impact of having parents who have been detained or deported can result in severe mental health problems, such as PTSD, chronic depression and anxiety, acting out behaviors, and difficulties in school. Many immigrant parents work long hours in low-wage jobs and often work in more than one job. Even when children who are undocumented succeed and complete college or advanced degrees, they are likely to continue working low-wage jobs like their parents because of barriers inherent in their legal status. This leads to further frustration and hopelessness as these young people work to escape this perpetual “outsiderness.” Legislation such as the Development, Relief, and Education for Alien Minors (DREAM) Act has been proposed to help support undocumented youths who came to the US before age 16, which allows them to study and/or serve in the military as a path to citizenship.

What new information does this article provide?

This article provides several recommendations and outlines approaches for mental health treatment for undocumented immigrants, derived from the first author’s extensive clinical work with this understudied population.

What are the implications for psychiatric practice?

Psychiatrists and other clinicians interested in better serving undocumented children and adults can do so by addressing the many barriers to care that may be present in their practice, by providing trauma-informed and culturally sensitive care, and through collaborative work with the community.

Unaccompanied refugee minors-those who enter the US without a parent or guardian and with no one to care for them in the US-are at risk for complex mental health problems that emerge in the context of high exposure to traumatic experiences and losses. At the end of 2011, 35.4 million people (including 10.4 million refugees) were categorized by the United Nations High Commission for Refugees as a population of concern because of displacement; almost half were children younger than 18 years.

Studies have shown that unaccompanied refugee minors are likely to have experienced or witnessed extreme traumatic events and consequently have higher rates of anxiety, depression, and PTSD than accompanied minors and native-born youths.

 Adjustment to settlement in the host country often leads to distress and uncertainty because youths must negotiate a new language, culture, school, and community.

Prevalence of mental health problems and use of services

Some studies have suggested that immigrant populations may have lower rates of psychiatric disorders. This finding has been termed the “immigrant paradox,” in that immigrants appear psychologically healthier than might be expected from their socioeconomic status and circumstances compared with immigrants who are born within or are longer-term residents of the US.6 Many explanations have been suggested for this phenomenon, including loss of protective cultural practices and supports, discrimination, social isolation, and negative living conditions in the US, which are psychiatric risk factors for US-born and second-generation immigrants. Within Latino subgroups, however, there is variation in how well the paradox holds.

 A study of undocumented immigrants (15%), documented immigrants (73%), and US-born Latinos (12%) treated in a Hispanic mental health program found that those who were undocumented were more likely to have anxiety, adjustment, and alcohol use disorders. They also had lower rates of lifetime inpatient and outpatient treatment.

Barriers to treatment include fear of being discovered, lack of finances or health insurance, language barriers, the need to work multiple jobs and long hours. A national study of immigrants who have experienced political violence found very low use of mental health services by this group. Immigrant men who come from countries with a history of political violence were less likely than their female counterparts to access mental health services, although they were as likely to suffer from anxiety or depression.

Raquel is a 28-year-old undocumented immigrant with 2 children: a 10-year-old son Giovanni and a 6-year-old daughter Sofia (both US citizens). She has family members who are legal residents and who live nearby.

Raquel is experiencing significant stress. She works every day at lowpaying jobs to support her family, yet she still struggles financially. She is depressed and anxious-there have been immigrant “sweeps” at workplaces like Raquel’s. Her family and church are supportive, but there are many barriers to her being able to receive treatment.

Giovanni also shows symptoms of anxiety that have led to academic and developmental problems. He is protective of his sister and worries about his mother being deported. He is also aware of the discrimination around him.

Culturally responsive approaches, such as the Cultural Formulation model or the genogram, for diagnosis and treatment engagement can be used to address the issues this family faces. Because Raquel works long hours and has limited free time, short-term therapies for adults that increase coping abilities and are strength-based are beneficial. In addition, information about safe ways to access needed services and supports (solution-focused and psychosocial issues addressed early) is invaluable.

You can learn about community- and faith-based centers in your area that offer support and safety; partner with these venues to provide psychoeducation and build trust regarding mental health services. Assist patients via coordinated outreach efforts with these centers. You can partner with schools to offer counseling, support, and coping strategies for immigrant children. Parents’ hesitation about services for their children can be overcome by evoking their motivations for their child’s success and providing education about the various programs available as well as emotional support.

 Mental health providers can assist with outreach and improve psychiatric care. Strategic areas that have demonstrated success include social support services combined with treatment, community outreach, rapport-building strategies, psychoeducational groups, and brief solution-focused and socioculturally relevant therapies.

 Early assessment and intervention for psychosocial stressors, substance use disorders, and barriers to care are important when treating undocumented immigrants, especially because of the high rate of early treatment dropout and low access to care. Nonprofit organizations-particularly those that can provide concrete service related to accessing social programs, food stamps, legal resources, or immigrant resettlement programs-are good partners for delivering mental health services.

Schools are other centers that can be used to provide effective social supports. Studies show that undocumented refugee minors need intensive educational services, cultural training, and culturally appropriate mental health services-all of which can be provided in school settings.

 In a PTSD therapy study, unaccompanied refugee minors who showed the most mental health improvement in response to psychiatric treatment were those who concurrently received social support from their foster families and teachers.

Because social support and integrated services can lower or mitigate the effects of stressful life experiences, clinicians can assist by collaborating with the young person’s support system. Interventions such as Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) include components to help train teachers and caregivers in trauma-informed approaches while students receive group therapy on school premises.

Community outreach and supports. Clinicians may have to use creative measures, such as partnering with churches and other social nonprofits that provide a sense of belonging. These are excellent settings for outreach and psychoeducation. Psychoeducational groups, regardless of the community setting in which they are delivered, provide social support, trust building, engagement, help with mental health problems, and information about legal rights and available resources.

Good assessment is crucial to engage patients in treatment, and the availability of bilingual clinicians and/or interpreters is essential. A full biopsychosocial assessment includes an evaluation of symptoms; social stressors; social supports, including family systems; immigration history; explanatory model of illness or distress; potential barriers to treatment; motivation; and immediate needs. Yznaga

 found that genograms can be helpful in building rapport, understanding the patient’s family structures, and assisting in learning about the patient’s world view and presenting concern. The genogram is also a tool for identifying family as a potential resource for social support and for identifying successful coping strategies within the family.

The first step in treatment may need to focus on case management for responding to psychosocial problems. Early sessions include inquiring about the patient’s feelings concerning medications, individual therapy, and other modalities of treatment, as well as assisting with any barriers to accessing preferred treatments.

 have developed a motivational interviewing intervention for Hispanics that engages the patient around his or her understanding of and motivation for treatment. The Cultural Formulation Interview focuses on the patient’s perspectives on the problem, the role of others in influencing the course of the problem, the impact of the patient’s cultural background, the patient’s help-seeking experiences, and current expectations about treatment and other forms of care.

Given the risk for early treatment dropout, brief solution-focused therapy can be helpful when working with undocumented patients who may respond best to direct, problem-solving, supportive, and informational approaches. Important themes to consider are:

• Interdependence and the centrality of family as both social support and stressor.

• The importance of spirituality for coping and meaning making.

• Experiences of discrimination, acculturation stress, alienation, and fear as well as immediate tangibles such as unemployment.

• Other resources for social support and community building, especially for individuals who are living in the US alone, without any family or other social supports. These can include faith-based organizations, local immigrant or cultural organizations, and immigrant resettlement organizations. Some of these may be able to help with the immediate psychosocial, housing, and economic needs.

If anxiety and depression are treated with cognitive-behavioral strategies, the clinician should consider not only acute and historical trauma but ongoing social stressors as well. The goal is to help patients attain mastery and control over the forces that threaten to overwhelm their coping capacities-school-based therapies such as CBITS have been found to be helpful because they help young people learn and use coping skills to combat anxiety and chronic environmental stressors.

Dr Fortuna practices adult and child psychiatry with a specialization in immigrant and refugee populations. She is also a researcher in the field of mental health service research and is currently participating in a National Institute of Drug Abuse International Collaborative study of dual diagnosis treatment with Hispanic immigrant populations. She is a researcher at the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Mass. Dr Porche is Associate Director and Senior Research Scientist at Wellesley Centers for Women, Wellesley College, Wellesley, Mass. Her research focus is on socio-emotional factors that impact on academic achievement for children and adolescents. The authors report no conflicts of interest concerning the subject matter of this article.

 Potochnick SR, Perreira KM. Depression and anxiety among first-generation immigrant Latino youth: key correlates and implications for future research. 

 Perez MC, Fortuna L. Psychosocial stressors, psychiatric diagnoses and utilization of mental health services among undocumented immigrant Latinos. J Immigr Refugee Serv. 2005;3:107-123.

 Passel JS, Cohn DV. Unauthorized Immigrant Population: National and State Trends, 2010. Washington, DC: Pew Hispanic Center; 2011.

Huemer J, Karnik NS, Voelkl-Kernstock S, et al. Mental health issues in unaccompanied refugee minors. 

5. Bean T, Derluyn I, Eurelings-Bontekoe E, et al. Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents.

AlegrÃ­a M, Canino G, Shrout PE, et al. Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. 

 Fortuna LR, Porche MV, Alegria M. Political violence, psychosocial trauma, and the context of mental health services use among immigrant Latinos in the United States. 

 Rousseau C, Lacroix L, Singh A, et al. Creative expression workshops in school: prevention programs for immigrant and refugee children. C

 Fortuna LR. Balancing culture and fidelity in the development of a psychotherapy or co-occurring disorders in adolescents. Presented at: Adapting Interventions for Minority Children and Families Meeting; 2010; Washington University, St Louis.

 Ngo V, Langley A, Kataoka SH, et al. Providing evidence-based practice to ethnically diverse youths: examples from the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) program. 

Yznaga SD. Using the genogram to facilitate the intercultural competence of Mexican immigrants. 

 Lewis-FernÃ¡ndez R, DÃ­az N. The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. 

Articles

Despite the need for mental health support, undocumented immigrants underutilize mental health services. Many endure traumatic experiences while emigrating that put them at psychological risk and once in the US, undocumented immigrants face multiple psychosocial stressors.

Clinical Issues and Challenges in Treating Undocumented Immigrants

, Dr Brian Johnson challenges young people to resist “zombification by the zombie masters”-or, becoming addicted (“zombified”) by the individuals and systems (“zombie masters”) that sell and deal drugs and benefit from the misfortune of others. Dr Johnson starts 

Widespread Zombification in the 21st Century and the Wars of the Zombie Masters

 with a question and a warning: “How do you know what a zombie is? The zombie masters will be hunting your brain over the next few years. You should know how to protect yourself.”

The author is an expert and experienced physician and researcher in the field of addiction. He is director of addiction psychiatry and associate professor of psychiatry at SUNY Upstate Medical University, Syracuse, NY; he taught at Harvard Medical School for 30 years and is extensively published in the fields of psychiatry and addiction. This book is evidence of his expertise in and passion for educating young people about the real facts of addiction. He succeeds in engaging the reader with both fantasy and frankness.

When I first started to read the book, I wondered how far the author would be able to carry the story line of “zombification”-the loss of self (body and mind) inherent in addiction. Would he keep the interest of a young person with this “funky” approach? I think he succeeds in presenting an interesting yet highly informative narrative about the social, medical, and psychological aspects of drug abuse. The book is a candid story about the biological mechanisms and neuroscience of drug addiction.

This appealing narrative challenges young people to critically examine the issue of drug addiction. The book is a framework of information without delivering what an adolescent might perceive as another lecture by an adult. This is more than a frank and candid guide. It reads like a wise teacher in a science fic-tion or action movie. I think it works and will introduce an abundance of important facts to young readers (adolescent to emerging adult).

The first part of the 9-chapter book describes how drugs of abuse became widespread in the 21st century in the United States. A chapter on the “upper zombie” drug groups (eg, cocaine, methamphetamine, ecstasy) includes data on cigarettes/nicotine. In the section on cigarettes, the author introduces the concept of “beautification and denial”-marketing strategies by the cigarette industry (and others) to lure the young and the beautiful. He describes in detail the process of nicotine addiction with graphic stories of individuals whose denial slowly results in illness. Other chapters in the book are “Zombification Techniques” (zombie masters’ use of gateway drugs), the “Downer Zombie Drug Group,” “Treating Zombies,” and “Relating to Zombies.”

The second part of the book, “The Wars of the Zombie Masters,” is a series of chapters on US and international history (American Civil War to the 20th century) and social impact of the drug trade industry. This section includes everything from the early American tobacco industry (and its related slave trade) to narratives of gang wars today.

The author ends by asking: What should you do about the dangers of zombie masters? Here he gives practical advice to young people on how to detect addiction, how to stay safe, how to think critically, and how to talk about the problem of drugs.

This book can benefit young people by exposing them to some intense but valuable material. It would be wise for parents to become “occasionally interested,” as described in the title. Moreover, the book encourages adults-parents and therapists-to start a dialogue on addiction with their children/patients. Information can be found at 

With this creative and engaging eBook, the author challenges young people to resist “zombification by the zombie masters”-or, becoming addicted (“zombified”) by the individuals and systems (“zombie masters”) that sell and deal drugs and benefit from the misfortune of others.

Lisa R. Fortuna, MD, MPH

Articles

Clinical Issues and Challenges in Treating Undocumented Immigrants

Widespread Zombification in the 21st Century and the Wars of the Zombie Masters: