2.)  KP: What are some of the common clinical issues facing immigrants?

Sinead: Many, whether they’re adults or adolescents, are coming from families with multigenerational exposure to traumatic stress.  For example, there may be trauma within the family, from domestic violence (DV) or sexual abuse, or trauma related to cultural violence due to poverty or political oppression.  But, for the most part, I often see many generations of traumatic stress being repeated.

With the older clients, I tend to see more dissociation, everything ranging from mild dissociation within Post Traumatic Stress Disorder (PTSD), to more severe types of dissociation, like people who are struggling with diagnosis of Dissociative Disorder Not Otherwise Specified.   More rarely, we will see somebody with full blown Dissociative Identity Disorder (DID) – which is formerly known as multiple personality disorder

KP: For those not familiar with the term, can you explain what you mean by dissociation?

Sinead: Sure.  When a person has been exposed to some form of traumatic stress – whether it be physical abuse, or sexual abuse, and there is no means of escape – meaning that when that trauma took place, they couldn’t fight it or get away from it – then the only way they’re able to get through the overwhelming experience is by having a part of themselves leave the situation mentally.  The body is still there during the abuse, but the mind escapes.  So, there’s this disconnection that takes place.  When one is dissociating, their awareness is not in the present moment.

This is adaptive in the context of trauma because it helps keep the psyche safe in some way; it’s essentially a very strong coping mechanism to get through overwhelming stress in the moment.

In my work with you, I see two typical scenarios.  One consists of those who have been living in the US from a very young age and who are still undocumented in terms of their legal immigration status.  Then, there are the adolescents who recently arrived to the US; some of those individuals are documented and some are not.

With the adolescents who have recently arrived to the US, they often struggle with what you’d expect regarding acculturation: missing their friends, family, food, and lifestyle of their home country. However, another significant struggle is the adjustment to living with biological parents and siblings who they do not have a close relationship with, due to their primary attachment bonds being developed for the caretaker who raised them while they were growing up in their home country.  Often, that person is a grandparent whom they consider to be more of a mother than their biological mother, so problems arise when the expectations of the biological parent are that their child automatically feel close to them, confide in them, and be happy.  Instead the child may wish to be back in their home country and distress may be expressed somatically rather than verbally in the form of headaches, G-I problems, insomnia, etc.  Additionally, if the child reunites with their parent during adolescence, this is even more of a struggle because the stage of development they are in regarding separation/individuation and the movement towards autonomy may cause them to seek connection through peers rather than parents; thus further challenging the reintegration with their family.

With the adolescents who have been here for a long time, they identify the US as their home country and culture.  As President Obama says, they are “Americans in their heart.” These youth do not feel very connected to their country of origin and have not been able to return there because of documentation status.  They often prefer speaking English to Spanish, even when others, like their parents, prefer to speak with them in Spanish.

The key struggle they face is that they don’t have the same advantages or opportunities as their peers who they may have known their whole lives.  For example, being able to get a summer job – they can’t get a normal summertime or after-school job like their friends.  Even when they want to be productive and contribute to the community, they’re still not able to.  They can’t even get volunteer positions because they need to have a social security number in order to get a background check.  So, they often feel bored and frustrated.  They feel very much left out of the normative activities that their peers are doing.

Once they get beyond the age of being able to participate in summer camp, their opportunities are even more limited. That’s when they can be more prone to high-risk problems – spending time on the street, unwanted pregnancies, or just even more depression, frustration and anger.  Unfortunately, their parents who are also here illegally, aren’t able to monitor their kids as well as they’d like due to the stressors they often face, such as having limited economic resources and needing to work two or three jobs.

As a clinician, it can be very hard to offer hope or some sort of reasoning about healthy choices, when the community isn’t really giving them many options.  So, again, it’s common to see a lot of frustration and anxiety among these youth, which can lead to social and academic problems, like school failure.

KP:  It’s good that we’re talking about this because, unfortunately, so many oppressed populations – like undocumented immigrants – can be pretty invisible.  I read that children account for about 15 percent of undocumented people in the US and this translates to nearly 2 million undocumented youth in our country.  It’s important to look at the realities they face and how this impacts things their emotional wellbeing.  The toll that external stressors and lack of opportunity takes on people; especially how devastating it can be for young people, who see themselves as just normal kids on one hand, but at the same time, they’re seeing their peers being given so many more opportunities.  You can see how this would contribute to anger, depression and anxiety about their future.

Sinead: Exactly.  So, what you often end up seeing are parents who are highly stressed on multiple levels and needing to work all the time.  So, they may have their adolescent kids take care of the younger ones.  The adolescents feel frustrated that they aren’t able to do fun things, and then on top of that, they sometimes feel burdened by parental responsibilities because the family can’t afford childcare.  Alternatively, their parents may feel that it’s not safe for them to be doing things in the community due to violence or discrimination as undocumented people. So, even in the instances where the adolescents may be able to participate in after-school or summer activities, they’re sometimes unable to do this because the parents need or want them at home.  This keeps them cut off from age-appropriate experiences and interests. So, again, the kids end up feeling disconnected, bored, and wanting more freedom.  This can lead to a huge strife in the relationships between the children and their parents; this comes up in therapy a lot – the struggle between wanting to have more freedom and the parents saying, “I don’t want you to get hurt.”

Unfortunately, when kids who are lacking in opportunity and freedom get more time away, they can be at higher risk of making “mistakes” or bad choices.  Let’s say you have a young female that realizes that she can’t access certain resources that others who are documented can.  She may perceive that getting pregnant is a means to say, access housing.  It’s a “solution” in a concrete way because her baby will be born a US citizen and this will give her access to housing that she otherwise couldn’t afford.  The other piece with a pregnancy like this is that the young person may see a child as a solution to their unmet emotional attachment needs that are common in highly stressed families.  They may idealize what it means to have a child, thinking that they will have that deep closeness that they didn’t have or aren’t getting in their family of origin.

It can be so easy for others who don’t understand how dire their situation is, to simply judge the young person for getting pregnant, but it’s almost the perfect set up for this – that when you give kids no opportunities, you can understand how something like getting pregnant can be seen as a viable option.

KP: You’re essentially saying that this is a conscious decision, to get pregnant as a teenager?

Sinead:  Yes.  I have had 15 year olds who think they’re pregnant and when they get their pregnancy test and find out they’re not, they get really distraught.  Alternatively, they may come back later after they’ve gotten pregnant and they’re quite happy.  Now, I’m not saying that this is the case for every teenager I see, but there are quite a few cases where this is the situation, especially if they feel that they don’t have a future.  For instance, if they can’t go to college, which has been the case for most undocumented youth.  Now, with the Obama policy that was put into place, at least they have the option of working, but up until then, that wasn’t even a possibility.

Now, on a side note with the teen pregnancy piece, I’d like to say that it’s important for me, or anybody else for that matter, to not insert one’s own cultural judgments about when it’s appropriate for somebody to get pregnant.  In many cultures, it can be more socially acceptable to get pregnant at a younger age.  Despite this, however, the fact remains that there are higher levels of physical risk to both the baby and mother, as well as the possibility of long-term psychological and social problems with teenage pregnancy.

KP: Right.  Now, these young undocumented people that you are talking about are sometimes referred to as “DREAMers,” in reference to the “Development, Relief, and Education for Alien Minors” (DREAM) Act introduced to Congress in 2001 that was designed to offer conditional residency to youth that had lived in the US for several years.   Obama’s recent policy enacts some, but not all of this legislation – primarily allowing them to avoid deportation and apply for work permits.  With the college piece, I know that there are some colleges that will accept undocumented youth, but it sounds like it’s complicated, with many not having access to financial aid to pay for school.

Sinead: Yes, even if they’re accepted to college, they may not be able to access enough financial aid to attend.   At least, now there’s the option of working for these youth, so now getting a high school diploma has a purpose.  Before this, there was less incentive for undocumented youth to stay in school.  As you know, they have the right to drop out at age 16, so you see a high drop-out rate because there’s low incentive to get up early in the morning and go to school and do your homework, etc. because when they finally graduate, it’s just a piece of paper that’s essentially meaningless…even if they’re valedictorian.  So, they realize this and think, “why should I make the effort to graduate?”

Now, with these new policies in place, there is a reason for kids to stay in school, so that’s a positive.

KP: What you’re talking about is important – it reflects the need to understand mental health concerns within a broader context.  It can be easy for people to look at something like depression or anxiety, as just a “problem” that somebody has.  And, while there can be biological predisposing factors to many diagnoses, the external pieces, like the ones you’ve been talking about – access to opportunities, discrimination, and poverty – all play a significant role in impacting emotional health.  Feeling like you don’t have much of a future, as is the case for many undocumented youth, will impact one’s mental health in a negative way, needless to say.

Next Section: 3.) You do a lot of trauma work.  Can you talk about the types of modalities you use when treating trauma?