Building Bridges in Mental Healthcare for Immigrants

Every community faces a unique lived experience, some of which can make accessing mental healthcare difficult. In recent years, barriers to essential psychological and psychiatric services have been made more clear during the COVID-19 pandemic, through public health research. According to the American Journal of Psychiatry, one particular population that often bears the burden of these obstacles is immigrants, with lifetime prevalence ratesof psychiatric disorders for first-, second-, and third-generation immigrants at 19.3%, 35.27%, and 54.64%, respectively¹. In an effort to tackle the belief that mental wellbeing is a luxury, it is important to consider how everyone can benefit from mental healthcare and what causes disparities.

Mental Wellbeing and the Immigrant Experience

Immigrants, defined as anyone who is a resident of a country outside that of their birth, face unique challenges, many of which overlap with mental health challenges². The experience of being undocumented can pose challenges in insurance coverage, which can be a major barrier in being able to afford care, psychological and otherwise. Undocumented legal status can also pose other implications ranging from Medicare ineligibility and fear of repercussions in seeking healthcare³. Given many immigrants first communities in the United States are either highly urban or highly rural, geography itself may pose a barrier to access. In a rural community, the nearest point of care for a psychological concern could be counties over, placing professional help out of reach for many who cannot take the time off work to make that trip. In an urban community, long wait times, cost of living, or housing instability can make care difficult, regardless of proximity to a given clinic. While it is key to avoid generalizing across all immigrant experiences, many recent immigrants lack the income stability and financial freedom to invest in preventative mental health efforts. To meditate, do yoga, take walks, journal, one presumably needs time off work, a safe living environment, and money to access classes or materials. Beyond prevention, the cost of treatment, particularly in places without strong mental-physical health coverage parity, can be prohibitively expensive for a recent immigrant⁴. Copays for psychiatric medication and the time demands of longitudinal psychotherapy can make seeking care feel intimidating or impractical for those who must prioritize basic needs. Further, a lack of employment or inconsistent employment that many immigrants encounter, particularly those who are undocumented, can impact the reliability of certain benefits like health insurance. Even with the opportunity of consistent employment, many of the first jobs that are available to many immigrants at entry level may not offer benefits inclusive of mental health-related specialties. This is underscores a systemic need for greater integration of psychological care and primary care, along with standardization of parity policy.

Barriers to Mental Healthcare

While income concerns are one of the more salient obstacles facing immigrants, a deeper cultural stigma in immigrant communities may permeate discussions around mental health. It is important to note that much of this stigma varies from family to family, background to background, so while taboos around mental illness are still prevalent, no two experiences are the same. The idea of resilience in the face of adversity is a quality greatly admired in popular viewpoints of the immigrant experience, but resilience has its limits. In certain settings, studying for a major entrance exam, resilience can be an adaptive quality, but being resilient in the face of long-term, structural discrimination may be taxing. Researchers have coined the term “John Henryism” to describe how many groups adopt determination, strong work ethic, and high-effort active coping as ways of remedying chronic environmental pressures and socioeconomic obstacles⁵. Many may have been inspired of “rags-to-riches” depictions of the immigrant experience, but few narratives do justice to the social stress, isolation, or even depressive symptoms associated with the John Henryism driving that mobility. When resilience becomes a primary source of self-worth for an individual, admitting a need for help can seem akin to admitting a character flaw. Asking for help can already be a vulnerable experience for many, so these internal factors can be especially detrimental to mental healthcare.

In moving to a foreign country, community and culture can be protective for mental wellbeing as religious sites, cultural centers, and local businesses can be inclusive, welcoming third places, outside of work and home, to form social connections. When xenophobia is prevalent and cultural diversity is lacking in an area, it is less likely for immigrants to have safe access to the social infrastructure needed for a sense of belonging⁶. By adopting an approach that merges cross-cultural psychology and environmental psychology, changes to urban design, community programs, and local governance can improve quality of life and, by extension, mental wellbeing in this population. A host culture’s negative stereotypes that characterize immigrants as uneducated, dangerous, or opportunistic can drive immigrants to social isolation and loss of culture for fear of confirming such beliefs. The discomfort of confirming a negative stereotype is referred to as stereotype threat, which can have negative consequences on achievement and cognitive functioning⁷. What results is a cycle where facing stereotypes adds pressure to live within their constraints, which in turn jeopardizes the mental wellbeing and community support needed to weather the immigrant experience.

Migrant Farm Workers and Suicidality

Multiple factors work as determinants for the mental wellbeing of immigrants, and many more are involved, from spiritual traditions to gendered stigmas around help-seeking, that are not discussed in detail here⁸. In addition to exploring causal factors, it is worthwhile to support this with specific examples of immigrant mental health disparities showing up in certain regions. One such example is the crisis of migrant worker suicide, a persistent issue facing both urban and rural immigrant communities in the past decades. In Georgia for example, 60% of first generation farmers had suicidal thoughts in the past year, due in part to a shortage of mental health providers, farm-related injuries, and income instability⁹. Overall, non-European female migrants face the highest rates of suicide attempts, with migrants generally facing higher suicide rates than natives to a country¹¹. Given the potentially traumatic reasons behind migration, from war, religious persecution, or natural disaster, risk for psychological harm is already high initially, even prior to the challenges of acculturation¹⁰.

Certain drivers of suicidal behavior, social isolation, threat of deportation/status changes, and low literacy on navigating new health systems, are more prevalent within immigrants, who face risks of language barriers, family separation, and fears for family in their country of origin¹¹. Further, a growing proportion of immigrants and refugees are children, so early exposure to adversities in vulnerable age groups can compound other suicide risk factors. Children who experience traumatic events early in life, to then be faced with chronic structural discrimination and mental healthcare barriers may have worse psychological outcomes later in life¹⁰.  In this light, the connections between the unique socioecological dimensions of immigration and adverse psychological symptoms become more clear. Because measuring the reasons behind suicide attempts can be challenging and migrating populations can be difficult to access in research, efforts to better understand the unique risk factors of each ethnic background can illuminate avenues for suicide prevention.

Strengths and Solutions

Given the current state of mental wellbeing within the immigrant community, it can be easy to overlook key assets to mental wellbeing that can be a part of the immigrant experience¹². While it is valuable to note areas where immigration can increase vulnerability to mental health challenges, many immigrants possess characteristics like competency in multiple cultures, strong ties to spirituality and religion, social capital, and ethnic pride. Notably, there is some overlap between risk areas and assets, indicating how flexibility in environmental factors and the approach to mental health programs can shape results. Especially in building psychological safety nets at the community level, focusing on a strength-based rather than deficit-based perspective can be instrumental in driving progress.

Reaching marginalized communities can be difficult, but there are viable ways of breaking down these barriers. The American Psychological Association recognizes a lack of diversity in mental health professionals, with approximately 80% of clinicians being white¹³. This illustrates a need to expand the cultural competency of this field, so any provider, regardless of background, can be capable of offering culturally-inclusive and sensitive care. Another valuable approach is for mental health providers to explore local resources to meet deeper housing, transportation, or health needs, so a clinician can act as a liaison to address other upstream needs. At times, food security, financial flexibility, and employment are the fundamental prerequisites to mental wellbeing, so a provider with the capacity to provide this can be particularly effective. Another instrumental, but approachable method is establishing interpretation services that accurately reflect cultural ideas in order to accurately assess clients. Ideally, interpreters would be in-person and trained for psychological care settings, but digital alternatives for language services can still be a useful starting point.

Despite ongoing efforts in professional training on diversity and culturally integrative treatment strategies, access to clinical settings may still be difficult. One avenue to bridge this gap is through effective, low-cost self-care strategies that cater to the lifestyles and circumstances of immigrant communities. While self-care activites are certainly critical as they become consistent habits, there would ideally be a combination of self-care and professional support to address the unique needs of this group. Practices like physical activity, mindfulness, consistent sleep hygiene, spiritual engagement, and being a part of a social group are just some example of culturally accessible self-care practices to incrementally improve mental health¹⁴. For some people, this may look like an evening walk with family, or simply a silent meditation before sleeping. Regardless of the form it takes on an individual basis, these tactics can be an effective starting place to build bridges across the obstacles immigrants face in their mental health. When individuals do their part and mental health practitioners are also prepared to expand access and adapt their practice to different cultures, certain barriers to wellbeing can be eroded.

For more resources on taking care of your mental health as an immigrant, please explore: National Network for Immigrant and Refugee Rights