Crossroads: The Psychology of Immigration in the New Century

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Barriers to Treatment While an increasing number of immigrants are seeking mental health services, most immigrants underutilize these services. A number of barriers to culturally sensitive and appropriate mental health services for racial/ethnic minority and immigrant populations have been well documented in the literature. Both distal and proximal barriers (Casas, Raley, & Vasquez, 2008) affect the use of mental health services by immigrants. These barriers can be broadly grouped into the following categories: social-cultural, contextual-structural, and clinical-procedural. Some important social-cultural barriers include differences in symptom expression (e.g., somatic symptoms) (Alegría et al., 2008) and conflicting views about the causes of (i.e., attributions) and ways of coping with mental problems (Atkinson, 2004; Koss-Chioino, 2000). For example, some immigrants may view self-help as the best means of dealing with mental health problems (Donnelly et al., 2011) or may lack an understanding of how psychological problems can be treated from a Western perspective (Inman & Tummala-Narra, 2010; Leong & Lau, 2001; M. C. Wu, Kviz, & Miller, 2009). Others may prefer alternate sources of help rooted in their cultural contexts (e.g., curanderos, Ayurvedic healers, priests, and imams) (Comas-Díaz & Greene, in press; McNeill & Cervantes, 2008). Another social-cultural barrier involves stigma, which some cultures associate with mental health problems (Brach & Fraser, 2000; Leong, Wagner, & Tata, 1995; Nadeem et al., 2007; Wu, Kviz, & Miller, 2009). More specifically, some cultures that maintain strong family ties see individuals with mental health problems as bringing shame to the family, destroying the family reputation, exemplifying an overall family weakness, or as retribution for family wrongs (Hong & Domokos-Cheng Ham, 2001). In some cases, individuals may believe that mental health care should be sought for more severe problems, such as psychosis, but not for problems thought to be less serious (e.g., anxiety, depression). Contextual-structural barriers include lack of access to appropriate and culturally sensitive mental health services (Lazear, Pires, Isaacs, Chaulk, & Huang, 2008; Wu et al., 2009), lack of knowledge of available mental health services (Garcia & Saewyc, 2007), shortage of racial/ethnic minority mental health workers and/or persons trained to work with racial/ethnic minority persons (APA, 2009a), older persons and culturally diverse elders (APA, 2009b), lack of access to interpreters, and lack of resources (e.g., lack of child care, transportation, finances) for accessing services (M. Rodríguez et al., 2009). Unauthorized immigrants face additional challenges related to documentation status (e.g., ineligibility for services provided by the county or state, fear of identification as undocumented, and deportation) (Yoshikawa, 2011). Those who live a migrant existence typically do not seek help, either due to fears related to unauthorized status or to moving from place to place in search of work (Hadley et al., 2008). Immigrants in rural areas may face additional barriers including lack of access to culturally competent services and service providers (Cristancho, Garces, Peters, & Mueller, 2008). Clinical-procedural barriers include lack of culturally sensitive and relevant services (Maton, Kohout, Wicherski, Leary, & Vinokurov, 2006); “clinician bias” (Maton et al., 2006); communication problems related to language differences and cultural nuances (Kim et al., 2011); misdiagnosis of presenting problems (Olfson et al., 2002); failure to assess cultural, linguistic, and procedural appropriateness of tests for targeted populations (Dana, 2005; Kwan, Gong, & Younnjung, 2010; Suzuki et al., 2008); lack of attention to culturally embedded expressions of resilience (Tummala-Narra, 2007a); and failure to use the most efficacious mental health interventions (McNeill & Cervantes, 2008) (e.g., evidence-based interventions adapted for use with minority and immigrant populations). Clinicians may also use Western-based theories of development that may not be suitable when working with immigrants from collectivistic cultures (Zeigenbein, Calliess, Sieberer, & Machleidt, 2008). For example, a clinician may downplay the role of religion and spirituality in the client’s life (McNeill & Cervantes, 2008) and overemphasize autonomy and independence as therapeutic goals (Dwairy, 2008). While contextual-structural and clinical-procedural barriers can be found across varied regions of the United States, they are becoming ever more prevalent in small towns and rural communities of the South and Midwest, where a growing number of immigrants from Mexico, Central America, and South America in search of low-skilled labor opportunities are settling. Unfortunately, these communities particularly lack the service infrastructure that is necessary to meet the mental health needs of Latino immigrants (e.g., access to health care, immigration assistance, and breaking down language barriers) (Buki & Piedra, 2012). 66 Report of the APA Presidential Task Force on Immigration
Treatment Considerations Assessment and Diagnosis There is extensive literature suggesting that assessment and diagnosis are challenging when working with immigrants in clinical settings (Comas-Díaz, 1997; Park-Taylor et al., 2010; Vazquez-Nuttall et al., 2007). Having previously addressed these challenges in some detail in the section on Assessment in Clinical Settings, we now highlight a few that are directly tied to the culturally encapsulated assessment instruments themselves: a lack of standardized translations of assessment instruments, as well as a lack of appropriate normative standards and studies concerning the reliability of test scores with various immigrant groups. From a more comprehensive perspective, it is important that the role of sociocultural context be comprehensively understood and seriously dealt with in the clinical process in order to provide ethical and appropriate standards of care in assessment, diagnosis, and treatment. A challenge in assessment with immigrants is the lack of valid and culturally appropriate diagnostic tools sensitive and comprehensive enough to capture cultural variability in the symptomatic expression of and coping with psychological distress. This presents significant challenges to psychologists who may rely on established testing and assessment strategies and instruments. For example, failure to take culture into consideration can result in “clinician bias,” which may be manifested in the tendency to universally apply Eurocentric models of illness, contributing to overpathologizing and a lack of attention to resilience (Dana, 1998) (see Assessment With Immigrant-Origin Adults and Children). It is important to note that the system of diagnosis outlined in the fourth edition (text revision) of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; American Psychiatric Association, 2000) has been thought to have universal applicability even though this diagnostic system is culturally constructed in a way that privileges Western or Eurocentric notions of mental illness (Pieterse & Miller, 2010). While the most recent edition of the DSM does offer guidelines for culture-specific diagnosis, it fails to Immigrant Populations in Clinical Contexts Failure to take culture into consideration can result in “clinician bias,” which may be manifested in the tendency to universally apply Eurocentric models of illness, contributing to overpathologizing and a lack of attention to resilience. acknowledge that the diagnostic system in the DSM–IV–TR is culturally specific (Pieterse & Miller, 2010). The diagnostic process itself can emphasize pathology and weakness over resilience and resources (Atkinson, 2004). Although it is true that the DSM–IV–TR includes a culture-specific section in the text, an appendix of culture-bound syndromes, and an outline for cultural formulation to enhance the crosscultural applicability of the manual, it continues to be insufficient in addressing cultural variability (Park-Taylor et al., 2010; Roysircar, 2005). Alternative diagnostic methods that supplement traditional psychiatric diagnostic approaches can be used to better assess and describe immigrant clients’ psychological distress (Pedrotti & Edwards, 2010), such as looking at disorders as lying on a continuum as opposed to being “present” or “absent” (Oldham & Morris, 1995). Further, it is important that clinicians self-assess the extent to which their socialization informs their evaluation of the racial and cultural data of the client (see Suzuki et al., 2005). Because of the limitations of existing diagnostic systems, scholars recommend that all phases of assessment and diagnosis, including the clinical and/or diagnostic interview, test administration, interpretation, report writing, and feedback to the client, consider the social, cultural, and linguistic context of immigrant clients and the coexistence of pathology and resilience (Harvey, 2007). Clinicians should consider the fairness and utility of diagnostic tests in the context of language, educational background, and cultural norms. It is also important that clinicians understand the implications of psychological testing and diagnosis on an individual basis and recognize that many immigrant clients are concerned about diagnostic labels due to cultural stigma and/or immigration status. Additionally, routine consultation with colleagues who may be more familiar with the client’s sociocultural context, the specific diagnostic tests being considered, and culturebound syndromes would be especially helpful in tailoring a culturally competent approach to assessment and diagnosis (see Assessment Challenges). Up to this point, assessment has mainly and quite appropriately been addressed in reference to educational 67
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Report of the APA Presidential Task
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Crossroads The Psychology of ImmIgr
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Preface One of the benefits of serv
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Diane Elmore, PhD (APA Public Inter
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2011; C. Suárez-Orozco & Suárez-O
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2010; M. H. Lopez & Taylor, 2010).
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designed with their educational obs
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al., 2006), communication problems
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Sloan, & Sperling, 2011) and toward
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• The mesosystem is made up of in
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lesbian, gay, bisexual, disabilitie
Page 26 and 27: contributed to the growth of undocu
Page 28 and 29: All other countries 42% FIGURE 3. T
Page 30 and 31: to learn English (Bayley & Regan, 2
Page 32 and 33: Exclusion Act of 1882) specifically
Page 34 and 35: and mental health outcomes. Discrim
Page 36 and 37: adaptation: acculturation, Cultural
Page 38 and 39: In a number of studies, strong iden
Page 40 and 41: documented the problems caused by a
Page 42 and 43: Populations Facing Unique Challenge
Page 44 and 45: American region (Mexico, Canada, Ce
Page 46 and 47: the government or a group the gover
Page 48 and 49: Notably, in 2000, approximately 650
Page 50 and 51: often rely on their ethnic immigran
Page 52 and 53: Life span Considerations Looking at
Page 54 and 55: Transition to adulthood in the Unit
Page 56 and 57: In a study of Korean elders, there
Page 58 and 59: those of native English speakers an
Page 60 and 61: linguistic group in the United Stat
Page 62 and 63: or deported, immigration officials
Page 64 and 65: Immigrant students whose education
Page 66 and 67: to read in the home language promot
Page 68 and 69: & Mapp, 2002). Teachers, in turn, v
Page 70 and 71: In a knowledge-intensive economy, h
Page 72 and 73: separation from country of origin,
Page 74 and 75: As individuals negotiate their iden
Page 78 and 79: and traditional mental health setti
Page 80 and 81: effective than those conducted in E
Page 82 and 83: development, to remediation). Thera
Page 84 and 85: Considerations for the Field The Un
Page 86 and 87: time. For example, under what condi
Page 88 and 89: summary of recommendations Recommen
Page 90 and 91: • Support opportunities for dialo
Page 92 and 93: Culture brokering: When children of
Page 94 and 95: Protective factors: Conditions in f
Page 96 and 97: eferences Abraham, M. (2000). Isola
Page 98 and 99: Bedolla, L. G. (2000). They and we:
Page 100 and 101: Carhill, A., Suárez-Orozco, C., &
Page 102 and 103: Delgado-Gaitan, C. (1994, April). M
Page 104 and 105: Gee, G. C., Spencer, M., Chen, J.,
Page 106 and 107: www.splcenter.org/get-informed/inte
Page 108 and 109: LaFromboise, T., Coleman, H. L., &
Page 110 and 111: McKitrick, D. S., Edwards, T. A., &
Page 112 and 113: psychological, and educational appl
Page 114 and 115: Robjant, K., Hassan, R., & Katona,
Page 116 and 117: Stepick, A., Stepick, C. D., & Labi
Page 118 and 119: the job that’s tough”: The ELL
Page 120 and 121: Waters, M. C., & Jiménez, T. R. (2
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