Challenges in Treating Undocumented Immigrants
Which of the following represents a barrier to care for unauthorized immigrants?
Concerns about being reported to the authorities
Inability to communicate fluently in the dominant languages of community clinics
Inexperience with navigating the health system
All of the above
“Ms. A” apologized with difficulty in heavily accented English: “I’m sorry, Doctor, but I had to work nights.” She had missed two appointments to assess whether her 18-year-old son met eligibility criteria for special services based on a psychiatric disability. Consequently, representatives from the city agency postponed its meeting with the family in anticipation of my report. The agency supervisor had already granted us two extensions. Despite the delays, the agency appreciated Ms. A’s attempts to bring her son to the appointment and wanted to see his case resolved successfully.
Ms. A led her son into my office and apologized again, this time for her fraying uniform, which smelled faintly of cleaning agents: “I’m sorry, but I have to go to work after.” The edema under her bloodshot eyes betrayed a chronic lack of sleep. Her son towered above her, wearing headphones, trendy black athleisure wear, and unstained white sneakers. She settled into her chair as he swiveled his away and drowned us out with music.
She narrated her son’s trajectory of progressive decline. The family had migrated to the United States from Mexico when he was 5, past the period for early intervention services when any developmental delays could have been detected. Her son’s inability to communicate in English led to his repeating the first grade. Two more years elapsed before a school psychologist hypothesized that his lack of class participation could be from inattention rather than language difficulties, and she referred him for his first psychiatric evaluation. His parents accepted the diagnosis of attention deficit hyperactivity disorder (ADHD) but not medication management, and his symptoms persisted. By middle school, his antagonistic relationships with teachers worsened: he refused to follow rules, argued daily with adults, frequently lost his temper, and was sent most days to the principal’s office. “We were too busy working to pay attention,” his mother whispered, with tears welling in her eyes. They returned to their former psychiatrist, who diagnosed him additionally with oppositional defiant disorder.
“What kind of work do you and your husband do?” I asked.
“I clean offices in midtown Manhattan. His father works one job as a waiter and another as a deliveryman.”
Her son’s conduct worsened in high school as his parents worked even more to send funds to an expanding family in Mexico. His pattern of arriving tardy to school in ninth grade escalated to truancy beginning in tenth grade, with not enough attendance for promotion. Forced to repeat the year, he preferred to play video games and smoke marijuana with his neighborhood friends rather than attend school. He refused to attend regular outpatient appointments with his psychiatrist and psychotherapist. His parents tried reasoning with him, to no avail, and their demanding work schedules prevented them from monitoring him closely. To pay for his growing marijuana use, he sold shoplifted items for several months, until he was arrested. Based on his history of untreated psychiatric illness and no prior criminal record, the judge ordered the city agency to obtain an independent evaluation from a psychiatrist and subsequently arrange a treatment setting where he could receive services. “We left Mexico to escape violent crime, and my son is turning into a criminal,” Ms. A said, shaking her head.
We reviewed his current symptoms and completed a diagnostic assessment. As part of my standard social history, I asked, “So I’ll list your employment as a cleaner and your husband’s employment as a waiter and deliveryman?”
Her eyes widened in alarm. “Do you have to? We’re not documented.”
“Let me check.” I called the agency supervisor on speakerphone. Despite conducting hundreds of evaluations for various agencies, it never occurred to me that this routine question might be controversial. The supervisor and I briefly exchanged pleasantries before I asked, “Is it mandatory to document sources of income as part of my evaluation for your agency?”
“Let me check. I’m putting you on hold.”
As we sat in silence, I worked through contradictory thoughts and emotions. Was her request unethical? Why shouldn’t I list their sources of income if they are working? If they aren’t paying full taxes as citizens, then why should other taxpayers fund his therapeutic placement? What has her son done to take responsibility for his health now that he is approaching adulthood? Why should the mental health system intervene when his parents deliberately chose not to arrange for greater supervision of him or agree to use medications when his illnesses were less severe?
I discovered the source of my frustrations: first, my parents—and then aunts, uncles, and cousins—had to endure months of separation from each other as they waited for work visas to enter the United States. It wasn’t fair that families such as this one could deliberately break the law and benefit from social services when others obeyed the law with significant hardships. Popular news accounts about families torn apart after an undocumented member is deported because of illegal entry (1) do not move me, since hundreds of Asian and Middle Eastern families in my hometown community suffered family separations before they could sponsor relatives; forced familial separation for a period of time was a normative experience in our childhoods. Our ancestral countries have not shared a border with the United States that we could knowingly cross illegally.
But was it true that this family faced no hardships? Ms. A had told me that rampant drugs and violent crime in their hometown compelled them to migrate, a threat that my parents never faced as economic immigrants. This family has not taken a vacation in 13 years in order to raise the standard of living for their relatives in Mexico. They have worked grueling hours in the hope of providing economic and educational opportunities to their son, even if he has not yet taken advantage of their sacrifices. Who knows if they’ve been paid minimum wages, if their employers have threatened to report them to immigration services for deportation, if they avoid medical appointments out of fear of being caught? Perhaps I was being too harsh from my countertransference to their migration status: I’ve met hundreds of people from varied racial, ethnic, and linguistic groups who say they do not believe in mental illnesses such as ADHD or in the efficacy of psychiatric medications—the sad reality is that this family is no different. Am I a worse person, a worse psychiatrist, for feeling conflicted about this?
We heard ruffling sounds on the speakerphone. “I have an answer for you,” the supervisor said.
“According to agency guidelines,” the agency supervisor said, “you do not have to document migration status or sources of income at all.”
I thanked the supervisor as Ms. A smiled and exhaled in relief. I continued exploring my countertransference. As an evaluator independent of the family and the agency, my professional responsibility is to provide an honest, objective evaluation consistent with local laws and regulations. It is not to triage health resources based on the politics of federal immigration policy. The supervisor’s response confirmed this understanding, so why my continued ambivalence? After all, I hadn’t gotten upset when she explained the two missed appointments, their history of migration, or her and her husband’s employment.
My anger arose at her request. By asking me to not document their sources of income, I felt outraged that she would enlist me in an act of possible collusion against the law, forcing me to explicitly have an opinion about her life circumstances and side either with or against her. My instinct was to side against her based on my initial conception of who deserves society’s resources. But by framing her request as a question, she deserved an answer that I did not know. To assuage her, and myself that I was not breaking the law, I contacted the agency supervisor. I also felt envy and resentment at their family’s cohesion: she and her husband toiled day and night to earn income for their family, just like my parents had done on arriving in the United States, but my family did not have the luxury of being together in its initial years.
The ability to draw an analogy of shared parental struggle for a better life in this country softened me.
“I won’t document this information,” I reassured Ms. A.
Each person must find ways to resolve the myriad, unexpected dilemmas that arise in clinical work. In this case, to report this family’s migration status or sources of income would risk harming them without any legal necessity. Ultimately, our society has mechanisms to govern the distribution of health resources: people elect officials to debate and create legislation, and the courts deliver opinions that interpret laws. None of these functions is my role as a clinician, and external regulatory bodies have supplied sufficient practice guidance in this type of situation for now.
“I’ll finish this report and send it over,” I said, as I always do after each evaluation.
“Thank you, Doctor,” Ms. A repeated several times as she walked toward the door.
With his music blaring past his headphones, her son whispered, “Finally,” and followed her to the exit.
Health Coverage For Undocumented Immigrants
In a 2016 report, the nonpartisan Pew Research Center estimated that the number of unauthorized immigrants in the United States—defined as those who entered the country without valid documentation or those who violated the terms of a lawful admission, such as staying past a visa expiration date—accounted for 11.1 million people in 2014, falling from a peak of 12.2 million in 2007 (2). One framework to analyze the effect of immigration laws and policies on health services is to identify those restricting access to any services, those granting minimum rights to services, and those granting more than minimum rights to services (3). Federal laws restrict unauthorized immigrants from coverage for routine health visits through federally funded programs, such as non-emergency Medicaid, the Children’s Health Insurance Program, or the Patient Protection and Affordable Care Act (4). However, unauthorized immigrants can receive emergency medical services without restriction and apply for Emergency Medicaid if they qualify for low-income status (5). Federal restrictions also apply to unauthorized pregnant women and children, including those known as “DREAMers” who qualify for the Obama administration’s Deferred Action for Childhood Arrivals program, although children born in the United States whose parents are unauthorized immigrants are eligible for the same types of coverage as other American citizens (6, 7). Despite their full exclusion, unauthorized immigrants contributed a net total of $3.5 billion to Medicare’s Hospital Insurance Trust Fund in 2011 through payroll or self-employment taxes, leading some analysts to raise questions about the ethics of excluding them (8).
Notwithstanding federal restrictions on routine health care, undocumented immigrants may have minimum or more than minimum rights to services based on their geographic location. States can use nonfederal funds to provide health coverage at community health centers and safety-net hospitals (9); 16 states and the District of Columbia provided such services as of 2011 (10). The state of New York implemented its Basic Health Program in 2016 to provide health insurance for preventive and primary care to adults with incomes up to 200% of the federal poverty level and may expand the program to cover unauthorized immigrant adults (11). Agencies may also enact specific guidelines. For example, the Chancellor of the New York City Department of Education reiterated in January 2017 that its staff would not proactively record the immigration status of any student or family member, but would protect such information if shared, under the city’s confidentiality policy (12). Hence, clinicians should provide emergency care to unauthorized immigrants as they would to others and follow local policies for practice guidance in nonemergency situations.
Mental Health Service Utilization Among Unauthorized Immigrants
Despite the option of private insurance, most unauthorized immigrants are uninsured and opt for safety-net care (13). Unauthorized immigrants face unique barriers to care, such as a requirement to present documentation to receive services in some institutions, concerns about being reported to the authorities, inability to communicate fluently in the dominant languages of community clinics, and inexperience with navigating the health system (14). Research with this group is limited, since many institutional review boards have not adopted policies responding to the distinct needs of unauthorized immigrants as a vulnerable population (15). The few existing studies show that unauthorized immigrant children and adults experience higher rates of anxiety, depression, and posttraumatic stress disorder compared with authorized immigrants and citizens (16). Unauthorized immigrants are likely to face psychosocial stressors such as difficulty finding employment, workplace exploitation, limited freedom to return home (17), and lower rates of referral to government agencies for domestic violence (18) and child maltreatment (19). Consequently, adjustment and substance use disorders may be higher among unauthorized immigrants than among authorized immigrants and citizens (20).
Studies on utilization show mixed results. Compared with authorized immigrants and citizens, unauthorized Latinos have lower lifetime rates of inpatient and outpatient service utilization (21), but unauthorized Fuzhounese show higher rates of hospitalization, rehospitalization, and treatment discontinuation (22). These results dispel notions of unauthorized immigrants as a monolithic group. Clinicians may have difficulties arranging outpatient follow-up appointments because of patient stigma, difficulties with getting time off work, and preferences to pay in cash for diagnostic studies and medications, which can limit financial resources for future care (23). Despite the lack of systematic epidemiological research on mental disorders in this population (24), the studies cited above suggest that clinicians should screen broadly for mental disorders when unauthorized immigrants present for services.
Cultural and Social Influences on the Patient-Clinician Relationship
Apart from societal and patient-level barriers to caring for unauthorized immigrants, clinician-level barriers may also exist. Culture and ethnicity can trigger powerful transference and countertransference reactions of overfriendliness, mistrust and hostility, or ambivalence (25). Clinicians may face individual biases, language barriers, cultural misunderstandings, and their own attempts to serve as “gatekeepers” of health and social services in treating immigrants and minorities (26). Cultural competence initiatives in medicine have encouraged clinicians to consider their reactions to patient identities as a way of reducing health disparities for disadvantaged groups (27). Too often, however, such initiatives treat culture as a single static variable rather than a dynamic interplay of interpersonal processes, or as a collection of patient traits that explain treatment nonadherence without understanding the conditions responsible for disparities (28, 29).
In response, cultural psychiatrists have recommended approaches that situate cross-cultural aspects of patient care within the social institutions and circumstances that structure health resources. Older models of transference and countertransference that attributed cultural differences to either patients or clinicians have yielded to analysis of the patient-clinician relationship at the intersection of social, political, and economic forces (30, 31). DSM-5 now includes a definition of culture as “systems of knowledge, concepts, rules, and practices that are learned and transmitted,” including within the patient-clinician relationship (32). The 16-item Cultural Formulation Interview (CFI) can help clinicians ask patients about their identities, relationships, and conceptions of illness and treatment (33). A CFI supplementary module also encourages clinicians to contemplate how such patient factors influence diagnostic assessment and treatment planning (34). Undocumented immigrants confront particular structural vulnerabilities of social stigma, inferior political status, and the economic disadvantages of frequently working in hazardous, humiliating conditions without access to basic provisions (35, 36). By engaging curiously with a patient’s narrative, allowing for the possibility of extreme affect, and processing countertransference, clinicians can cultivate a space for empathy with those whose life experiences and cultural backgrounds differ dramatically from theirs (37).
D. All of the above
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