Abstract
The debates on the mental health benefits associated with immigration are mixed. On the one hand, immigrants are provided with more opportunities not available in their home countries. On the other hand, they are far away from home and may have been exposed to traumatic experiences on their journeys to the receiving country. Even after settling down in the receiving country, most continue to face legal battles associated with their immigration status, as shown in this study. This study examined the risk and protective factors associated with the mental health conditions in a sample of 39 immigrants and refugees seeking legal services on the US-Mexico border. Participants were recruited from a southwestern community agency serving the region’s immigrant population over the past three decades. Negative mental health states including stress, sadness, and anxiety were frequently reported by the participants. Six themes were identified as significantly related to the participants’ adjustment in the US: (1) political turmoil and safety issues; (2) economic hardship and extreme poverty; (3) trauma before and after resettlement; (4) immigration status; (5) family relational strain; and (6) identity struggle and acculturation. Overall, results demonstrate the complexity of issues pertaining to cross-country migration, cultural sensitivities, and mental health.
Introduction
International migration can be a stressful event that involves a series of socio-psychological adjustments (Bhugra, 2004; Wong, Correa, Robinson, & Lu, 2017). In 2015, the immigrant population constituted 13.3% (42.1 million) of the US population, an increase of 1.7 million from the preceding year (Zeigler & Camarota, 2015). From 1970 to 2013, the nation’s foreign-born population rose from 4.7% to 13.1% (Pew Research Center, 2015). Debates on the mental health benefits associated with immigration suggest the effects are mixed. On the one hand, immigrants are provided with opportunities not available in their home countries (e.g., family reunification, job opportunities, and upward mobility). On the other hand, they are far from home and may have endured traumatic experiences on their journey to the US (e.g., Ao et al., 2015; Cook, Shannon, Vinson, Letts, & Dwee, 2015; Kirmayer et al., 2011; Rettger, Kletter, & Carrion, 2016). Worse yet, even after settling down in the receiving country, most continue to face legal battles associated with their immigration status in the US, as shown in this study.
While many studies to date have looked at how the acculturation process unfolds, fewer have delved into the emotional distress and challenges experienced by political migrants and undocumented families who may have sustained substantial psychological strain and social exclusion. This study sheds light on the life stories of socially marginalized immigrants and refugees who are seeking legal services on the US-Mexico border by examining the risk and protective factors that are associated with their mental health and well-being. Overall, our study stresses the delicacy of issues pertaining to cross-country migration, cultural sensitivities, and psychiatric health. The examination of contextual factors conducive to the preservation of a healthy mental state can assist clinical practitioners in formulating effective health care delivery systems serving this growing but at-risk population.
Background
Migration takes place for a variety of reasons, and under a variety of different conditions. The pull and push factors that shape motives for relocation can influence the nature and complexities of migration. In particular, unlike proactive migrants who seek to maximize the benefits of migration (e.g., improvement of life quality, family reunification, and job opportunities), reactive migrants who are forced to relocate are pushed out of their home country due to political turmoil or religious persecution (Hirschman & Massey, 2008, Papademetriou & Fratzke, 2016; Richmond, 1993). Consequently, the different experiences of the migration journey (whether forced or voluntary) are likely to impact the quantity and quality of resources immigrants bring along to ease their transition into the receiving society (see Paat, 2013). Indeed, acculturation-related concerns (e.g. stressors), which are prevalent among recent immigrants, or immigrants confronting legal complications, were found to be associated with a range of mental health disorders and challenges that immigrants face (Garcini et al., 2016; Potochnick & Perreira, 2010). Unlike refugees fleeing to escape persecution, asylum seekers whose review is under consideration must secure their refugee status or risk being repatriated (USCIS, 2015; Zong & Batalova, 2016). Yet, encountering traumatic events (e.g., mass violence, exclusionary policies, government intimidation, war-like conditions, physical assaults, material losses, and the killing of families) in their home country are common experiences that necessitate fleeing (Cook et al., 2015; Fyfe & McKay, 2000; Refugee Health Technical Assistance Center, 2011).
As one of the world’s top refugee resettlement countries, the US accepted 69,933 refugees in 2015 and offered asylum to 25,199 individuals in 2013 (Zong & Batalova, 2015). Research shows that refugees often experience mental health symptoms such as distress, anxiety, depression, post-traumatic stress disorder, adjustment disorder, somatization, psychosis, substance abuse, and suicidal ideation (e.g., Abbara et al., 2016; Ao et al., 2015; Bettmann, Penney, Freeman, & Lecy, 2015; Hodes, 2002; Kane, Ventevogel, Spiegel, Bass, van Ommeren, & Tol, 2014). Like refugees facing prolonged future uncertainty or cumulative structural adversities in the resettlement country (Kirmayer et al., 2011), immigrants’ susceptibility to environmental stress and poor mental health is associated with a number of ecological factors such as the lack of hospitality (e.g., prevalence of racism), social seclusion, isolation, unemployment, financial instability, limited job skills or English proficiency, a lack of control over life, culture shock, feelings of relative deprivation, or value clash (e.g., between achievement, expectations, and aspirations) that promote a sense of failure (Ambugo & Yahirun, 2016; Bhugra, 2004; Gonzales, Suárez-Orozco, & Dedios-Sanguineti, 2013; Hollander, Bruce, Ekberg, Burström, & Ekblad, 2013; Paat, 2016; Takeuchi et al., 2007). There is evidence that undocumented immigrants are more likely to experience problems dealing with health, illness, and hospitalization due to their lack of health insurance and other barriers to access. In addition, many undocumented immigrants do not have access to preventive health care (e.g., Derose, Escarce, & Lurie, 2007; Hacker, Anies, Folb, & Zallman, 2015; Rodríguez, Vargas Bustamante, & Ang, 2009). Despite the heterogeneous post-migration processes experienced by immigrants, the empirical links between access to services and social barriers for immigrants needing mental health assistance are well documented in the current literature (e.g., Asgary & Segar, 2011; Mckeary & Newbold, 2010; O’Mahony & Donnelly, 2010; Saechao, et al., 2012; Sarría-Santamera, Hijas-Gómez, Carmona, Gimeno-Feliú, 2016).
Methods
Using a mixed-methods approach constituting intensive interviews and short surveys, this study assessed the risk and protective factors associated with the mental health conditions of immigrants and refugees seeking legal services on the US-Mexico border. Participants were recruited using purposive sampling in the summer of 2015, from a southwestern community agency that has been serving the region’s immigrant population for three decades. As the largest legal immigration services provider in west Texas and New Mexico, delivering services to approximately 30,000 low-income individuals and families annually, the agency houses six units of legal services (e.g., general legal services, removal deference, crime victims, refugee resettlement, legal orientation, and unaccompanied minors). With supervision from the agency’s staff members and the University of Texas at El Paso’s faculty partners, as well as help from student research assistants, the data collection took place in two phases (i.e., survey administration and interviews) at the agency’s offices through a process that maintained the anonymity of the research participants. The study, including research materials and protocols, available in English and Spanish, received ethical approval from the University of Texas at El Paso’s Institutional Review Board.
A total of 298 adult participants, who were seeking or currently receiving legal services, were asked to complete a 15- to 20-minute survey consisting of closed-ended, open-ended, and Likert-type questions pertinent to their life quality, stigma-related concerns, language proficiency, social integration, physical well-being, overall mental health, services received, social challenges in accessing services, and sociodemographic characteristics. The response rate for the first phase of the study was 85.1%. Based on the participants’ responses to the mental health items, a total of 39 participants 1 were selected to participate in a 30- to 45-minute in-depth interview (Appendix 1) in which the research team used open-ended questions and probing to solicit rich information on issues and examples that would be difficult to obtain through the survey method in order to understand the realities of the participants from their own perspectives. To compensate for their time, the participants in the first and second phases of the study were each reimbursed with a $5 and $15 US dollar gift card, respectively.
Data analysis
Qualitative data analysis was informed by the grounded theory method (Charmaz, 2006). All interviews were transcribed verbatim and all Spanish interviews (34 out of 39) were subsequently translated to English and proofread by at least two bilingual and bicultural research assistants. In preliminary data analysis, interview tapes were reviewed and transcripts were examined line by line repeatedly to identify patterns and look for commonality, consistency, recurring themes, clusters of themes, outliers, and unique cases. Next, as the basis for data selection, coding schemes and analytical constructs were established prior to sorting the data using a systematic indexing process. Using NVivo qualitative data analysis software, the participants’ experiences that were relevant to the constructs were categorized based on their respective contexts and relationships with other constructs. Pseudonyms were utilized throughout this process to protect the participants’ identities.
Findings
Participant characteristics
The mean age of the 39 participants was 44.7 years; 36.8% were males. On average, the participants had a high school/GED equivalent education corresponding to a mean educational attainment score of 5.5 (range 2–9); the mean English proficiency index score was 6.9 (range: 3–12). A total of 27 (69.2%) of the participants were not employed, although surprisingly, the same proportion had permission to work at the time of the data collection. More than half of the participants (22, 56.4%) reported that they did not have enough money to meet their family’s basic needs. Most (33, 84.6%) had reliable transportation, but only half (21, 53.8%) had access to affordable health care, and one-third (13) had health insurance; 20 (51.3%) acknowledged that it was difficult for them to seek help from other agencies or churches.
With respect to immigration status, 9 (23.1%) of the participants were undocumented. Further, among all the participants, 19 (48.7%) had relocated due to occupational opportunities, 16 (41%) had migrated to reunite with their family members, and 8 (20.5%) were identified as refugees or asylum seekers. These reasons for migration were not mutually exclusive. Three-quarters (30, 76.9%) stated they were fully aware of their legal rights in the US.
The participants reported the highest mean score on stress, and the lowest mean score on agitation. When asked about exposure to adverse conditions or events in their home country and/or the US, the participants reported a mean of 2.08 events (range: 0–5) (e.g., harsh political or economic events, negative or distressing interactions with immigration officials). More than one-third (15, 38.5%) of the participants felt lonely and isolated in the US. In response to questions about two weeks or more of symptoms in the last year, the mean scores (on a 5-point scale from 1 “Not applicable,” 2 “Less than half the day,” 3 “About half of the day,” 4 “Most of the day,” to 5 “All day long”) were: stress 3.5, sadness 3.1, anxiety 3.0, agitation 3.1 and hopeless 2.8.
Categories, subcategories, and associated themes and illustrative text.
Political turmoil and safety issues
While the decision to migrate was often personal, some cross-country moves were grounded on a constellation of political and safety reasons. A number of the participants in this study felt compelled to flee their home country following a traumatic experience (e.g., the death of a family member or a personal assault). No longer feeling safe in her home country, Rosa, a long-standing resident of Ciudad Juárez in Mexico who was already in her late adulthood at the time of the interview, shared her reluctance to immigrate despite much persuasion from her adult daughter residing in the US. Having been granted conditional US permanent residency and actively looking for employment, Rosa, who had a spacious home in Mexico, agonized about the pain of having to start a new life as she coped with the painful experience of losing her 35-year-old son. My daughter brought me here … [In the past,] I would tell her no … “Well, why should we go? … I have my Visa to cross.” … We did not lack anything … food, clothing … electricity, telephone, … cable, we had everything. What happened was that … they killed my son.
As a public accountant in Mexico, Miguel, too, had lived a comfortable life until his businesses were attacked by gang members of the drug cartel. Currently struggling to secure a low-paid hourly job in his profession in the US and hoping to sell his business premises which had been attacked in Mexico, Miguel described how his decision to come to the US alone unfolded: There were several attacks on the businesses I owned … I did not want them to attack me again at that same store so I closed the business, opened another one which lasted two years until they attacked my store again … I said to myself, “Ok, I have this business. It seems prosperous … but my store had been attacked twice.” Many times the saying goes, “The third time’s the charm” … maybe I would be dead in my third encounter, so I decided it was best to go to the US.
“Gloomy,” “not trustworthy,” and “dangerous” were some of the words used by the participants to describe the political conditions in their home countries. Lack of security and the need for a tranquil life were among the primary reasons that provoked the cross-country move for the majority of the participants in this study. As the participants shared their concerns, incidences of gang violence or rivalries, assaults, vandalism, thefts, kidnappings, environmental decay, blatant discrimination, corruption at all levels, and extreme poverty were used to vividly depict their neighborhoods. After losing her husband to cartel violence and facing death threats herself, 35-year-old Mariana, who brought along her two children to find “peace, tranquility, and security” in the US, stated: In Mexico, all windows have many bars like in a cage, unlike here. Here, we have real windows with no bars or locks, nothing. You can go and eat a burger at the park and you’re at peace. In Mexico … you cannot do that anymore.
Despite describing the journey from Mexico to the US as “nerve-racking,” Juliana, an undocumented mother of two children who risked her life by “crossing rivers” over a decade ago, shared the relief she had felt after her family received protection from the US government: Well … if something happens, I have more faith in the authorities here … Here the law is the law and … no one can break away from it. Over there (in my home country), if I do something [against the law] and get arrested, they (the authorities) will release me if I offer them money (bribe) [but] not the case here … that is what I want for my children.
Economic hardship and extreme poverty
The political unrest in the participants’ home countries also ignited related economic crises and instability. Food shortages and poverty were frequently raised as concerns by many of the participants. As Pablo illustrated, “Food is a big problem in Cuba … you have to think about … how you are going to eat … because there is nothing, and … clothing is also a big problem.” Coming to the US only with what he was wearing, 53-year-old Felipe, another Cuban refugee, shared Pablo’s concern, “We lacked everything from intimate apparel to shoes. Things were very hard over there (Cuba).” Indeed, according to Cuba’s National Office of Statistics, an average Cuban made approximately $25 (687 pesos) per month in 2015 (Whitefield, 2016). Also from Cuba, Jesus told the interviewer, “The problem is that … in Cuba, one works and works and never has anything.” Even with free education and health care for life, he added, “In Cuba, social status does not exist because there is so much poverty. There are people who have more and the ones who have less, but everyone is pretty poor.” Passing through five countries (i.e., Panama, Costa Rica, Nicaragua, Honduras, and Mexico) in his escape to the US, Jesus recounted an unforgettable experience in his journey through Panama: The first time I got here, I went to a supermarket and saw all the food … the big aisles full of food … I got tears in my eyes and I would only think of Cuba, in the whole town that doesn’t have that possibility and my family needing things in Cuba … That emotion was very, very, very horrible.
Male participants were not immune from this social phenomenon either. After becoming unemployed for an extended period of time, Carlos began to sell second-hand products to supplement his wife’s meager income. Carlos, who traveled with only his backpack to the US, shared his life story with the interviewer, Life in my country is very hard … When you get to a certain age, it is very difficult finding a job over there. So … if you have family members with a good job … they have to take you in, and if you don’t have anyone, you have a tougher time. In Mexico, the churches don’t help you with anything … neither does the government … There are very few jobs for many people. You have to be very well prepared … even if you get a [college] degree over there … you can’t get a job … and here (in the US), you can get jobs in anything … you move forward. This is the country of opportunities.
Trauma before and after resettlement
Achieving the goal of settlement is never easy for displaced migrants embarking on anxiety-provoking journeys that are filled with transitions, uncertainty, and risks. Despite arriving safely in a country that offers protection and opportunities, some participants continued to be haunted by their pasts and by recurring traumatic experiences (e.g., losing friends, leaving families behind, facing the unknown, losing their heritage, meeting unreliable coyotes, and starting from “scratch” in a foreign place). As 32-year-old Ariana disclosed her memory of collecting garbage cans in her early childhood with her 7-year-old sister in exchange for money and helping out the household, she shared the hard decision she made to leave her impoverished neighborhood in Mexico behind, “Well … at that moment, it was sadness because we had to leave everything – the house, clothes, toys, friends, everything … We came only with what we were wearing.” Although she managed to gain some college education after many years residing in the US, leaving at the time was unsettling for her, as she related, “We came with fear … We didn’t know English, we didn’t know where we were going to live … We didn’t know anything.” Unlike Ariana, who still maintained contact with family in her birth country, some participants described losing contact with the family they left behind upon their arrival in the US.
Some stories recounting the journey of migration as dramatic and involved challenges such as facing “inhumane treatment” by officials, fracturing a shoulder, enduring humiliation, being robbed or assaulted, witnessing rapes, landing in a hospital, passing through life-threatening zones, and walking until one became “black and blue.” These experiences were especially true for the male Cuban participants who had to travel further to get to the US compared to their Mexican counterparts. Jesus shared his traumatic journey in detail: I went through two assaults … in three hours, going through Costa Rica and Nicaragua in the middle of the night …They left us without a dime … Our lives were in danger … It was an armed robbery … After that we walked for almost six hours, going through the country … crossing rivers … swimming in the middle of the night … crossing the country illegally … It was very dangerous … Then in Mexico … I spent 16 days in a prison … They (officials) wouldn’t give out any information … We were prisoners. Every day was the same … just being locked up.
Even when the Cuban participants survived their daunting trip to the US and received asylum, their living situations did not improve right away, with the participants lacking instrumental support (e.g., in learning to catch the bus or read the bus schedule, trying to figure out how to use the US currency, sending money at the post office, or getting around on their own) being the most vulnerable. Jesus had only been in the US for the past five months; he was stressed about not finding employment and spoke of the trauma of being in a foreign country vastly different from Cuba, “We have to be walking, we have to take the bus … at all hours. Every time I have to go out somewhere, I have to spend all day moving around.” Pablo, for instance, had frequented several local homeless shelters while trying to save up some money to pay for his own place. Hypervigilant about petty theft at the shelter, he illustrated the reality in a homeless shelter, “There were drug addicts … alcoholics, and I had to be there with all those people, sleeping on the floor [without covers]. That was traumatic for me. I had never lived like that before.” He further shared his frustration about his ordeal: In the Salvation Army … what happens is that you … leave at 7:00am in the morning and you can't go back till 6:00pm in the evening. And you can’t have … the luggage. In other words, I walked. So then, since … I don’t take the bus … I would walk … I was on the street all day because I didn’t have anywhere to go … But it was hard being on the street [and] seeing myself on the street … I had a place to sleep [at night] and they (the shelter) gave me lunch but I was on the street [during day time], with my little suitcase.
Immigration status
In addition to being stereotyped and stigmatized as ethnic minorities, locating and securing employment was deemed the biggest challenge for the participants without proper legal documentation. Although Ian came to the US undocumented a decade ago and had felt welcomed in the country, he shared the challenges of having to rely on temporary work: There had been times when they did not pay me. People had made fun of me … because of my [immigration] status … I went through periods of looking for work until I found an opportunity for undocumented workers … I had traveled from city to city based on what I heard about the opportunities for work. Sometimes I had been disappointed when they told me that there was work and there wasn’t any.
Not having legal immigration status also hindered the participants’ geographical mobility and freedom to move around the country. The feeling of being trapped at home and afraid to get stopped at a checkpoint was a confession made by numerous undocumented participants. For instance, 46-year-old Abril, a mother of three who fled Mexico to escape violence and provide for her children, disclosed her anxiety about her immigration status: First of all, you suffer a lot … going around with fear … you get anxiety because you simply don’t want to go outside. At the place where I live, sometimes immigrant officials are around a lot … To me, there has been anxiety, depression … due to the seclusion. Well … with the police…when they stop you and give you a ticket … there’s always that fear that they’re going to ask you … Even though you look normal … you speak English … Thank God! No … they’ve stopped me like three times … never did they ask me … I sat in my car praying, “Please God … they don’t ask me.” … I have the kids at the back … I have made my life here and … I don’t know Mexico. I don’t remember Juárez … Those have been bad experiences for me.
In addition, a lack of legal immigration status prevented many undocumented participants from attaining upward mobility and, in some cases, attending post-secondary education. Having recently obtained her conditional residency (green) card, 30-year-old Amelia shared the stress she experienced prior to being granted legal residency in the US, “It was stressful … I went through depression due to the stress that … I couldn’t do much … I wanted to excel in everything – my education … [and] jobs. I just couldn’t, due to my [immigration] status.” For some undocumented participants, restriction of freedom encompassed missing family members and relatives’ funerals in their birth countries. Even with legal immigration status, 39-year-old Clara, a single mother supporting her daughter on the meager income provided by her job as a gas station attendant, talked about the ordeal of having to renew her work permit annually: Well, I guess my immigration status. That’s something that really stresses me out and depresses me, really … I renew my permit … every year … There’s a lot of anxiety, a lot of not knowing what is going to happen … What if? You know, there’s always a “what if” I don’t get my permit renewed … and that really gives me a lot of anxiety. The discrimination is less when you speak in English. When you can defend yourself, the discrimination is less … I have had bitter experiences related to discrimination. When I came to this country … I was very young but there was a sign “No dogs, no Mexicans, no Blacks.” That was a bitter experience.
Family relational strain
Relational strain between parent and child was not uncommon for the participants who did not see eye-to-eye with their US-born children on family socialization patterns and parenting practices. Even though Suzy, a mother of three adult children who had been in the US for three decades, believed that life in the US was indeed better for her and her family, she noticed that her children turned out differently, “I think my children have developed a little differently than what I would have wanted but it is because of the freedoms [here] … [and] … how they understand freedom.” When asked for clarification, Suzy pinpointed the “lax” parenting practices that discourage harsh physical punishment in the US yet fail to promote the behavioral standards she was raised to uphold as a child or the same level of obedience she desired from her children: If it were me, they (my children) would have given me a good one (blatant disobedience) … [But growing up,] my father would have turned to look at me with these eyes … that would have frightened me … Those are the things that I don’t like from here. When he was little, he wasn’t like that. He was happy with what I’d buy him. Now he is a rebellious teen … a rebellious teen who doesn’t value what one does for him and it makes me very sad … Sometimes he is disrespectful to me … It makes me very sad. I left my life – my entire life over there (Mexico) – for them (my children). He … had the control and said, “Nobody will help you here because you are from Mexico,” and I believed that … and so when … I found my courage and … I left … [Before that], if I was fearful of confronting many things … I just wouldn’t say anything but that time I took the first step [to leave] … and understood that there was help … for battered women. When we came here, my husband also changed a lot … He began to tell me … things like, “I am the one in charge here and I have control and you all will do as I say,” and … I began to believe all of these because I didn’t know that there was help … It was something very frustrating because of the things he would say and how he said to them (my children), “If you try to do something, you will go back to Mexico, I will send you back to Mexico and you are not even free here because they [immigration officials] … can get you … I will report you to immigration” … It was his way of scaring others and I thought that it was true. The first time, I had a passport (in Mexico) … My husband … didn’t allow me to go back for my passport so I stayed in this country [but] … my [immigration] paperwork wasn’t processed … The second time … I left him … It was very painful … My daughter was … with him and he didn’t allow me to talk to her, to see her, so I had to just find a way … to come back here (the US).
Identity struggle and acculturation
Feeling trapped between two social worlds was a typical experience for the participants who had not previously been accustomed to the life in the US, yet felt compelled to leave their birth country. Reflecting on what made leaving her birth country so difficult, Abril replied, “[it was] very hard because when one leaves their people over there … and one doesn’t know when one will return, [and when one returns,] they (their people) might not be there anymore.” Originally from Cuba, Felipe also shared the struggle with his new identity. He expressed his helplessness, “Being an immigrant … you are not going to feel good … It doesn’t matter how they treat you … good or bad … you are never going to feel good.” He added, “When one leaves his country … one leaves his life.” Although Felipe came to the US to escape oppression and poverty in his birth country, he stressed his loses, “There’re customs, there’re cultures … money can’t buy that. No one gives them to you either … So, it’s not easy.”
Asked if life in the US was better for him and his family, Bruno replied, “As far as … economic support … yes. But with respect to life, this is a very different kind of life than in Mexico. In Mexico … despite not having much, life … is more cheerful. Here, it is duller. That’s the difference.” Also from Mexico, 53-year-old Ashley shared similar view, “Life in the US is sad.” She clarified, “Maybe you have all the commodities – a nice house, a brand new car, but I think emotionally, morally, you are not happy … for being far away from family.” Like others, Laura, currently staying in the battered women’s shelter, explained her challenge with adjustment: It has been difficult … because … you never imagine that you will be in a place like this, you know? … We have always been in our house, in our home surrounded by family … and we took a step backwards, so, it’s like “Wow,” it was very stressful.
Indeed, acculturation remained a troubling issue for some, especially the older participants. Alma, in her early sixties, shared her challenge: I had been in the US several times [before migrating] … But as I said … it is not easy … to conform yourself to the life in this country … First, because you do not … understand the English language … And that … takes points away … It’s uncomfortable for me … to not know English … I understand a little. I know how to defend myself … [But] at this age, I am already 63, not much clicks for me, it’s difficult. Sometimes I see unfair things … and it makes me feel uncomfortable. When you come from [a different] country … you [come with] a different feeling because you don’t know what’s going to happen … When the night falls, you feel sad because you miss your family, you get emotional … But … I come to accomplish something … I come to help my family … I have to learn … You know that you need to be here, there’s no going back … you can’t.
Discussion and conclusion
Immigrants and refugees often suffer significant psychological distress and trauma (Kirmayer et al., 2011). Nevertheless, empirical findings suggest that not only are immigrants less likely to receive mental health services, but they also are more likely to rely on general or primary care physicians to receive such clinical intervention, raising concerns about the accessibility of mental health services (see Kaltman, Pauk, & Alter, 2011; Nadeem et al., 2007; Orozco, Borges, Medina-Mora, Aguilar-Gaxiola, & Breslau, 2013; Straiton, Reneflot, & Diaz, 2014). This study examined the risks and protective factors associated with the mental health state of immigrants and refugees seeking legal services on the US-Mexico border. Given the intensity of certain negative mental health states (e.g., stress, sadness, and anxiety) exhibited by the participants, our study suggests that immigrants and refugees seeking legal services may benefit from more effective and thorough mental health screenings if integrated with access to appropriate care. Additionally, since social isolation may prevent them from accessing services, having access to several needed services (e.g., mental health services coordinated with primary care or other health care services) in one location, with a trusted organization (e.g. a legal clinic), may increase the likelihood that immigrant clients will receive not only the legal services they need but other clinical and social services as well.
The availability of employment opportunities and social networks presented a protective effect on the mental health state of this subpopulation, while exposure to pre- and post-migration traumatic events could pose potential risk factors. Like other studies, our research showed that removing financial hardship is likely to improve immigrants’ mental health (Ambugo & Yahirun, 2016). Thus, we recommend the promotion of government and political initiatives to assist socioeconomically disadvantaged migrants to become economically independent. Because the lack of resettlement support can lead to integration challenges, social service agencies serving immigrants and refugees are urged to enhance resettlement support delivered to immigrants and refugees by initiating contact, making them feel welcomed, empowering them with information, and offering affordable clinical/mental health services. It must be noted that receiving mental health treatment may be culturally stigmatizing among the non-western population (Bettmann et al., 2015). Thus, it is imperative that mental health providers educate themselves about the culture of their immigrant clients, the unique historical context shaping mental health functioning, and various ecological factors influencing mental health beliefs or perceptions. Health care providers can also help immigrant or refugee patients understand the roles of the mental health care system in the resettlement country (Bettmann et al., 2015).
Our study has limitations. Selection bias is likely because the participants were recruited from one community agency. The retrospective data are influenced by recall bias, the qualitative findings may not be generalizable and the cross-sectional design limits causal inferences. Researchers interested in further exploration of the mental health well-being of immigrants and refugees are encouraged to explore structural variables to understand their psychiatric need. More research is needed to advance a structurally sensitive understanding of this vulnerable population and provide a framework of knowledge that can be translated into effective policies encouraging a socially inclusive and healthy community.
Footnotes
Acknowledgements
We are indebted to the participants who were willing to share their life stories with us. We thank Ms Melissa M. Lopez, Executive Director of Diocesan Migrant & Refugee Services, Inc. and the agency for their assistance in facilitating the data collection process. Many thanks also to Drs Guillermina Gina Núñez-Mchiri and Silvia M. Chavez-Baray, who are part of the CAP2 grant, as well as student research assistants Laura Cristina Lopez, Claudia Silva, Marisela Padilla, Eva Gonzalez, Jessica Morales, Caroline Soto, Karen Morales, Jessica Ayala, and Dolores Rosales for their assistance in the research project (e.g., data collection, entry, cleaning, transcription, translation, and proofreading).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study effort was supported by the Community-Academic Partnership Capacity-Building Program (CAP2) funded by the College of Health Science, The University of Texas at El Paso.