Keywords

Introduction

This chapter will explore the diversity among Spanish-speaking Latinos in the United States, as well as highlight shared experiences of individuals immigrating to the United States from Latin America. Latinos immigrate to many countries, and there are significant populations in Spain, the United Kingdom, Sweden, Canada, and many other countries. However, the great majority of this migration is to the United States, and we focus on the challenges of this population which may be quite similar to those faced by Latinos in countries not in Latin America.

Specifically, challenges immigrants face upon coming to the United States will be discussed with the objective of assisting clinicians in engaging and serving this population. To this end, the chapter will be divided into four main sections: (1) factors that contribute to a Latino identity starting from infancy, (2) common themes to consider when serving this population during the perinatal period and early childhood, (3) the impact immigration has on children, and (4) suggestions for clinicians of various professions and agencies working to make their services more accessible and welcoming to this community.

Factors Contributing to Sense of Identity

Ethnicity and “Race”

“I’ll check the box if it says Latino, but I won’t check for Hispanic. I don’t like that word,” a Latina client explains. For some people, the term Hispanic reminds them of Spain, the conquistadores, and represents the destruction of their culture and land, a part of their identity and history they would prefer not to remember, much less include in a description of their identity. Latinos are not a homogenous culture; there are twenty-two Spanish-speaking countries in the American continent, each influenced to varying degrees by their own indigenous culture, colonization, and slavery. To assume that someone from El Salvador will have a similar perspective and culture as a Colombian would be to fall prey to the false narrative that often paints a shallow image of Latinos.

Latino, Hispanic, and Latinx are terms to describe an ethnicity; since Latinos vary immensely in appearance and skin color, ethnicity is the only way they can be categorized. Telles and Ortiz (2008) explain that members of a dominant societal group develop ethnicities when they see themselves as different from the “other group” and want to firmly outline their dominance and protect their perceived superiority (p. 211). Given that Latinos cannot be defined by any one “race,” census checkboxes oftentimes leave darker-skinned Latinos without an option; “I’m not white, but I’m not black. What do I mark?” is a common response when confronting the question “What race are you?”

Mexicans were the first to bear the burden of responding to the United States census. After the United States taking over of much of Mexico in 1848, white became the de facto predominant group (Gomez 2007). A few decades later, Mexicans were officially granted US citizenship with “full rights” but lost much of their property and were given low-status positions (Ortiz and Telles 2012). Although Mexican Americans are considered white on census documents, they are often treated as second-class citizens.

The United States is not the only country plagued by inequalities tied to the color of their skin; indeed skin color is a preoccupation in many if not most cultures. Telles (2004) described how Latinos of African descent, living in Brazil, experienced more discrimination, had lower socioeconomic status, and fewer occupational opportunities than those not considered of African descent. How skin color and other physical properties affect Latinos living in countries with less pigment variation has been more complicated to define. Villarreal (2010) interviewed 2400 adults in contemporary Mexico asking them to identify their own skin color (i.e., white, light brown, dark brown), socioeconomic status, level of education, occupation, and household income. In analyzing the data, Villarreal found that darker skin was positively correlated with lower educational attainment and socioeconomic status.

These findings support Massey’s (2009) assertion that humans are wired to create schemas to represent members within groups. In the United States, Latinos with lighter complexions might be told that they do not “look Latino,” questioning their sense of identity and belonging. However, in some cities in the United States, they may also feel marginally protected from police officer’s threats to ask for legal documentation from anyone who looks Latino or, more commonly stated, “who look Mexican.” Latino parents may feel the need to protect their children in different ways, depending on how “dark” each child is: the impact of color appears inescapable.

Language and County

In South America, Central America, and Spain, Spanish is the main and, in some areas, only language spoken. Of course, speaking Spanish does not define one’s identity. Learning to speak Spanish does not make one Latino; however, not speaking the language can profoundly affect one’s understanding of the Latino identity.

Although Spanish is the primary language, it is not the only one.

Isabel described how she arrived in the United States from Mexico and why she decided to come. She spoke slowly and with noticeable effort. The clinician asked if she spoke any languages besides Spanish. Isabel responded that she spoke Nahuatl, the Aztec language. Spanish was her second one, and she’d learned it in the United States because no one in her community could speak Nahuatl. She shared her experience of discrimination not only from nonimmigrants but also from those in the Latino community who made fun of the way she spoke, refused to repeat things, and overall treated her poorly. This is consistent with Villarreal’s ( 2010 ) explanation that much of the discrimination in Mexico is between indigenous and nonindigenous populations. Isabel was in the United States because her family in Mexico did not have food or adequate clothing. At this point in the conversation, she took a deep breath and told the social worker that her father was sick and could not pay his medical bills. She explained that the medical system where she was from was not like it is here, “Si no puedes pagar, aunque estés por morir, no te van a ayudar.” (If you cannot pay, even if you are about to die, they will not help you.) She was sending money so her father could get the treatment he needed. Isabel wiped her eyes and described how she tries to think about her father’s treatment when other Latinos excluded her because of her language.

As Isabel’s story demonstrates, an immigrant brings with her schemas learned through socialization in her home country and now must learn the subtleties of social interaction within and between groups in the new country. This involves not only learning about obvious structures and dynamics such as immigrant versus nonimmigrant but also considering those less obvious schemas that categorize Latinos as separate from one another, such as country of origin, educational level, and language. Many are more likely to feel their identity tied to a region or country than any other characteristic of “being Latino.” Stereotypes form about entire countries and individuals separate themselves based on these stereotypes.

Even if no stereotypes are at play, the experience of growing up in each Spanish-speaking country is different. Someone from Guatemala may feel excluded at an event with mostly Argentines. Their accent is different, they may not understand all of the vocabulary or slang, and the issues of these countries differ vastly. Someone growing up in the United States would not have their cultural identity lumped with someone from Australia, England, Ireland, Tanzania, or Singapore even though English is the official language in these countries. Although US citizens growing up in different regions will have diverse accents, references, and customs, they can vote in the same elections. Language is a unifying variable for people growing up in South and Central America; and as we have explored, this is not enough to create a unified identity.

Immigration Status and Identity

An individual’s identity is related to what it looks and feels like to be Latino, which greatly depends on one’s immigration status. The following cases explore the different experiences of two immigrant women.

Sofia came to the United States on a Fulbright scholarship to obtain her masters in linguistics. She fervently studied English since age twelve; she has an accent; there are words she does not understand; sometimes she feels shy but is able to communicate effectively and eloquently. She attended a well-known university in Colombia for her undergraduate degree and was at the top of her class. She came to the United States while the drug-related violence was at its peak, and the nightly news reported on the day’s kidnappings. She, along with most Colombians, lived with some level of constant fear. The opportunities she saw for herself in Colombia were bleak; she searched for other options and applied to a Fulbright scholarship which allowed her to obtain a master’s degree at a university in the United States. As she got off the plane and set foot in Miami, Sofia knew that her student visa would allow her to stay for 2 years. There were people at the university who could help her consider different immigration options to prolong her stay.

As it turns out, while Sofia was studying, she met a fellow student, who was a US citizen. After getting married she had a pathway to citizenship. They started a life in the Midwest and have three children. As the years passed, she reached a point when she had lived in the United States longer than in Colombia. The hardest pieces of her journey are balancing the possibility of a better life for herself and the guilt she feels for being so far away from her family. Immigration may bring great joy and opportunity but comes at a great cost.

In contrast

Mariana came to the United States by crossing the Mexican border. She decided she would make the journey at 21 years of age. She could hardly remember her life before being sexually abused by her father. She thinks the abuse must have started when she was a baby and believes this is why everyone describes her as a “sick baby.” She watched as her father sexually abused her sister, ultimately resulting in her sister birthing three of his children. She grew up in a small town in Mexico and was not allowed to go to school. She takes a deep breath before describing what she did every day, “Yo limpiaba el popo de las vacas,” or “I cleaned the cow’s poop.” She also describes her feet constantly burning: “La tierra era muy caliente, y yo no tenía zapatos,”“The ground was very hot, and I didn’t have any shoes.” There was a school in town, but the supplies were expensive, and her family did not have money to buy them. She was shunned by her peers and their families. They talked behind her back and consistently called her names. When she was 19, she was able to convince her father to allow her travel to a bigger town in Mexico to find work. She told him it would be good for everyone, because she would send money. She is grateful that somehow her father accepted. This was the last time she saw him.

In the big city, she had trouble finding a job and sent very little home. She was hungry. Her father started to pressure her to return. She knew upon her return, the abuse would resume. She had an immense fear of her father impregnating her, which would keep her stuck forever.

Just like Sofia, Mariana looked for the available options, and the only option she saw was crossing the Mexican border into the United States. She knew that life there would not be easy. She had heard countless stories of women being sexually abused on their journey to the United States, of people getting sick and even dying on their way. Yet, anything seemed better than the torture of her own home. She crossed the border with no knowledge of English, limited reading and writing skills in Spanish, and no set plans.

She now has a son and a daughter, and one of her greatest fears is ever having to go back to Mexico. She doesn’t want her children to know their grandfather and fears for her daughter’s safety if she is ever to meet him. Mariana works from 6 a.m. to 4 p.m., making egg rolls in a factory. She lives paycheck to paycheck, and her electricity often gets disconnected, creating repeated crises. When she has money, she sends it to her mother to buy food. She is constantly tired, has a variety of health problems, and yet is eternally grateful to the country that gave her a second chance at life.

Common Themes When Working with Latino Immigrants

Religion and Spirituality

The majority of Latinos in the United States identify themselves as Christian; in their review, Stolley (1997) describes that approximately 90% of Latinos declare themselves as Catholic, and 75% report attending a religious activity weekly (p. 35). Additionally, Latinos have been shown to become more active in religious activities as they age (Stolley 1997). Together, ethnicity and the church serve a role in conserving ethnic customs, language, and solidarity (Calvillo and Bailey 2015). In addition to ascribing to religions such as Catholicism and Protestantism, Santeria and Espiritismo may also be included in the belief systems of some Latino subgroups (Kramer and Lu 2009).

The opinion of the church or the church’s view on mental health and treatment can greatly influence how one seeks treatment. Latino immigrants are more likely to seek counseling or treatment from general health providers or from the church or clergy than from mental health providers, and less than 1 in 20 Latino immigrants receive services from mental health professionals (NAMI 2006).

Mariana told a close friend about crying spells she was experiencing. Her friend encouraged her to pray to God for happiness and relief. When the crying did not cease, Mariana sought counsel from her priest.

It is important to understand the role of religion in mental health for Latinos and incorporate spirituality, clergy, and religious practices in treatment as appropriate. Of course, not all Latinos identify with Christianity in the same way, and their relationship with the church or God should not be assumed but explored as one aspect of the evaluation process. Additionally, forming relationships with pastors, priests, and clergy may be helpful in providing quality services for this community, as well as reaching them.

Somatization

Keyes and Ryff (2003) describe somatization as “the expression of physical symptoms in the absence of a medically explained illness” (p. 1833). As is clear from both Mariana and Sofia’s story, many immigrants come to this country in some way impacted by their experiences of past trauma. Somatic symptoms are common reactions to traumatic experiences across populations. In his book, The Body Keeps the Score, Van der Kolk (2014) describes, “The lives of many trauma survivors come to revolve around bracing against and neutralizing unwanted sensory experiences” (p. 205). Thus, when working with any individual who has experienced trauma, being aware of body sensations and their somatic experience is essential.

There is some evidence to suggest that Latinos may be even more likely to report somatic complaints. Escobar et al. (1987) found that in their sample of 3132 community respondents in Los Angeles, Mexican-American women over the age of 40 reported more somatic symptoms than their non-Hispanic white counterparts. Interestingly, this difference was only present among women. These authors also found lower levels of acculturation to be associated with higher levels of somatization. Their findings provide further support that therapists and physicians need to be aware of the presentation of these symptoms in their clients/patients.

Choice of language (English vs. Spanish) might also play a role in determining the intensity with which symptoms are described. With a sample size of 152 youth (ages five to seventeen) and their parents (majority mothers), Pina and Silverman (2004) compared how Cuban American Latinos, non-Cuban American Latinos, and European American youth meeting DSM-IV (Diagnostic and Statistical Manual, version IV) criteria for an anxiety disorder described their symptoms. Authors found that the results depended on the language in which the youth choose to take the assessment. When the assessment was taken in English, Cuban Americans reported perceiving their somatic symptoms as less distressing than non-Cuban Americans. However, when youth choose to take the assessments in Spanish, non-Cuban Americans reported their symptoms as more distressing than Cuban Americans. Regardless of language choice, Cuban American and European American parents described fewer somatic symptoms in their children than did non-Cuban Latinos. Language choice, and how this affects client’s reports, may be particularly important for clinicians to consider when working with interpreters, as perhaps the nuisance or severity of the perceived intensity of symptoms may be lost in translation.

Whether the presence of somatic symptoms influences an individual’s perception of their need for mental health treatment or prevents people from accessing mental health services were research questions explored by Escobar et al. (2010) and later by Bauer et al. (2012). Escobar et al. (2010) used a sample of 4864 participants who were identified as Latino, Asian, and non-Hispanic white and found that three or more general physical symptoms were associated with both the presence of a psychiatric disorder and service utilization, regardless of ethnicity. However, those identified as white non-Hispanic utilized mental health services at significantly higher rates than Latinos or Asians. Bauer et al. (2012) analyzed data from a National Latino and Asian American (sample size of 2554 Latinos and 2095 Asian Americans) to see if somatic symptoms impacted individual’s perception of need for mental health services. These authors found that for first-generation Latinos, somatic symptoms were associated with both their perception of need of mental health services and their use of these services; this was not the case for third-generation Latinos.

Perhaps the biggest takeaway for clinicians from this research is how necessary it is to pay attention to clients’ perceptions and reports of somatic symptoms, take them seriously, and explore their potential connection to emotional disturbances. Therapists and doctors providing psychoeducation on the physical symptoms commonly presenting with different types of mental health disorders may also be helpful in serving to inform clients, reduce stigma, and even in relieving some anxiety.

Brujeria

One explanation for increased somatic symptoms in some cultures is the understanding of body and mind as connected (Bauer et al. 2012; Maldonado-Duran and Aisenstein 2011); this may also be an explanation for the presence of culture-bound syndromes. The influence of Santeria and other spiritual practices on Catholicism and mainstream Latino culture has created several culture-bound syndromes or illnesses that are a combination of psychiatric and somatic symptoms considered to be a recognizable disease only within a specific society or culture (Maldonado-Duran and Aisenstein 2011). From clients and patients, authors have learned that mental health symptoms may be attributed to having mal de ojo/evil eye (thought to be caused by someone who is jealous sending evil thoughts and energy toward the other person), due to some other form of hexing, witchcraft (brujeria), or ill will. In these cases, individuals are more likely to rely on home remedies, or remedios, to treat symptoms. For example, performing una limpia (cleansing), or rubbing an egg all over one’s body is believed by some to clean one’s energy or body. In addition, first seeking help from a trusted person such as a curandero, or healer, is common (Maldonado-Duran and Aisenstein 2011). It is always important for providers to ask the individual or family what they believe to be the cause of the symptoms (Torres 2015). Feelings of judgment or skepticism could cause a client to decide not to engage or terminate services. A better understanding of cultural beliefs as well as genuine curiosity to learn more can assist the provider in building rapport and creating a multidimensional approach to treatment which considers the client’s belief system.

Providers can also inquire about what types of healing practices have already been pursued. These could include limpias, fasting, prayer, massages by sobadores (from sobar- soothing through touch), wearing certain jewelry (like something with red color or coral beads), completing rituals with certain oils, and herbal preparations and supplements (Kramer and Lu 2009). Being aware of these practices is particularly important with prescribing or discussing the possibility of taking psychotropic medication. Among the more rural Latinos, these are often seen with great suspicion and fear of becoming addicted.

Intimate Partner Violence

Intimate partner violence occurs across cultures, race, ethnicity, and socioeconomic status (Kantor et al. 1994). Although some studies have shown that rates of intimate partner violence within the Latino community are not statistically different than rates within the white non-Hispanic community (Caetano et al. 2004; Kantor et al. 1994), factors such a documentation status, substance abuse, and pregnancy may serve as predictors of intimate partner violence within a Latino community (Van Hightower et al. 2000). Clinicians understanding the context in which intimate partner violence begins for many undocumented clients is important in order to effectively and compassionately work with clients in these situations. Below are two case studies which illustrate important factors to consider when working with undocumented immigrants in violent intimate relationships.

Belen grew up in a small town in Mexico. Her mother suffered from untreated mental illness and as a result physically and verbally abused her daily. Belen never met her father; her mother had many partners, all for a short time. She states that from a young age, she was convinced of her worthlessness, “la vida de los demás hubiera sido mejor si yo no hubiera nacido,” or “others’ lives would have been better if I had not been born.” At age 10, her mother walked into the room where she was being sexually abused by her uncle and subsequently beat her for “letting this happen.” Things only got worse, and by age 16, she was tired and wanted a way out. She met someone, a 30-year-old man, who offered an exit. He would take her out of Mexico and into the United States. No one in Belen’s family objected.

She crossed the border with him and left one prison to enter another. She was not in love with this man, although also describes being unsure of what being in love means. The first night in the United States, he positioned her to have sex, and she did believe it was an option, to stop him. “Eso es lo que tenía que hacer,” she says. “This is what I had to do.”

Belen was searching for an escape from her pain and from the people who hurt her. In this search for escape, she became more vulnerable to falling into the hands of another abuser. The setup is conducive both for beginning the honeymoon period of an abusive relationship and engaging the partner in a power dynamic. This potential partner provides the way out, the salvation, and a glimpse at the possibility of feeling loved and valued. If one’s deepest desire is to escape, and there are no apparent alternatives, how can this opportunity be turned down?

She experiences both physical and sexual abuse from her partner and still describes it as better than what she used to live. She wishes the childhood pages of her life story would have been written differently; she wishes more options for escape would have been possible. Yet, if given the same alternatives, she would still fill the pages of her story with abuse from her husband in the United States rather than more of the abuse she lived in her home country. Belen and her abuser now have four children together.

When it comes to intimate partner violence, the question of why the victim does not leave is always posed. Belen views her options without her husband as dark. She grew up without a father and does not want the same for her children. Although staying with her husband will undoubtedly affect how her children view relationships, she is more afraid of their physical and emotional survival if she leaves their father. She also lacks the belief that other men could be different. To understand her belief system, her therapist asked her how she would respond to her daughter if she told her she was being forced to have sex. Belen said she would tell her, “Que todos los hombres son asi.” “All men are like this.”

She watched her mother suffer constant abuse by men that left her, and Belen’s own history is filled with men who have hurt her. The few friends she has share similar experiences and describe that enduring physical and sexual abuse is their “duty as a wife.” The ending of Belen’s story is yet to be determined, but she is better off than many because she has been able to seek help.

Another client, Josefina, was with her abusive partner for eighteen years, before she ultimately decided to leave for good. In those eighteen years, she left for periods of time, but her electricity would be disconnected, her children would complain that they missed their father, and he would promise her he had changed and that he loved her more than life itself, and so she would return. In the final incident that led to her abuser going to jail, Josefina was able to summon the courage to ask her social worker to accompany her to the police station to file the police report. The social worker was able to help with the language barrier, and Josefina felt that with her social worker present, the police officer would not focus on her documentation status. While her abuser was in jail, he constantly sent her letters both describing how much he loved her and how everything was her fault. After he served his sentence, he once again began stalking her and threatening her current partner. “Nunca me va a dejar en paz. Si lo deportan, él va a empezar a molestar a mi mama en México. Ya me lo ha dicho. Yo no se que le hará a mi mama.” “He will never leave me in peace. If he gets deported, he will start to bother my mom in Mexico. He has already told me he will do this,” Josefina explains.

Providers must express compassion and validation for the reasons clients may now find themselves in an intimate partner relationship, as well as safety plan with clients, respect the client’s right to self-determination, and be careful not to paint an unrealistic picture of what it will be like to leave the relationship. Clients are often in the most danger of death when they choose to leave (Tjaden et al. 2000), and only the woman herself can fully understand the lengths to which their abuser is willing to go to torment (or end) their life. Providers need to be aware that safety planning is a constant process that does not end nor begin when clients leave the relationship. Additionally, conversations with a social service worker may be the first time the client has felt free to entertain the possibility of leaving, as close family members may be telling them the opposite, or excusing the abuser’s violent behavior with comments such as, “O simplemente es un hombre celoso, todos los hombres son asi,” “Oh he’s just a jealous man; all men are like that.” Leaving an abuser is not the same in all contexts, and in an environment where comments like these are all the client hears, it will take more courage and planning to ultimately find a way out, if that is the choice made. Additionally, clinicians in the United States and other countries with mandated reporting laws, as some states, require a hotline is made to children’s division for all families where physical violence is occurring between parents, and other states do not. Including children in safety plans and finding accessible therapeutic services for children are necessary steps in promoting the families’ well-being.

The Impact of Immigration on Children

Forming an Identity

Sofia and Mariana both made the choice to find their way into the United States; both of their choices were centered around the search for more opportunities, escape from danger, and the possibility of a better life. With time, the United States will become part of their identity, part of their every day, and part of how they raise their children. Depending on their interactions in the United States, the color of their skin, English proficiency, accent, education, literacy level, income, and documentation status, they will spend moments, periods, or a lifetime feeling that they do not belong in the United States and yet retain a deep desire to stay.

Children born in the United States to Latino parents also struggle with their identity; they may feel as they fit into what it means to be Latino in the United States but not what Latino means in their parent’s home country. They may be defined as Latino in the United States and as “gringo” or American elsewhere. Even if their parents only speak Spanish in their home, their accent often does not match the accent in their parent’s country of origin. Thus, when in their parent’s home country, they will be asked where they are from. This can be difficult if they feel their parent’s country of origin holds part of their identity. Some children have the experience of being told they speak English well when they are in the United States and that they speak Spanish well when they are in the Spanish-speaking country—as if neither was their language and thus both surprising.

Many undocumented immigrant youths feel stuck between two worlds: two countries, two cultures, two languages. They cannot go back to their home country because they have no resources there but also feel unwanted in the United States, labeled as “illegal” and consequently as criminals. Adolescence is a time of trying to develop one’s identity, and this can be even more difficult for minority adolescents for reasons of language, physical features, and social stereotypes (Spencer and Markstrom-Adams 1990).

In Sofia’s case, her husband is from the United States and speaks Spanish. They speak only Spanish at home so that her children learn Spanish. However, she could have married a man who did not speak Spanish, and in that case, her children might be monolingual. Even with both parents speaking Spanish, teaching children is not easy, and for a multitude of valid reasons, children of Spanish-speaking parents may not learn the language fluently. If parents’ English is limited, this can create communication difficulties within their families. In some families the children have “forgotten Spanish,” and one or both parents only can understand and speak Spanish, creating a barrier between them.

Using “Spanglish” can serve as a way to generate a sense of belonging—two friends who both have parents from Spanish-speaking countries and who grew up in the United States might speak to each other mainly in English but use Spanish words occasionally. They understand each other perfectly and can say whichever word occurs to them first. The ability to communicate in this way can increase their sense of connection. However, the use of Spanglish can also serve to isolate.

Elsa, age 21, a “Dreamer Footnote 1 ” grew up in the United States, and speaks a fluid blend of English and Spanish. She understands both languages, but her spoken thoughts can sound to others like a garbled version of Spanish. After Elsa’s baby’s arrival, she began attending a Spanish language support group. While she understands everything, she has a hard time presenting her thoughts and comments in Spanish. After the group, she explains her appreciation for the information and community but feels “very different from the other ladies.”

The struggles of identity and belonging are not bicultural children’s defining features. They may feel split between two countries, but this can foster a deep understanding of both differences and similarities between humans and countries. As they continue to accept and develop their identity, learning to feel comfortable within different cultures can help them quickly adapt to new situations and have empathy for those with different experiences. They learn and represent that despite many messages to the contrary, first and foremost we are all human. Those who are bilingual are a big part of the solution to improving access to services for the Spanish-speaking Latino population in the United States. For many second-generation immigrant children, there is also a sense of internalized discipline and responsibility to take advantage of the opportunities available to them based on their parents’ immense sacrifices.

Raising Children in the United States

Immigrant parents profoundly desire to instill this sense of discipline and responsibility in their children. Sofia explains, “One of my biggest fears as a mother was that my children would end up being ungrateful. It was my impression that in the United States children were given everything they wanted. That was not my case in Colombia, and I want my children to appreciate the work that goes into everything they have.” Mariana describes how she has spent hours trying to convince her eleven-year-old daughter that she is too young to get her eyebrows waxed or to shave her legs. Her daughter pleads with her because all of her friends are doing these things and boys at school are calling her “a bear” when they see her unshaven legs. To Mariana, these conversations are incredibly foreign; she was concerned about having shoes, not the thickness of her eyebrows. Mariana works to maintain her flexibility, reminding herself that these conversations are proof of the new life she’s created; yet, she feels her daughter is constantly pushing her limits. Martinez et al. (2011) echo Mariana’s comments, as they describe that parent’s attempt to teach their children values from their home countries can be a source of conflict. Children may feel parents do not understand anything about their needs or what it means to grow up in the United States.

Belen’s story provides another example of what it is like to raise children in the United States. Soon after arriving, she became pregnant. A few months after her daughter was born, her husband was deported. She was alone, at seventeen, with a newborn, no documents, unable to speak English, and no idea what to do. She decided to go back to Mexico to be with her husband, her only “protection.” There they stayed until their daughter was two-years-old. Faced with continued abuse from her family, limited food, and the desire for her daughter to have a life different from her own, Belen and her husband crossed the border again. Belen did not think it was safe for her daughter to cross with them and decided to leave her in the care of an aunt. A citizen uncle brought Belen’s daughter to the United states two months later.

Belen described that her daughter wanted nothing to do with her when she arrived in the United States and kept yelling for her aunt. Suárez-Orozco et al. (2011) describe Belen’s daughter’s experience as two different attachments disruptions, one from the parent and the second from the caregiver to which the child attached in the parent’s absence (p. 224). Through tears, Belen describes this as was one of the hardest periods of her life and still feels tremendous guilt for leaving her daughter. She worries this may have caused irreparable damage in their relationship. Belen is one example that others need to leave their children for much longer, potentially causing increased tension in their relationship and attachment trauma for the child. Fathers may leave their children for multiple seasons a year, to work in the United States and send money back home. It is not unusual for children who have been separated from their parents to feel anger toward their parents for leaving them as children and in some cases also taking them away from their current caretakers (Suárez-Orozco et al. 2011).

Marisol was separated from her parents, Adela and Francisco, for much longer than Belen was from her daughter. Marisol’s parents left her with her grandmother when she was nine-years-old and were finally stable enough for her to come to the United States when she was fourteen. Marisol describes being resentful that her parents took her away from her familiar surroundings in Mexico, to a new city where she is not familiar with the culture, language, and has no support system. She struggles to make friends at her school, because she feels very self-conscious about her English-speaking abilities, and finds it easier to keep to herself to avoid potential embarrassment.

Suárez-Orozco et al. (2011) describe that parents’ feelings of guilt over the separation can result in inconsistent discipline and overindulging the child, causing further complicated family dynamics (p. 225). Francisco and Adela report giving Marisol anything she asks for, but despite all their efforts, Marisol does not confide in them, behave, or treat them in the manner they feel she should. Francisco is concerned that her daughter is quickly getting out of their control. Adela often feels frustrated because she tries to model the behavior she wishes to see from Marisol, but this seems to have no effect. Parents may feel they took away from their children the opportunity to be “Latinos” in the country of their origin, with different representations of what a family is, friendship, closeness, and support from extended family members.

Acculturation can be a struggle for immigrant parents and their children, especially if the children acquire behaviors from the new culture that do not fit with the parental culture. Many times “maladaptive” psychological responses are misinterpreted by teachers and parents and the child is dismissed as willfully “mean” or “disrespectful” and punished accordingly, which reinforces the response (Stirling and Amaya-Jackson 2008, p. 670). Children can find themselves in situations where they are misunderstood or their actions misinterpreted due to their developmental experiences.

Impact of Deportation on Families

Belen’s daughter was too young to remember when her father was deported, but she knows this happened. She also knows she was born in the United States and that if her parents were deported, her mother would find someone in the United States to be her legal guardian. She knows her mother wants her to have the opportunities the United States offers; yet, she fears watching her mother being forced to leave and not knowing when she could see her again. She wants her mother present at the moments they have both worked toward (e.g., her high school graduation) and knows if her mother is deported, this will be impossible.

Children born outside of the United States fear their parents’ deportation because they have spent most of their lives in the United States and do not want to leave the only home they know. Many children live with the intrusive devastating images of what it would be like to watch the deportation of their parents.

Unfortunately, classmates might trigger this fear. These comments can be well-intentioned, “I heard on the news last night that Mexicans are being deported. I am really going to miss you,” or can be a form of bullying—kids chanting, “Go back to Mexico.” Either way, these comments hurt deeply and may result in children wanting to stay home to avoid these comments and ensure nothing happens to their parents. This leaves mothers and fathers navigating these difficult conversations. Social workers, mental health professionals, teachers, and health-care providers can help by holding space for parents to discuss their own fears and emotions. In turn, with their own needs met, parents will be more able to provide emotional support to their children in these potentially excruciating conversations.

Improving This Community’s Access to Services

Current Access

Children’s opportunities and development will largely be affected by how well their parents can access services. Sofia does not need to work with interpreters nor does she need to be given documents in Spanish; she has health insurance provided by her place of employment. It is more comfortable for her to speak in Spanish, but every day she spends in the United States, English becomes more natural. She can go to a therapist and describe her emotions in English with relative ease. If there is ever a word or idiom she does not understand, she can ask her husband.

Sofia interacts with many people in the health-care system who do not believe she is a citizen. She is excluded from certain conversations, and by certain people, because of her accent and darker skin color. On some days she is unsure others will ever believe she belongs in the United States. Yet, she will always be able to advocate for herself and for her children. With her income and her husband’s income, she fits comfortably into the middle class. She lives in a white neighborhood, where her children go to an excellent public school. She has mostly white friends. She is not around the Latino community often. She visits Colombia every other year and brings her children. Every time she visits, she feels less like she is at home where she grew up while still missing her family when she is in the United States. Her heart is spread across two subcontinents. These are her challenges. Her challenge will not include external barriers to accessing mental or physical health services.

Unlike Sofia, Mariana knows very little English. Growing up, Mariana worked hard to teach herself how to read and write in Spanish; she learned how to write her name and phonetically sound out other words. She makes many mistakes and feels embarrassed. Mariana experiences more intense stereotyping and discrimination than Sofia because of her educational status, which is consistent with Ortiz and Telles’ (2012) research. With this literacy struggle in her native language, learning English becomes extremely challenging. She works at a factory all day, which is filled with other immigrants, many of whom speak Spanish. She has no English-speaking friends. She comes home from work and takes care of her children. Sometimes they answer her in English, and she understands some of what they say but can only respond in Spanish.

She does not have health insurance. She avoids going to the doctor unless she feels “sick enough,” in which case she goes to a community health clinic, urgent care, or emergency room. She needs interpreters. If she is lucky, the interpreter arrives on time, but more often the interpreter is late or never arrives. The interpreter may be physically present in the room or over the phone. When she has to communicate over the phone, she reports often not being able to hear what the interpreter is saying. She has had interpreters who are professional, speak clearly, remind the doctor to look at her, and interpret everything as it is said. Unfortunately, she has also had interpreters who interject their own opinions, tell her she cannot ask certain things, or shame her after she asks questions. In smaller Latino communities, it is not uncommon that the client has a previous relationship with the interpreter and therefore does not feel comfortable disclosing personal information. To avoid all of these situations, parents often bring a child to interpret. All of this places the child in a parenting role, and can create an imbalance in the structure of authority within the household, and places unnecessary pressure and stress on the child.

As if all of this does not make the appointment hard enough, Mariana is constantly wondering what her rights are as an undocumented woman. She wonders how each person will treat her and is in constant dread of the question that always seems to come: What is your social security number? How will the person ask? What will she say back? How will they respond to her? Negative encounters have kept her away from treatment in the past.

The negative experiences that cause Mariana to avoid medical treatment make it that much more difficult to seek mental health treatment. Mariana would meet criteria for posttraumatic stress disorder. Due to her father’s (and mother’s) treatment of her, she internalized the belief that she was worthless. She wakes up at night with nightmares, her heart beating ferociously, and her entire body sweating. She lives in constant fear of having to go back to Mexico. She is alert to every danger, and she is deeply afraid that someone will sexually abuse her children. Yet, until a few years ago, she never received mental health treatment.

How to Make It Better?

If the interest is truly to provide women like Mariana with better medical and mental health services, many things need to change, including access to health insurance and a path to legal status in the United States. Perhaps easier places to start would be increasing the number of Spanish-speaking providers (both for physical and mental health), more in-depth training for physicians and therapists on how to use interpreters, and more reliable access to highly trained interpreters. Beyond this, it will involve looking around clinics and hospitals and asking the following questions:

Are there any pictures or art on the wall of people who represent this population?

When are clients asked for their social security number, and is it necessary to do so?

Could alternative questions be asked before requesting a social security number that would provide the same information and create less anxiety?

What is the literacy level required to read the brochures or information provided?

Is information provided in the client’s native language? If yes, is this information as easy to access as the English versions?

When the client calls, is anyone available to talk to them in Spanish? If not, is an interpreter available? How will the client know the interpreter is available? Are clients given instructions on how to access the interpreter in a language they understand? Many times, the recorded voice gives the information for a Spanish line in English.

Is adequate time provided for clients to fill out forms, especially if literacy level is low? Is there anyone available to help fill out forms?

If the client is trying to speak English, but has limited English proficiency, how patient is the staff?

What is the policy around using family members, children in particular, as interpreters?

Receiving interpretation for a twenty minute medical appointment is much easier to tolerate and do effectively than the interpretation required for a weekly hour mental health therapy appointment. When necessary, and done effectively, participating in psychotherapy through an interpreter is beneficial and certainly better than no treatment. However, the likelihood of going to a therapist who does not speak Spanish is extremely low for someone who has difficulty advocating for themselves in English, is unsure of who to trust, thinks mental health treatment is only for those who are “crazy,” and has never disclosed past trauma.

Without already having the community’s trust, seeing a flyer for mental health services is unlikely to be effective. Some level of trust needs to be established to decide to begin therapy. Successfully engaging Spanish-speaking, uninsured, and potentially undocumented clients in mental health treatment involves going out into the community and gaining their trust. This could look like having an information table staffed with Spanish-speaking providers, resources, and basic need items stationed at a well-attended Spanish mass. Partnerships with churches can be key because the church is a sanctuary, comfortable, and trusted place for many Latino families. Potential clients who see that the providers really do speak Spanish, are friendly, do not ask for their documentation status, and describe therapy in a way that could apply to them are much more likely to engage with the organization. Not having eligibility criteria in terms of diagnosis is also beneficial for engaging clients. Therapists focusing on the symptoms, behaviors, or situations in the person’s life that would need to change for them to feel better is the best practice for engagement (Dixon et al. 2016). Focusing on diagnosis instead of specifically what the client reports needing can scare clients into thinking they are being labeled as “crazy.” Intentionality about how and when to bring up the topic of taking psychotropic medication is also crucial for continued engagement with this population. Many Latinos have negative beliefs about taking medication and show a preference for psychotherapy over medication (Guarnaccia et al. 2005). Psychoeducation around identifying symptoms of depression, anxiety, and PTSD, as well information on reasons why mental health symptoms develop, may help clients self-identify a need for further support.

Engaging the community requires making treatment accessible, in terms of price, childcare options, and location. In some cases, this means going into their home. Serving this population means answering machines have recordings in Spanish and that every time a monolingual Spanish speaking person calls, there is someone who can answer in Spanish. It means having signs and all resources in Spanish. Offering multiple services through one agency is also advantageous. For example, a few programs in St. Louis offer case management and basic need items, as well as mental health treatment. Many clients come in once because they need diapers, the next time because they need help filling out their food stamp application, and the third time they tell the case manager how they cannot sleep at night. This time the case manager has gained their trust and introduces them to the therapist; a connection is made.

Holding a series of groups covering a variety of topics, from how to enroll children in school to intimate partner violence, is another effective method of getting information into the community and allowing community members to meet services providers without ever having to identify the specific type of help needed. The impact of these groups and presentations cannot be underestimated. Belen obtained treatment because an acquaintance of her’s heard a presentation, in Spanish, about intimate partner violence and mental health and gave Belen the presenter’s number. Belen also knew and trusted the person who coordinates the group series, asked her about the presenter, and when she heard good things, she decided to call; she has now been engaging in therapy for almost 2 years.

When clients engage with a therapist through an interpreter, likely one of two things occurred: (1) the English-speaking therapist presented to this community, effectively used an interpreter in his/her presentation, and showed the community that he/she was willing to make the effort to reach them, or (2) someone who had already gained their trust helped them through the process of connecting with the English-speaking therapist and interpreter. If agencies who do not have Spanish-speaking staff want to increase their impact in this community, forming partnerships with organizations who already have Spanish-speaking staff working with the community would be a good place to begin.

Offering this population access to services is a huge step, but it is not enough. Services must be provided in a way that keeps client engaged. Lack of trust is a barrier to accessing potential services, and it is also a barrier to remaining engaged once beginning treatment. As described by Chang-Muy and Congress (2009), trust can be difficult to establish with immigrants who are unsure of the rules of the new country and who may fear official sites. The authors discuss that it may be necessary for the therapist to disclose more personal information about himself or herself than they would with other clients to help establish that trust. This might also mean that more sessions are provided with this population than would otherwise be necessary, as the therapist holds the container for the client to go at his/her own pace. Beginning a structured treatment protocol such as trauma-focused cognitive behavioral therapy (TF-CBT), or the reprocessing phase of eye movement desensitization and reprocessing (EMDR) therapy, too quickly, before adequate trust and safety is established in the therapist–client relationship might lead to an even greater likelihood of the client leaving treatment than would be the case with other populations. Chang-Muy and Congress (2009) also discuss the notion of shame and guilt with immigrants, especially those who have experienced trauma or violence, and the frequent perception of their life events being in some way deserved or self-created. This may impact the time it takes to disclose all of their experiences, thoughts, or feelings, further highlighting the importance of establishing trust and longevity in the therapeutic relationship.

Other important factors to consider when engaging this population through the course of treatment are establishing clear boundaries around the relationship from the onset. For many clients, this will be the first time they have engaged in therapy or any type of formal service provision; thus, they will not know what to expect. It is up to the therapist to make this clear from the beginning to avoid any potential shame of “doing the wrong thing” later in treatment. For example, providing clear information and rationale around expectations for payment, policies for receiving gifts, interactions if seen in the community, rules around social media, mandated reporting, and what boundaries continue to exist after treatment has completed can avoid much potential future confusion and uncomfortable conversations. Mandated reporting of suspected child abuse and neglect may not be something that exists in the client’s home country, and so this is something providers may need to spend extra time explaining. Additionally, parental behaviors that in the United States would be a reason to make a report to Children’s Division may be the norm in the client’s home country. Having conversations around these differences, explaining how different contexts impact how the method of discipline is perceived by the child, and helping clients to learn how these systems work in the United States are part of the providers job.

All humans deserve access to health services and this population is no different. However, they will not access services that are not developed with their needs in mind. If this country’s health system is to become one that includes this population, practitioners, program directors, and organizations must make a consistent effort to include their voices and perspectives when making decisions. Once these efforts are made and trust is established and maintained, clients will become the agency’s biggest supporters and allies.

Fig. 5.1
An artwork of a man sitting on a chair and reading a book to the infant sitting on his lap.

Role of the Father. (Original artwork by Ana-Marcela Maldonado-Morales)

Full size image