Schuyler W. Henderson
Introduction
Immigration has a unique relationship to the field of mental health: many of the prominent early figures who shaped contemporary mental health were themselves migrants—from the Freuds and Erik Erikson to Eric Kandel and Leo Kanner—
and some of the earliest and most important stud- ies that formed the initial evidence base for the practice of mental health, particularly in child psychiatry, involved immigrants. Indeed, immi- grants have long been drawn to work in the field of mental health, though often facing prejudice as they do so [30]. All of this is to say that immigra- tion is not simply a demographic characteristic of patients contributing to their psychosocial profile or that can come under the microscope in mental health (as a stressor, as a variable, as a mediator or moderator of outcomes, as a cultural factor to be accounted for): immigration has played a role in shaping what we know about mental health and how we know it.
And yet there is no doubt that immigration remains a hotly controversial political topic. For
some years at the end of the last century, it seemed that in the United States and Europe, immigration and migration status was going to play a less prominent political role, while interest in the social (and health-related) consequences of race, gender, and sexuality became more promi- nent while thinking around these topics became subtler; though immigration has always provoked disagreement and political complaint, it seemed to have settled into something that was often rec- ognized to be a good thing much of the time.
Rates of migration and acceptance of refugees into the United States, for example, appeared to be on the rise [27, 40]. Over the past few years, however, immigration has again become one of the most bitterly fought social issues. The United States has been called a “nation of immigrants”
(indeed, that was the title of John F. Kennedy’s final book [21]), but in the twenty-first century, this same term “nation of immigrants” became increasingly necessary not so much as a reminder of a shared past but as a way of countering increasingly exclusionary and bigoted anti-immi- grant rhetoric (as in Barack Obama’s address to the nation in 2014 [25]). As the population of the United States became, proportionally, increas- ingly foreign born, and as migration (particularly from Northern Africa and Turkey) increased in Europe, and alongside the so-called war on ter- ror, Islamophobia, the reality of terrorism, and with the success of increasingly xenophobic poli- ticians (such as the “Americans first” policies
S. W. Henderson (*)
Department of Clinical Psychiatry, New York University, New York, NY, USA
Department of Child and Adolescent Psychiatry, Child Study Center, Bellevue Hospital, New York, NY, USA
e-mail: [email protected]
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under President Donald Trump [38]), immigra- tion has again become violently controversial.
Anti-immigrant rhetoric (such as the frequent claim, e.g., that immigration increases the risk of violence, including terrorism and sexual vio- lence) and anti-immigrant policies directly affect people and therefore directly affect clinical encounters [35]. Broadly, anti-immigrant rheto- ric and policies depress access to mental health services and increase stressors in immigrant pop- ulations, both of which have significant public health effects; more specifically, these pervasive cultural attitudes make conversations around immigration more difficult, even in confidential or supposedly neutral settings.
It is nevertheless important to address immi- gration when working with any migrant popula- tion, and though there may be a shared discomfort in broaching the topic, the responsibility is on the mental health clinician to become more comfort- able obtaining an immigration history, allaying or addressing any concerns the immigrant has about safety and security, and ensuring that the immi- grant understands the extent to which discussing his or her immigration status is a safe topic.
Safety First
Beyond simply the cultural and political contro- versies around immigration, there are potential immediate legal consequences to a disclosure of immigration status—whether one’s own or the immigration status of another member of the family, such as a parent reporting on a child’s sta- tus, or a child on an uncle’s, for example. These legal consequences for disclosure or discovery of certain immigration statuses (or, to put it more bluntly, being officially identified as “illegal”) may include family separation, detention and deportation. This means that in addition to per- sonal sensitivity around the subject, clinicians need to disclose whether they are able to keep information around immigration status confidential.
At the hospital where I work, immigration sta- tus is not formally obtained and those without current legal immigrant status will not be
reported; this is not a universal rule in health care settings, and practitioners should know their set- ting’s rules on this and, if necessary, disclose them before obtaining information that could put their client/patient in jeopardy.
The National Immigration Law Center has provided a useful guide for practitioners offering advice (which they acknowledge cannot consti- tute legal advice) on how to address immigration officials and officers who may attempt to enforce immigration laws in a health center, including ensuring that patient information is protected or not accidentally disclosed [24].
Clear policies that are visible, legible, and understood by all the practitioners and support staff in any clinical setting are required so that someone accessing mental health care will know what they can or cannot disclose as they seek care.
Models of Migration
While migration status is often categorized by legality (such as determining if someone is an
“illegal alien”), and while this legality may be the most significant factor—and stressor—in terms of a migrant’s current mental status and psycho- logical safety, legality itself says little about the process of, and rationale for, migration.
Voluntary and Involuntary
Migration is often viewed as either voluntary or involuntary (forced) migration. Voluntary migra- tion typically involves economic or employment- related migration, from the vast number of agricultural workers (thought to number in the millions of migratory farm workers in the United States [23]) or construction workers who travel across national lines to build skyscrapers and homes, to the expertise-related migration of engi- neers and physicians or graduate students. Family reunion is another voluntary reason for migra- tion, as families come together around employed family members (sometimes disparagingly referred to as “chain migration,” even by people
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who themselves have this “chain migration” in their own history).
Involuntary or forced migration refers to peo- ple who are forced to leave their country of origin due to violence, persecution, fear of persecution, or environmental disasters. One such population is the “refugee,” defined legally as someone who:
owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, member- ship of a particular social group or political opin- ion, is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it. [39]
Although “refugee” is a well-recognized legal status, people who have fled their country of ori- gin may not have qualified for the designation because of political decisions made on a global scale or decisions made by immigration officers when they are seeking asylum.
But the distinction between voluntary and involuntary migration is not always clear cut. Of course, there are multiple reasons for migration, and “voluntary” migration may not be voluntary insofar as economic disadvantage, global ineq- uity, and social injustice may drive people to work in another country (where they are fre- quently vulnerable and exploited), and the quest for “refugee” status is denied to many who are fleeing persecution.
Push and Pull Factors
In discussing the rationale for migration with someone, the focus should be less around a single motivation, and rather an attempt to understand the diverse factors that cause someone to move from one place to another. One way to think about this is in terms of “push” and “pull” fac- tors: the factors pushing someone away from a country of origin and pulling them into a new country. These push factors can be obvious (such as unemployment rates, persecution, poverty) or subtle and personal (such as getting away from obnoxious relatives), and similarly the pull fac-
tors can be clear (coming to a job at a university, to reunite with a partner) or difficult to express (dreams of a better life, a desire for something new).
It is worth remembering that even within a single family, there may be different legal sta- tuses, and certainly different narratives about rea- sons for migration, as well as different push and pull factors. One refugee family in the 1990s demonstrated this when the teenage children, for example, were thrilled to be in Chicago for the music scene while the parents were profoundly distressed by their inability to find work com- mensurate with their skills in their native Bosnia, though all had fled Bosnia together and all could similarly describe the atrocities they had wit- nessed and the fears they felt.
The Tripartite Model
In discussing models of migration, another way to conceptualize migration other than legal status and through understanding the rationale for migration is to look at the different phases of migration; an advantage of considering this model is that in this tripartite model, there are dif- ferent associated psychosocial stressors, which can be usefully elucidated.
The first phase is “pre-migration,” the period before migration. The stressors are often ones precipitating departure, including poverty, fam- ine, environmental disasters, war, systematic per- secution, and other systematic violence, such as gangs, political oppression, and domestic vio- lence [28]. These stressors can directly impact children’s and families’ development, disrupting employment and education, resulting in physical danger, somatic and psychiatric morbidity, and in stressing family relations.
The second phase is “migration,” the move- ment itself. The stressors here include psycho- logical stressors (loss of a homeland, exposure to dangerous situations, uncertainty) as well as the dangers inherent in migration (exploitation, exposure to human trafficking, victimization) and family separation, as when children are not accompanied by parents or when they are forci-
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bly removed from their parents [7, 13]. For example, Suárez-Orozco et al. reported that 85% of adolescents from Central America, China, the Dominican Republic, Haiti, and Mexico had been separated from parents for extended periods and that this separation was associated with subsequent depression in these youth [33].
The third phase is “post-migration,” which follows the arrival in the destination country.
Stressors here include the nature of the arrival (whether there has been detention, e.g., or forced family separation), as well as the challenges of re-settling in a new environment, such as learning a new language, negotiating new cultural expec- tations, exposure to stigma, the effect of policies and cultural attitudes around migration, and accessing necessary systems, including educa- tional and health care systems [4, 37].
Acknowledging the Journey
If a discussion about migration status can safely proceed, there are a multitude of ways of talking about migration and a multitude of frameworks for understanding the journey and its effects.
Throughout this chapter, in the hopes of covering clinically relevant issues that arise around migra- tion, one of the key points is that stories about migration will unfold like any narrative: they will be personal, complicated, consistent with some expectations and inconsistent with others.
One way to begin understanding the role of migration is to obtain a migration history.
The reasons for obtaining a migration history include:
• Understanding the person: Migration is usu- ally a very significant event in a person’s life, rarely indulged in frivolously, often involving both resilience and loss, and can be a centrally important feature in a person’s life. Leaving one’s home is almost universally a normative developmental experience; leaving one’s homeland typically involves difficult decisions and, even when forced, some degree of intent.
• Understanding relationships: Migration shapes who one lives with and who one does
not (e.g., whether a child is with parents or a child has been left behind with grandparents);
a migration narrative typically entails separa- tions, some of which are tremendously stress- ful, but may also involve important reunions (which can be stressful: I knew one child whose mother had come from a Central American country to join her 8 years after the girl had left that country, and the mother and daughter had both typical joys and complaints about one another, but had to negotiate a very complicated relationship around limit-setting, with a child unused to a mother who was now setting rules for her).
• Identifying strengths: If one thinks about how difficult it can be to move from one apartment to another, one may have increased sympathy for the immense strength it takes to move from one country to another. Rare is the migration story that does not in some way highlight a person’s resilience, courage, and capacity to survive.
• Identifying potential cultural differences: The migration story not only explains an event and how a person is connected to, or not connected to, family members and communities, but it will begin to give the listener an insight into potential cultural challenges in language, resources, expectations, and experiences.
• Identifying potentially relevant recent or dis- tant stressors: While migration stories may be positive and clear (as when someone makes a decision to move for educational reasons, obtains a visa, and comfortably re-locates), others may involve more complicated experi- ences or frank trauma, even multiple episodes of trauma.
• Identifying current stressors: Past trauma before or during migration is important to elicit, but current stressors, including ones related to education, employment, and family, can be the most closely correlated with current mental health. Practically speaking, although past events may be more horrifying, current stressors may be the ones that are most press- ing and need to be addressed first.
Treatment planning: The migration story can cer- tainly include a psychiatric history of treat- ment (such as having had treatment in one’s
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home country), but can also be important to allow for a fuller discussion of ongoing migra- tion plans, such as plans for moving on to a different city or even different country.
As when telling any personal history, some- one’s telling of their stories will be shaped by trust, expectation, and relevance—and given the controversy around migration and “legality,”
this sensitive topic may not be wholly disclosed during an initial encounter. In order to elicit a migration history, you can consider asking about:
• The journey (where they originated, where they moved to, how they arrived, where they are now): Where did you come from? Did you come directly here? How did you leave?
Where did you stay along the way?
• Reasons for migration: When did you start thinking about leaving? What were some of the reasons for moving? What ultimately made you decide to move? When did you know you were going to leave?
• The extent to which it was voluntary or forced:
Did you have a choice about where you were coming? Did you want to come here?
• Whether the journey is understood to be com- plete (for example, whether a return to the native country is anticipated or further move- ment for employment, family reunification):
Do you plan to return? Do you hope to return?
Do you want to stay here or do you see your- self moving on?
Challenges to Assumptions
In thinking about cultural competency in relation to immigration and obtaining a migration history, there are a number of assumptions about migrant communities that should be addressed.
The Permanence and Totality of Migration
Migration may not be forever: although this may be more obvious with migrants whose jobs
entail frequent travel (such as agricultural workers), it is also true that a migration narra- tive may include plans to return to a country of origin or to move on to other countries.
Furthermore, the connections with the home country should be considered: this includes what sort of connections are being maintained and lost, what sort of contact people are having (especially in this era of widespread electronic connectivity), and what sort of roles and respon- sibilities are being maintained (such as when someone is making money to send to family back in their country of origin).
Home
“Home” defines and shapes and creates who we are, through our relationships, the extent to which we do or do not belong, the things we are familiar with, and the ones that seem to come from outside; home is where we learn lan- guages, cultures, and rituals which come from the larger world but are inflected, shaped, and experienced in a private way. When one answers questions about where one is from, the answer is always a variant on “home.” As described by Henderson, Sung and Baily [18]: “Migration complicates and challenges simplified notions of home. With migration, we may have multiple homes, multiple places we come from, multiple cultures and societies in our backgrounds, shift- ing and changing and developing and intermin- gling. As such, migration can have a vast array of meanings—legal, psychological, and psychopathological.”
Being open to this plurality of meanings without necessarily being fixed to assump- tions is the most generous and productive stance when listening to people talk about their home. At the same time, it is necessary to remember that the question “Where is ‘home’
for you?” may well have the answer, “Here.”
Whether welcomed or not, migrants will to some extent have adapted and absorbed some of the customs and traditions of the society they are now in—a society inevitably influ- enced and shaped by countless prior migrations.
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Diversity Within Diversity
It is extremely important to remember that there can be immense diversity between, and within, migrant populations and that migrant status and country of origin are only broad indicators of demographic and cultural orientation. Indeed, within migrant popula- tions, ethnic and socioeconomic status can be highly variable [1]. For example, although a population may qualify as “refugees,” even within that popula- tion there will be multiple individual reasons for migration (push and pull factors), and these may differ within communities or families, as can legal statuses (there was a child in our program whose uncle was deported when caught by immigration services; she herself was not under threat of depor- tation as a citizen).
And of course, within migrant populations, there will be diverse educations, diverse pre- migration and post-migration employment expe- riences, and diverse experiences of persecution and safety (e.g., someone who has migrated for the “economic” reason of obtaining high-tech employment in Silicon Valley but was also a vic- tim of gender-based violence).
Language
Similarly, in addition to being cautious about cul- tural assumptions based on country of origin, so caution must be exercised when assuming that because someone is from a particular part of the world, they speak the dominant language there.
In a New York City clinic, some of the Central American and Mexican migrants do not speak Spanish as a first language, and this also hap- pened when children separated by Trump, Sessions, and Nielsen from their parents at the border were placed into detention centers or with agencies who had Spanish speakers but nobody who could speak local dialects and hence were unable to communicate with the children. It is then important to assess what languages are spo- ken by each person, which languages are spoken in the home (can the children, e.g., understand their parents?), and levels of fluency and compe- tency in the language(s) of the host country.
There are a number of issues that arise around language, particularly in migrant families: the extent to which the children and parents share (or do not share) language skills and fluency can result in conflict. When members of the family are not fluent, it is well-established that an inter- preter should be used, without assuming that the more fluent members can or should interpret in place of a professional interpreter.
Once again, language is an issue that can and should be specifically addressed. When meeting one or more members of a family, it is important to identify these generational differences. Can, for example, a grandparent function effectively outside of his or her language community? Or, as another example, can both parents attend parent- child conferences and understand the teachers?
Which adults can decipher report cards or help the child prepare for college?
Without trying to marginalize or belittle the migrants’ language skills, it can be important to not just identify language competency in the host nation’s language(s) but barriers to learning that language, including cost, availability of tutors, willingness/ability to learn a new language. Being unable to speak a dominant language can result in isolation, marginalization, and ensuing social dif- ficulties (including communicating with officials, obtaining appropriate papers, etc.). While it can be important and culturally valuable for children to learn the language of their parents and losing use of one’s original language may be a risk factor for psychopathology [9], competence in the lan- guage of the country the children are living in has been shown to predict social functioning as well as academic performance [36].
Stigma
Who are we meeting when we encounter
“migrants”? Given that the term is not all- inclusive or all-explanatory, one should neverthe- less be aware not just of how migrants are lumped together, but how the concepts and language of lumping have effects. The language one chooses is itself important and can import assumptions that are clinically relevant. In 1 study of 247 men-
S. W. Henderson