Why mental healthcare is not a safe space for undocumented migrants
Written by Maria Cohut, Ph.D. on July 14, 2020 — Fact checked by Gianna D'Emilio
People living in the United States with undocumented status often face higher rates of mental health problems but are unable to access appropriate formal care. We have spoken to experts and undocumented individuals to find out why — and what the best solutions might be.
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Trigger warning: This feature mentions experiences of trauma and sexual abuse. Please read at your own discretion.
According to Migration Policy Institute estimates, there are around 11,300,000 migrants with undocumented status living in the U.S.
The institute report that about 5,944,000 undocumented migrants were born in Mexico, while 1,774,000 were born in Asian countries.
Research shows that there are many reasons why people migrate to the U.S. without going through the typical legal channels and thus wind up with undocumented status.
Past studies suggest that migrants may choose to cross borders illegally because they are unable to find gainful employment in their home countries or because they hope to be reunited with family members who have already emigrated.
Other migrants cross borders illegally to flee areas saturated in crime and violence, and some are survivors of human trafficking. These are only a few of the many reasons for illegal migration.
Many undocumented migrants live with this status for decades, trapped in a complex legal web that makes it difficult for them to obtain documentation.
This situation means that the undocumented U.S. population faces huge difficulties in accessing healthcare, including appropriate mental healthcare.
In this Special Feature, we look at the evidence surrounding mental health risks for undocumented migrants. We also explore what prevents people in this situation from accessing mental healthcare and what kinds of policy changes might help.
To enhance our understanding, we have spoken to two people who have lived in undocumented communities in the U.S.
Additionally, we have also spoken to two experts: Prof. Luz Maria Garcini, a specialist in trauma, loss, and grief among Latino immigrants at Rice University’s Baker Institute for Public Policy, in Houston, TX, and Prof. Margarita Alegría, from the Department of Psychiatry at Harvard Medical School, in Boston, MA.
Disclaimer: We have changed some contributors’ names to protect their identities.
Very high rates of mental distress
Recent studies have shown that in the U.S., immigrants — and particularly people without documentation — face disproportionately high rates of mental health issues, compared with the general population.
In a study published in the Journal of Consulting and Clinical Psychology in 2017, Prof. Garcini and colleagues found that undocumented Mexican migrants have a significantly higher risk of developing symptoms of anxiety and depression, compared with the general population.
Data from clinical interviews with 248 people in this situation who lived close to the California-Mexico border revealed that as many as 23% met the diagnostic criteria for a mental health disorder: 14% met the criteria for major depressive disorder, while 8% and 7% reported symptoms consistent with panic disorder and generalized anxiety disorder, respectively.
Another study from Prof. Garcini and colleagues — this time published in the Journal of Traumatic Stress in 2017 — indicated that 82.7% of 248 undocumented Mexican migrants living near the border reported a history of trauma.
Traumatic events included experiencing violence, witnessing violence, or living in a context of poverty. Many participants had experienced six or more traumatic events.
Forty-seven percent of the participants met the criteria for clinically significant psychological distress. Of these, 59% had experienced domestic violence or another form of bodily injury, 56% had witnessed violence, 55% had lived in poverty, and 53% had witnessed violence toward a loved one.
Prof. Garcini emphasizes that these findings are “alarming,” adding, “The prevalence of traumatic events among undocumented immigrants in our study is much higher, compared with estimates for other U.S. populations.”
Other investigations, such as a study featured in the Journal of Social Service Research in 2019, suggest that undocumented Latina migrants have much higher rates of post-traumatic stress disorder (PTSD) than the general population.
The study, conducted with the participation of 62 Latina migrants, concluded that this group experiences an incidence of PTSD almost four times higher than that faced by women in the U.S. in general: 34% versus 9.7%.
According to one of the study authors, Carol Cleaveland, Ph.D., from George Mason University, in Fairfax, VA, the effect of trauma on these women does not appear to lessen over time, even after they have lived in the U.S. for a significant period.
“We found that time in the U.S did not lessen trauma symptoms among the women studied, a fact that is concerning, given that they typically came here to escape violence and severe poverty in their countries of origin,” says Cleaveland.
These issues extend beyond first-generation migrants. Research published in JAMA Pediatrics in 2019 found that, among 397 U.S.-born Latinx adolescents with at least one immigrant parent, around half expressed a persistent worry about whether or not U.S. immigration policy might lead to the deportation of a family member
Such concerns were associated with heightened anxiety, poor sleep, and fluctuations in blood pressure.
Migrants face ‘constant chronic stressors’
Why is mental distress so common among undocumented migrants and their families? The answer, specialists say, is complex.
Prof. Garcini explained to Medical News Today that people in this situation face many internal and external stressors that make it hard to cope mentally and emotionally.
There are, Prof. Garcini told us, “constant chronic stressors that [undocumented migrants] face in their everyday lives across multiple domains, including work, family (e.g., separation from family), discrimination, stigmatization, exploitation, socioeconomic adversity, and limited healthcare, among many others.”
One of our contributors, Marcela, explained how her mental health has been severely affected by factors within and outside of the undocumented community that she is a part of.
“What first comes to mind for me, regarding mental health, is the stigma that exists within the undocumented and immigrant community,” Marcela told MNT.
“When I was younger, I struggled with mental health in my family because I went to a counselor for depression and self-harm at a really young age, but at the time, my family wasn’t supportive at all. They viewed mental health as a privileged illness because, in their view, only the wealthy could afford going to therapists and counseling, while everyone else had to work for a living.”
“Immigration policies that came after didn’t help with this,” she continued. “When policies around DACA [Deferred Action for Childhood Arrivals] come up, my automatic sentiment is to panic for my family.”
DACA is an immigration policy that allows undocumented U.S. residents who entered the country as children to access a renewable 2-year deferment of deportation, which can allow them to apply for an official work permit.
Earlier this year, U.S. President Donald Trump challenged DACA in the Supreme Court with a view to rescinding the policy, an action that caused turmoil in the country.
In June, however, the Supreme Court decided to uphold DACA. Still, the action initiated by the president fostered additional tension within undocumented communities.
Marcela told MNT that she felt this tension deeply. “When DACA was [almost] rescinded, I worried for my older sister, who was overcome with emotion when she heard the news and ended up withdrawing from community college,” she explained.
Moreover, Marcela continued, “I felt panic that if something were to happen to my parents, and they were to get deported, then it would force my older sister to essentially become a single parent for my younger sister, who was in middle school at the time, and that made me feel very helpless.”
Stigma and threatening policies
Despite the high rates of mental health problems among undocumented communities, migrants and their families often do not seek professional mental health support.
That, experts explain, is partly due to cultural stigma surrounding mental health and partly due to laws and policies that mean that undocumented migrants could face deportation if they seek formal support.
One such law is the Public Charge rule, which allows authorities to deny a person a U.S. visa or citizenship if records show that they have accessed public health benefits while staying in the country.
“A major issue is the mistrust of government agencies, a lack of access to providers that speak other languages and [who] are from a similar culture, and [not having a] belief [that] they can be helped by mental health treatment,” Prof. Alegría explained to MNT.
“The Public Charge has [also] created confusion and fear of accessing public services, including healthcare in federally qualified community health centers,” she added.
Prof. Alegría emphasizes that language barriers and cultural differences can often be an insurmountable obstacle to accessing appropriate healthcare.
“The serious absence of a workforce that speaks non-English languages and is culturally aligned to their values, lifestyle, and customs is another obstacle,” the researcher told us.
“The bad experiences received by some immigrants in mental healthcare has not helped, either. Some believe the investment [required] to receive mental healthcare is enormous, given the likelihood of getting better. The quality, flexibility, and cultural appropriateness has not been sufficient, given the other priorities immigrants might have (e.g., food insecurity, housing instability, debt).”
– Prof. Margarita Alegría
Prof. Garcini also highlighted the “limited access to health services, mental health stigma prevalent in this community, and limited information about where to seek help and what that help would look like,” as well as the fact that migrants lead “busy lifestyles that may not accommodate [access] to traditional services.”
Undocumented migrants, she added, might also worry about the prohibitive costs of quality therapy.
Marcela told MNT that stigma around mental health within her own community has held her back from seeking formal support, even as she was able to identify the appropriate resources.
“Over the years, I recognized that the resources to help me are there, from having scholars who share similar experiences to mine that I can talk to, or my school’s wellness center, or the wellness advocate that [a program I am involved in] has provided,” she explained.
“However,” she added, “I feel like it’s my experiences from when I was little that have kept me from actually reaching out to these resources.”
For Marcela, this has meant limited access to the mental health resources that she requires.
“Because I didn’t have support from my family, with regard to my mental health, when I was younger, I don’t feel like I can reach out to them now, and that means that the only time I actually reach […] these [formal] resources are during the school year and in the summer when I’m interning,” she told MNT.
Historical ‘stress, pressure, cycle of abuse’
Another contributor, Klio, also explained to MNT that she was unable to access mental healthcare early on due to prohibitive costs and the fact that she had no medical insurance.
“In high school,” she said, “I noticed that I had severe mood swings lasting a few weeks or months. Because I didn’t have access to medical professionals (due to high costs and lack of insurance), I used the internet to look up symptoms. A lot of my symptoms aligned with bipolar II.”
“Economic hardship limits the options that immigrant/migrant families have,” Prof. Alegría explained to MNT.
Yet migrants, she pointed out, “experience considerably more stress than [other populations and] are more likely to witness violence due to residential segregation and concentrated disadvantage, resulting in compounded community trauma.”
Klio went on to describe the severity of the mental health issues that she experienced and how these — alongside the initial lack of formal care — contributed to further traumatic experiences.
“I experienced hypomanic episodes, where I mixed up dreams with reality. I had irrational thoughts, such as thinking if I uploaded a video on YouTube, I’d become famous and drop out of school. I occasionally experienced random shopping sprees, as well,” she said.
“Then, there were also low periods, aligning with depression. I skipped so much school because I didn’t have the mental and physical strength to get out of bed.”
Without appropriate support, Klio said, she experienced the symptoms well into college, and they exacerbated her risk of exposure to further trauma.
“I had those same periods of ups and downs,” she told MNT. “The ups turned into experiencing being hypersexual which led to many regrettable, hurtful experiences. I was raped my first year of college, which was also the first time I had sex.”
“I never processed the feelings until a year later; perhaps this was caused by habitual neglect. The downs still resurfaced after the ups. I remember the times where I forced myself to go to class, just to sit there, staring at the window, picturing myself hanging from the third-floor window.”
Like Marcela, Klio also noticed a link between concern about undocumented family members and fluctuations in mental health status:
“One thing I’ve reflected on is that these periods of highs and lows occur after being exposed to my father, who is also undocumented. Given the stress, pressure, and cycle of abuse, both from his own family preconditions and the conditions of being undocumented, I’ve noticed that they affect me directly. The poverty cycle and undocumented cycle mesh together effortlessly.”
Many women with undocumented status are afraid to seek assistance when they experience violence.
Prof. Alegría told MNT that, for instance, undocumented women who experience domestic violence “are scared of having to interact with police and the criminal justice system [because] the idea of having to report a partner is dangerous, since the person has to […] give personal and location information, with the fear of [Immigration and Customs Enforcement] being very real.”
“Even for people who report suicide attempts and have to be reported to the [Benefits and Entitlements Service Team] to screen if they need hospitalization, sometimes they send policemen/women to get the person if they do not respond on their phone,” she continued.
“But actually, this just exacerbates post-traumatic symptoms and increases the flight response. Having places like pharmacies or faith leaders that can serve as bridges to report family, child, or elder abuse/neglect is paramount [to addressing this issue].”
Changing mentalities within communities
MNT asked all the contributors what had to change, within society at large and in terms of policy, to address the disparities in healthcare access.
“It was not until college that I took up counseling, which is something that I desperately needed throughout my whole life,” Klio noted, adding that “Counseling is provided through the college I attend.”
She explained that the fact that the sessions were free allowed her to finally access the necessary, more specialized support.
Klio also spoke about the need to “shift the understanding of mental health for undocumented communities.” She said that this might be achieved by offering more resources free of cost and providing more education about mental health.
She emphasized the need to “shift the culture around how [immigrant communities] view mental health. It’s still a very stigmatized topic.”
“To be honest, it’s a convoluted problem that I don’t know how to tackle,” she admitted. “But perhaps it can start with the youth, who are more [open] to new ideas.”
Klio highlighted the need to stress the importance of mental health and provide support early on. She suggested that:
“This can be [done] through the education curriculum or, in general, [by] more people spreading awareness. I always found it odd that while physical education is required in public schools, mental health education isn’t, or at least, [it] wasn’t taught when I was in primary and secondary school.”
Marcela also emphasized the need to change the understanding of mental health within undocumented communities.
“The biggest thing I would want to change is for the undocumented and immigrant community to recognize that mental health affects everyone in different ways and that reaching out for professional help doesn’t mean you just want attention,” she said.
“Being told that I was faking my mental needs to get attention from my parents has impacted me very deeply, from having to deal with future issues like depression and eating disorders by myself, to not being open about my emotions in relationships that I have.”
Marcela also spoke about the need to educate influential figures within communities, such as teachers, about the realities of living as an immigrant.
“I think something important to discuss is the impact that immigration has on children in fully undocumented or mixed-status households, especially in regards to education,” she told MNT.
“I deeply feel for students who can’t concentrate on academics because they worry about their family members being deported,” she explained. “I think this is really unfortunate because if teachers don’t take time to know their students [one-on-one] and learn about their home situations, then these students can easily fall through the cracks, and their opportunities are cut short.”