Mattar S, Kimball S. The traumatic impact of US immigration policies: a call of action for mental healthcare providers. HPHR. 2021;37.
In this commentary, the authors argue that discriminatory US immigration institutions and policies have a direct negative impact on immigrant and refugee mental health. A close examination of these polices reveal a pattern of systematized racism and discrimination in the handling of immigrant arrivals to the US. The authors further argue that a comprehensive and culturally responsive approach towards the psychological care of immigrant individuals in the US must incorporate the traumatic effects of experiences of post-migration discrimination and racism, not only pre-migration traumas. Finally, a case is made for training mental health care workers to reflect on and examine how institutions and policies, as well as current health care approaches, may result in moral injury and institutional betrayal which can further exacerbate symptoms of PTSD, and experiences of discrimination, health inequities, and social isolation.
While some view recent images of United States (US) Border Patrol agents attacking and chasing Black Haitian men in an effort to deport them as an aberration, a in-depth understanding of the history of the US immigration system makes it hard to escape the conclusion that it was designed exactly for the purposes of separating and deporting Black, Indigenous, and People of Color (BIPOC) individuals. Instead of seeing this as an isolated incident, a historical understanding of the intentionally racist objectives of the US immigration system shows this to be a continuation of the ways in which the entire machinery of the US immigration system seems to have been put into place for the express purpose of excluding, often violently, BIPOC populations from receiving the rights and benefits of US Citizenship. These past immigration policies drive and shape our current immigration system, and have pressing clinical implications for immigrants and refugees. If mental health providers working with immigrant populations fail to recognize the traumatic effects of experiences of post-migration discrimination and racism, they risk missing a critical factor driving the distress or wellness of their their patients.
Knowing that the reasons that anyone migrates are complex, we use the word “immigrant” broadly to mean anyone who moves to a new place with the intention to stay, regardless of their immigration status. Within that group, individuals who are seeking safety from violence and persecution (refugees and asylum-seekers) face specific barriers, which we will discuss. A refugee is a person who is forced to flee their country because of threatened or actual violence, and is authorized to stay at the time of arrival in the US. Asylum-seekers are similarly fleeing persecution, but they initiate the application for approval to stay in the US after arriving, creating a long waiting period with an uncertain immigration status.
Returning to the earliest threads of how the US immigration system was built sheds light on the ways that it was leveraged to support explicitly racist intentions and policies. The 1790 Naturalization Act (Naturalization Act, 1790) was one of the first pieces of US legislation that explicitly regulated immigration, and it created and defined citizenship in the U.S. as a set of rights only available to “free white persons.” Soon after, in response to increasingly levels of Chinese migration in the 1800s, Congress passed the Chinese Exclusion Act in 1882 (Chinese Exclusion Act, 1882), which explicitly targeted a specific racial group, prohibiting the immigration of Chinese laborers. The act was strengthened by the Geary Act in 1892 (Geary Act, 1892), which reiterated the ban on Chinese laborers and required all Chinese immigrants to register with the federal government thus empowering the federal government to imprison and deport any Chinese nationals who didn’t comply. From the outset, the intent of federal immigration policies has focused on racialized exclusion.
From this inception of the US immigration system until now, there are countless examples of policies whose intent was racialized exclusion has driven the US immigration system (Kilty & de Haymes, 2008). In a recent example, the Trump administration invoked “Title 42,” (United States Code, 2006 Edition, Supplement 4, Title 42) on March 21, 2020, a policy which continues to this day. Title 42 allows for the deportation of individuals presenting to the Southwest border of the US to seek asylum, a group of individuals whose right to seek safety from persecution is normally protected by international humanitarian law, with the goal of protecting public health due to the COVID-19 health emergency. Yet there are discrepancies between the critical societal need to protect the public from a public health emergency and the broad enactment of this rule, which continues to be in effect today despite advancements and broad availability of alternative COVID-19 mitigation strategies, such as rapid testing and vaccinations. Documents leaked from the time of the enactment of Title 42 (Dickerson & Shear, 2020) confirmed that the intent of having such broad deportation processes was driven by a desire to enact an anti-immigrant political agenda, more than a true assessment of public health risk. The public health justification for deporting asylum seekers at the Southwest Border feels all the more tenuous when commercial and leisure border travel restrictions have been eased, and has led to prominent protests from the public health community about the misuse of public health as a justification for exclusion (Zard, 2022).
Given both the historical context and the current policy environment, the approach to psychological care for immigrant and refugee individuals in the United States must incorporate the traumatic effects of experiences of post-migration discrimination and racism, not only pre-migration traumas.
In general, psychological interventions to treat trauma are implemented using a broad approach to the traumatic response, without incorporating the context in which trauma and resilience occurs (Layne et al., 2011). Yet examining the larger political context, such as the US immigration policies and the dynamics of the refugee resettlement process is key to understanding best trauma-informed and culturally responsive practices to treat psychological trauma in this population. If we don’t do this, we risk placing the locus of intervention solely on the individual, only worsening the disparities that result from structural discrimination.
Adopting a politically-informed approach is as important for clinicians as trauma-informed care in serving the mental health needs of immigrant populations. This approach extends to being knowledgable about immigration policies and their impact, as these could place immigrants at risk for adverse health outcomes (Chavez-Dueñas, 2019; Kira & Tummala-Narra, 2015; Miller et al., 2019). For example, when considering trauma recovery for this population it is important to factor in the role of pervasive deportation threats and ongoing discrimination experienced by immigrants.
US immigration policies and practices have significant long-term implications for immigrants, including mental health problems, increased perceived discrimination, poverty, and a pervasive hostile environment for these populations, which result in health risks, low self-esteem, anxiety, feelings of insecurity, and isolation, as well as access to health services (Torres et al., 2018). Living with a constant fear of detention and deportation is a common occurrence among immigrants resettling in the US when the political environment implicitly and explicitly promotes an underlying tolerance of discriminatory practices, microaggressions and nativism (Chavez, 2008; Massey, 2020). Furthermore, these policies might result in ethno-racial trauma and the impact of nativism becomes a new experience for many immigrants, and a debilitating one (Chavez-Dueñas, 2019; Helms et al., 2010; Szaflarski & Bauldry, 2019).
For example, following the murder of George Floyd and others by police, many BIPOC immigrants in the US experienced confusion, disappointment, and fear regarding race relations in the US, the ways they were perceived due to their race, and the implications of racism for their lives and adaptation in the US, (Bentley, 2020) including access to health services, employment and education (Li et al., 2016; Perreira & Pedroza, 2019).
Understanding the US approach to criminalizing and detaining massive numbers of immigrants within US Immigration detention centers (also known as Immigration and Customs Enforcement (ICE) prison facilities) is critical in taking a politically-informed approach to immigrant health. Immigration enforcement activities at the national, state and local levels, including policies of exclusion, have clear implication for immigrants’ health and participation in public programs, (Perreira & Pedroza, 2019) which is critical for healthcare providers treating this population to understand.
While immigration offenses are civil, and not criminal, the popular vernacular surrounding detention and deportation seeks to criminalize those who lack a stable immigration status. Aranda & Vaquera (2015) argue that the use of the word “illegal” to refer to immigrants has resulted in their criminalization in the public’s eye and is the “lynchpin of colorblind racist policies toward immigrants that result in [these] racialized practices” (p. 91). As such, many individuals seeking asylum in the US are housed in prison-like facilities (frequently the exact same facilities that are used for criminal detention) that suggest that those housed there are criminals.
By 2019, the number of asylum-seekers detained in these facilities rose to 55,000, and the majority of them were Latinx from the Northern Triangle (Guatemala, Honduras, and El Salvador (Massey, 2020) Detainees placed in these facilities report experiences of discrimination based on race and country of origin (Saadi et al., 2020). Human rights violations are frequently reported in the form of family separations, overcrowded conditions, inadequate sanitation, inadequate meals, continuous lighting, sexual, verbal, and physical abuse, inappropriate medical care, among others (AILA, 2022; Saadi et al., 2020). All these problems contribute to multiple mental health problems, including PTSD, anxiety, depression, despair, risky behavior, social isolation, and self-harm, among others (Javidan, 2021) Providers caring for this population must understand and screen for a history of immigration detention and subsequent symptoms, using frameworks like those described by Saadi et al. (2020).
In order to better recognize the distress that can result from the experience of discrimination and racism post-migration, it is helpful to understand the frameworks of moral injury and institutional betrayal trauma. A violation of basic moral beliefs and expectations occurs when immigrants expect humane treatment while under the care of the U.S. government, and the reality of the treatment received violates their expectations. This deep cognitive dissonance can result in what Litz et al. (2019) call moral injury, or “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009). Similarly, the notion of institutional betrayal trauma, (Smith & Freyd, 2014) a concept derived from Freyd’s betrayal trauma theory refers to “deliberate acts or acts of omission (e.g., negligence) perpetrated by institutions onto individuals that rely on these institutions for support, resources, protection, and in some cases survival” (Smith & Freyd, 2014, p. 577). This is particularly salient when asylum-seekers come to the U.S. specifically seeking protection from persecution and torture and are met by a system that fails to offer true protection.
The U.S. government’s Zero Tolerance policy, which resulted in separations of children from their parents at the border, is a salient example of a policy that inflicts moral injury and institutional betrayal, with significant psychological sequelae (Alvarez, 2018). Every year, thousands of families, mainly coming from Central America, seek asylum in the US from extreme violence prevalent in their countries. As Smith & Freyd (2014) point out when discussing institutional betrayal, these families come with an expectation of fairness that is very different from the violence they are trying to escape (Smith & Freyd, 2014). Yet, in the case of the Zero Tolerance policy, children were forcibly separated from their parents, a practice that has been deemed as child abuse by the American Academy of Pediatrics (Wise, 2018), and that has been described as falling under the UN definition of torture (Oberg et al., 2021). These adverse effects have a compounding effect on these individuals, who frequently arrive with previous experiences of trauma (Garcini et al., 2020). The gap between what we outwardly promise, as a country where we recognize the right to seek asylum, and the reality of how we detain, separate and deport immigrants risks inflict feelings of moral injury and institutional betrayal long after indivuals are released or reunified.
Understanding the context of migration and examining the ways health providers might unwillingly perpetuate discriminatory practices requires a two-pronged approach of: a) self-examination and, b) advocacy:
a. Self-examination: Clinical work with immigrant populations requires a understanding of the context in which care is provided, which includes attention to power dynamics, systemic oppression, and the cultivation of effective skills to engage in culturally relevant interventions at an individual, systemic and community level (Brandenberger et al., 2019; APA, 2019). The APA Guidelines on Race and Ethnicity in Psychology (APA, 2019) encourage health providers to “engage in reflective practice by exploring how their worldviews and positionalities may affect the quality and range of psychological services they provide”. The guidelines also stress the importance of challenging racial and ethnic biases in order to “address practices that perpetuate oppression in practice settings, systems, and methods.” For example, it is well known in the field of refugee health , the ways providers can fall into a “rescuer” or “savior” mindset, perhaps due to the fact that refugee care in the US is mainly possible due to the financial aid provided by charitable organizations and private grants. Providing care for populations that are politically marginalized, like refugees, can promote a “feel good” stance that might unintentionally perpetuate power dynamics mirroring colonialism. Examples of ways to examine this type of implicit bias is to have regular conversations among health provider teams about ways to decolonize the system, such as examining hiring practices, ensuring patient voices are represented in those decisions that affect them, and participatory needs assessments (Mulumba et al., 2021; Palmquist, 2020).
b) Advocacy: Health providers treating immigrant populations have the possibility of being key allies, by advocating for systems that promote immigrant rights and health equity and center the patient experiences and voices to inform health care practices (Jacquez et al., 2021). By actively engaging in antiracist learning and practices, providers reduce the risk of unintentionally perpetuating racial harm. Likewise, engaging in political advocacy, such as advocating for more humane immigration policies, educating lawmakers about trauma-informed perspectives, or challenging public anti-immigrant stereotypes, helps to change the key drivers of immigrant health disparities. Advocacy can also take place at an organizational level, by examining the ways that systemic racism can be embedded in the very institutions created with the intention to seemengly help newly arrived immigrants to the US. Another form of advocacy is engaging in participatory research methods that center on immigrant voices, and involving community stake-holders in the implementation of systems solutions (Jacquez et al., 2021; Montero-Sieburth, 2020). Engaging immigrants in these processes fosters a sense of self-agency, which is instrumental in recovery from trauma, a sense of inclusion, and in their acculturation process.
Trauma-informed and culturally-responsive practices in immigrant and refugee health must strive to become politically-informed, by examining and challenging the discriminatory practices of the US immigration system. Without this critical reflection and action, providers are at risk of further perpetuating and exacerbating the psychological traumas experienced by immigrant and refugees both before and after migration to the US. Healthcare provider training should be enhanced by incorporating a politically-informed approach to trauma treatment, and engaging in intentional advocacy to challenge systematized racism, institutional betrayal, and colonizing practices.
The authors have no relevant financial disclosures or conflicts of interest.
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Sandra Mattar, PsyD is currently an Assistant Professor and Clinical Psychologist at the Boston University School of Medicine (Psychiatry)/ Boston Medical Center, Training Director of the Immigrant and Refugee Health Center, as well as Faculty/Supervisor at the Center for Multicultural Training in Psychology. She is a licensed psychologist with more than 20 years of clinical and teaching experience combined. She has done field research around war trauma in Lebanon. Dr. Mattar is a founding member of the Division 56 (Trauma Psychology) of the American Psychological Association (APA), and Past Chair of the Committee on Ethnic Minority Affairs of APA. She is currently an Associate Editor for the Journal of Psychological Trauma. Dr. Mattar was a contributor of the APA Race and Ethnicity Guidelines. Dr. Mattar’s research interests are on the intersection of psychological trauma and culture; immigrants and refugee mental health; mental health disparities; multicultural and international psychology; culturally responsive education and training, and mindfulness and spirituality. She holds a Yoga Teacher certification.
Sarah Kimball, MD is a board-certified internist and is an Assistant Professor at Boston University School of Medicine. Dr. Kimball has a expertise in immigration-informed medical care, where she has helped to research and build health systems that are responsive to the needs of im/migrant patients. She is currently the Director of the Immigrant & Refugee Health Center (IRHC) at Boston Medical Center, a comprehensive medical home that addresses the barriers that immigrants face to being holistically healthy. She is an associate editor at the Journal of Immigrant and Minority Health, with an expertise in Health Services Research.