This SCP Blog is written by David Talavera, a Clinical Psychology PhD candidate at the University of Houston who is completing his predoctoral internship at Harvard Medical School/Cambridge Health Alliance.
Let’s try a little exercise:
Pretend you’re a patient waiting for your therapist for the first time. You’re in the waiting room. It’s quiet. You hear the air-conditioning humming. You hear the receptionist typing away on the computer. You also hear, and bring your attention to, the clock that’s ticking the seconds away. You notice that it’s 5 till and you start to feel a little anxious knowing it’s almost your appointment time. Almost your turn. You’re up. Some thoughts start creeping into your head: Will my therapist accept me for who I am? How much information should I say about myself? Should I be entirely truthful about my life? I know I need it, but can I even be in treatment? I should probably leave. It’ll be safer if I’m not here.
What are your initial thoughts on this experience? Did you find those thoughts to be somewhat paranoid? Depressive or anxious in nature? They could very well be all of those. They can also stem from someone with an undocumented legal status. Undocumented individuals face several barriers to social equity in the United States, some of which include seeking and utilizing health care services (Stimpson, Wilson, & Zallman, 2014). Some of the reasons for not seeking health care include, but are not limited to fear of being deported (Berk & Schur, 2001). So what can we as clinicians do to make therapy more comfortable and less anxiety provoking for the undocumented individuals we see? Below I list some helpful tips to keep in mind. It is important to consider that this list is not exhaustive. It is, however, a good starting point to think more about the things we say and do when treating undocumented individuals. Further, this list is not fully detailed. There can be books, dissertations, and even careers solely focused on any one of these points. I encourage you to use this list as a jumping off point to learn more about how you can provide the best quality care for undocumented patients.
- Don’t refer to an undocumented patient as an ‘illegal’. That reference carries a derogatory connotation and would not be conducive to therapy work with the patient. Instead of asking, “How does it feel being an illegal?” you might ask, “How does it feel to be undocumented?” It’s not a good idea to refer to patients based on a single characteristic of theirs. People are more complex and multifaceted than their residency status and deserve to be seen with an open mind.
- Not all undocumented individuals come from one area of the world. Undocumented individuals migrate from different continents and speak different languages. Recent trends suggest that a large proportion of undocumented individuals migrated from Mexico, the Philippines, India, Korea, El Salvador, and China (Hoefer, & Baker, 2012).
- Consider the political climate. Undocumented citizens can be directly affected by the ever-changing national immigration policies. If you hear about a new law that might affect undocumented individuals I’d recommend reading up on it. Know the general impact it might have on your patient or your patient’s family. By no means are you expected to be an expert on these laws, but know the potential ramifications they may have on an undocumented individual. For example, if your patient is a recipient of Deferred Action for Childhood Arrivals (DACA), I’d advise you to know what that entails and be open to discussing any anxiety or depressive symptoms your patient may experience from its cancelation.
- Don’t be afraid to ask about immigration experience. Immigrants often face harrowing experiences traveling to the United States. These experiences can be traumatic and have long lasting psychological effects. Asking about these experiences can shed light on previously undisclosed trauma and provide valuable evaluative/treatment data. For instance, patients might disclose a traumatic immigration experience that exacerbates current depressive/anxiety symptoms or precipitated a diagnosis of PTSD. As with any history of trauma, don’t press unless the patient is willing and able to disclose such information.
- Don’t be surprised if your patient asks you for a psychological evaluation for a political asylum application. Some undocumented patients may have fled war-torn countries or persecution and are in therapy to manage psychological symptoms associated with those experiences. In some of these instances, patients may ask you to provide a psychological evaluation as part of their political asylum application. If this process is too complicated or confusing for you, I recommend to not worry alone. Consult with your peers about what to do and how to fill out any forms in that application. Several universities offer low-cost or free immigration and asylum clinics that can also help you collaborate with attorneys (Musalo, Meffert, & Abdo, 2010).) .
- Understand the difference between exile and immigrant. Salman Akhtar (1999) describes important differences between an immigrant and exile that can have lasting treatment implications. For one, immigrants leave their country voluntarily while exiles are often forced to leave their homeland. Further, in some cases immigrants have more time to prepare and leave their country, while exiles are sometimes driven out unexpectedly. In addition, immigrants have the option to return to their homeland and may experience nostalgia or the dream to return to their country of origin in the future. Exiles on the other hand often do not have the option to return home and might be troubled with different types of intrusive memories of their home country. Understanding these differences can be very helpful in guiding and shaping the types of questions you might have about your patient’s history.
- Discrimination can affect undocumented patients. Issues surrounding immigration policy have been a major focal point in media outlets in the last year. Political movements have used anti-immigration rhetoric to win national elections and excuse popular vote losses. It can be easy to get caught up in the whirlwind of the immigration debate regardless of your political views. We can’t, however, forget that these macro-level debates on policy and law have micro-level consequences for undocumented patients and their families. Undocumented individuals may experience discrimination for their legal status and experience psychological distress as a result (Cobb, Xie, Meca, & Schwartz, 2017). Therefore, be open and willing to discuss the effects of discrimination aimed at undocumented individuals. Open the therapeutic doors to these types of conversations and give the patient the freedom to talk about the fear and stigma associated with being undocumented. Validating patients’ fears and simply listening to can go a long way.
- Undocumented patients may fear working with government agencies or seeking health care. The fear of deportation is real. Undocumented patients might be reluctant to seek medical care or work with a mental health provider because they fear being reported them to the authorities. In fact, the fear of deportation is a common reason undocumented individuals avoid health care and wait until health issues are critical before seeking services (Hacker, Anies, Folb, & Zallman, 2015). If your patient is in need of urgent medical attention it is important to let them know that emergency rooms do not have a duty to report undocumented individuals to authorities. Although there are limits to that care, such as long-term hospitalization, it is recommended that undocumented individuals in need of urgent care seek emergency services.
David C. Talavera is a Clinical Psychology Ph.D. candidate at the University of Houston. He is currently completing his pre-doctoral internship at Harvard Medical School/Cambridge Health Alliance where he works at the Latino Mental Health Program. Before attending the University of Houston, he obtained his bachelor’s degree from UC Berkeley in psychology. His clinical and research interests include behavioral health medicine, culturally competent care, Latinx mental health, and Spanish-language mental health services.
Akhtar, S. (1999). The immigrant, the exile, and the experience of nostalgia. Journal of Applied Psychoanalytic Studies, 1(2), 123-130.
Berk, M. L., & Schur, C. L. (2001). The effect of fear on access to care among undocumented Latino immigrants. Journal of Immigrant Health, 3(3), 151-156.
Cobb, C. L., Xie, D., Meca, A., & Schwartz, S. J. (2017). Acculturation, discrimination, and depression among unauthorized Latinos/as in the United States. Cultural Diversity and Ethnic Minority Psychology, 23(2), 258-268.
Hacker, K., Anies, M., Folb, B. L., & Zallman, L. (2015). Barriers to health care for undocumented immigrants: A literature review. Risk Management and Healthcare Policy, 8, 175-183.
Hoefer, M., Rytina, N. F., & Baker, B. (2012). Estimates of the unauthorized immigrant population residing in the United States: January 2011. Washington, DC: Department of Homeland Security, Office of Immigration Statistics.
Musalo, K., Meffert, S. M., & Abdo, A. O. (2010). The role of mental health professionals in political asylum processing. Journal of the American Academy of Psychiatry & the Law, 38, 479.
Stimpson, J. P., Wilson, F. A., & Zallman, L. (2014). ED visits and spending by unauthorized immigrants compared with legal immigrants and US natives. The American Journal of Emergency Medicine, 32(6), 679-680.