DREAMers Living in the United States: A Contextual Perspective and Clinical Implications
“Mr. A,” an 18-year-old undocumented immigrant from Mexico, was referred for consultation to a community-based psychology outpatient clinic after presenting to urgent care for symptoms of a severe ataque de nervios, or panic-like symptoms with no organic etiology. Mr. A was brought to the United States at age 2 by his undocumented parents and has never returned to Mexico. His father had been the primary provider for their family, but he had recently been deported, and Mr. A is now working multiple jobs to provide for the family, including his ill mother and his two younger U.S.-born siblings. The patient, a graduating high school senior with an excellent academic record, is a recipient of the Deferred Action for Childhood Arrivals (DACA) program. He is interested in going to college, but given the limited financial aid and employment opportunities available to DACA recipients, he does not think he’ll be able to afford it. As a result, he is feeling anxious, worried, depressed, and hopeless.
Moreover, since his father’s deportation, Mr. A has had a substantial increase in intrapersonal and interpersonal stressors, including experiencing variations in self-perception and internalization of the undocumented stereotype, which includes feeling inferior to others, regarding himself as a hindrance to the community, and feeling undeserving of social and economic opportunity. As a result, he has experienced decreased self-esteem, a sense of being burdensome, and feelings of guilt and shame. He is also having trouble coping with the self-imposed burden imposed by his sense of an inability to repay his parents and other family members who have made sacrifices for his future in the United States. Despite his academic success in high school, he often feels sad and disappointed at the limited educational and employment opportunities available to him and his inability to help his family advance along the social and economic ladder. He also reports constant fear and worry about deportation, and symptoms of anxiety, including an inability to concentrate at school, trouble sleeping at night, and multiple unexplained somatic symptoms that have increased in frequency and severity since his father’s deportation. Additionally, he reports a recent increase in fear and avoidance of public places and distrust in others, which he described as disabling. His symptoms are significantly impairing his academic performance, work capacity, and social relationships, and he mentioned feeling at risk for drinking to cope with distress.
To emphasize the influence of context and culture on the patient’s symptom presentation, an adapted version of the Cultural Formulation Interview from DSM-5 (1, pp. 749–759) was used in diagnosis. A diagnosis of other specified anxiety disorder was made, with nervios and ataque de nervios as specifiers. Moreover, it was recognized that the patient was facing multiple and chronic psychosocial and environmental stressors requiring clinical attention, including disruption of family by separation, family illness, social exclusion, target of (perceived) adverse discrimination, academic and occupational problems, low income, limited access to health care, and legal difficulties associated with undocumented status. Although the patient attended a few therapy sessions, he was ambivalent about mental health treatment because of stigma, lack of time, and limited transportation. As a result, he terminated treatment prematurely, stating that it was more convenient for him to receive the support that was provided by his church community.
Undocumented immigration is a controversial issue at the forefront of current U.S. political discussion. Among the more than 11 million undocumented immigrants residing in the United States, more than 1 million are acculturated undocumented youths who were brought to the United States as children by their parents (2) and who meet the requirements of the proposed Development, Relief, and Education for Alien Minors (DREAM) Act. Under this law, first introduced in Congress in 2001 and reintroduced several times over the following decade but never adopted, these young immigrants, often referred to as DREAMers, would be given a time-limited conditional permit to remain in the United States and pursue an education or serve in the military, and eventually to receive permanent residency status.
DREAMers are at risk for psychological distress and diminished quality of life as a result of the many complex stressors they face, which are often experienced over an extended period, under harsh living conditions, and without access to adequate mental health services (3). DREAMers are often marginalized and discriminated against, and as a result they may become isolated from the larger educational and work communities. Many additionally experience separation from deported family members, and they do not have the option of traveling internationally to visit them. Moreover, DREAMers live in constant fear of deportation and experience a sense of voicelessness, invisibility, and limited opportunities due to their conflicting undocumented status (4–9).
Unfortunately, prevention and treatment interventions for addressing the mental health needs of DREAMers are limited. Efforts are needed to provide access to contextually and culturally sensitive interventions that reduce risk and increase resilience in this population. A key step in the development and implementation of mental health services for these at-risk youths is to reduce cultural and contextual barriers that prevent access to and use of needed mental health services. This includes increasing information and psychoeducation in order to reduce mental health stigma; to highlight stress as a risk factor to the mental health of DREAMers; to improve treatment adherence, including devising strategies for engagement and retention; and to disseminate information about treatment effectiveness of mental disorders and distress, including the combined use of medication and therapy. It is also important to facilitate access to affordable mental health services through collaboration with nontraditional sources of delivery available to DREAMers (e.g., religious institutions, school counseling centers, human rights and advocacy agencies, community centers), as well as to develop strategies aimed at improving the trust relationship between the community and the mental health service agencies to facilitate safe disclosure.
In terms of clinical implications, the following recommendations may be valuable in the development of culturally and contextually sensitive mental health interventions for DREAMers. First, using therapeutic techniques that facilitate the integration of context in therapy (e.g., life narrative, values-based interventions) and supporting the building of therapeutic alliances based on genuineness, empathy, and unconditional acceptance of the DREAMer’s background and situation would facilitate validation of the DREAMers’ experience, which is important for the healing process (10). Second, facilitating the development of adaptive coping strategies within a culturally and contextually sensitive framework (e.g., authenticating values and build cultural pride, validating aspirations and long-terms goals, and promoting self-care that is consistent with the immigrant’s values, such as familismo, collectivism, and spirituality) is important for instilling hope amid uncertainty and fostering resilience in the face of adversity. Third, clinicians may assume a role in facilitating the establishment of additional social support systems, including organized support aimed at reducing feelings of isolation and promoting altruism and engagement, which are consistent with the collectivistic attitudes often endorsed by DREAMers (10). Fourth, it is essential to facilitate the recognition and expression of cultural concepts of distress (e.g., nervios, ataque de nervios, susto), which will require the development of appropriate assessment measures as well as the building of a network of professionals knowledgeable in these concepts. Finally, it is important to emphasize that the undocumented experience has an impact not only on the individual him- or herself but also on the larger family system and social network surrounding the DREAMer. Thus, incorporating family and group therapy in interventions aimed at addressing the mental health needs of DREAMers could be particularly beneficial.
Debates on programs and policies pertaining to DREAMers are complex and multifaceted, and differences of opinion and divisions on policy options are long-standing. As clinicians, however, we may contribute by devising solutions grounded in evidence and developing alternatives designed to facilitate access to culturally and contextually sensitive mental health services for these at-risk youths, which is critical to protecting their mental health and their basic human rights.
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