ACKNOWLEDGING SYSTEMIC IMPACTS: Generalized Anxiety Disorder Among DACA-eligible Immigrants

Authored by River Ruiz and Carter Montgomery

University of North Florida

Clinical Mental Health Counseling

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Abstract

In the US, immigration policies have a significant impact on immigrant welfare. Immigrants often experience uncertainty for the future and worry about the difficulties they will face as they arrive and begin their lives in the US. As a consequence, generalized anxiety disorder (GAD), which is a mental illness characterized by extreme and excessive worry, can often develop in these populations. Under Deferred Action for Childhood Arrival (DACA), eligible immigrants are given two-year protection from deportation. While DACA was originally intended to promote the inclusion of eligible undocumented immigrants, without lawful immigration status, DACA-eligible immigrants and DACA-recipients still face a complex state of non-citizenship that offers only temporary relief. Counselors working with DACA-eligible immigrants who have GAD should be aware of these, and other complex layers, that influence these clients’ lives. While not all DACA-eligible immigrants with GAD will choose to seek mental healthcare for a variety of reasons, several resources are available on local, state, and national levels.

Keywords: anxiety, generalized anxiety disorder, undocumented, DACA-eligible immigrants, Deferred Action for Childhood Arrival (DACA), policies

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ACKNOWLEDGING SYSTEMIC IMPACTS: Generalized Anxiety Disorder among DACA-eligible Immigrants

In 2012, immigrants to the United States ages 15–30 who lived in the US for at least five years and met additional education and national/public safety criteria became eligible for Deferred Action for Childhood Arrival (DACA) (U.S. Citizenship and Immigration Services, 2021). DACA is not a method of receiving citizenship or legal permanent residence, but rather a two-year period in which recipients gained renewable protections from deportation, during which they are eligible for a work permit (Getrich, Rapport, Burdette, Ortez-Rivera, & Umanzor, 2019). DACA also provides opportunities for eligible immigrants to apply for driver’s licenses, bank accounts, access to higher education institutions, and more (Getrich et al., 2019; Tatter, 2019). DACA was terminated by the Trump administration in 2017, with later court decisions preserving DACA-eligibility only for those who were DACA-recipients currently or in the past (Batalova, Hanna, & Levesque, 2021). Since then, a 2020 US Supreme Court ruling determined that this recession of DACA was against federal law, and additional federal district court rulings have made it possible for new DACA applications to be accepted (Batalova et al., 2021).

This constant change in policies, which have significant impacts on the rights and lives of immigrants, can lead to increased symptoms of distress and anxiety in DACA-eligible immigrants (Suárez-Orozco & López Hernández, 2020). Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable anxiety or worry about a variety of things, lasting at least 6 months (Suárez-Orozco & López Hernández, 2020). Undocumented immigrants, such as DACA-eligible immigrants, may be more likely to develop GAD due to the extreme worry they may have about these policy changes over which they have no control (Suárez-Orozco & López Hernández, 2020). Unfortunately, the constraint of immigration policies, and sometimes inaccessibility of healthcare for DACA-eligible immigrants, complicate the decision to seek treatment for themselves and their families (Getrich et al., 2019).

State of Research

In 2018, half of all immigrants to the United States were Hispanic/Latinx, and 25% of these immigrants were Mexican (Budiman, Tamir, Mora, & Noe-Bustamante, 2020). The remaining half comprised of 28% Asian-born immigrants, 13% born in Europe, Canada, or other North American countries, and 9% born in another region (Budiman et al., 2020). Among new arrivals to the US, Asians have outnumbered Hispanic/Latinx immigrants since 2009 (Budiman et al., 2020), with the majority of new arrivals today being from China and India (Budiman, 2020). As such, much of the available literature on DACA-eligible immigrants today often focuses on Hispanic/Latinx and Asian immigrants.

Specific Constructs

Several themes are present in research regarding symptoms of GAD in DACA-eligible immigrants. One of the most salient elements in much of the literature was the impact of systems on immigrant health and well-being. The research focused on specific systems (healthcare, education, political, etc.) and how they influenced immigrant welfare (mental health and well-being (MHWB), symptoms of GAD, identity formation, etc.) as constructs in relation to DACA. These constructs were shown to have the potential for both positive and negative effects on DACA-eligible immigrants. Regarding mental health specifically, the research often showed that feelings of anxiety and uncertainty were common in this population.

Counseling Issues

When working with DACA-eligible immigrants, counselors should be mindful of the roles they may play in the systems that impact these clients. The process of immigration can have a significant impact on MHWB. Psychological effects may include culture shock and acculturative stress (Whitehead, Montero Hernandez, & Whitehead, 2020), such as struggling with navigating what may be an entirely new language, healthcare, and education system (Sue & Sue, 2015). Immigrants often also face additional stressors that come with arriving in the US, such as stigma and discrimination by US citizens who hold negative prejudice against immigrants (Sue & Sue, 2015). It is important for counselors to take the immigrant experience into account when working with DACA-eligible clients, so as not to pathologize what is in actuality an appropriate response to their experiences (Pappas, 2020; Sue & Sue, 2015). Additionally, it is important for counselors not to assume that a client’s immigration status is the only reason for their distress (Cadenas, Campos, Minero, & Aguilar, 2020; Sue & Sue, 2015). With this being said, counselors should be mindful that prolonged exposure to such negative experiences can lead to the development of mental health conditions such as GAD (Suárez-Orozco & López Hernández, 2020).

Role of Counselors and Counselor Educators

A 2020 study of counselors-in-training and new counselors showed that when working with DACA-eligible clients, counselors were able to identify areas in which they lacked the necessary knowledge and cultural competence, such as second language skills, migration-related information, and knowledge of resources (Whitehead et al., 2020). The study showed that these counselors wanted to learn more about client experiences to better understand/respond to their clients, while still managing their own vulnerabilities, lack of background training, and vicarious stress(Whitehead et al., 2020). With this in mind, counselor education programs play an important role in training counselors to have confidence in their skills, be more proactive with undocumented immigrants, and stay up to date on immigration policy; while emphasizing self-care and compassion (Whitehead et al., 2020). Learning to engage in coping strategies like self-care and compassion is not only important for counselors’ continuous growth, adaptability, and emotional availability, but also promotes empathy between counselors (Whitehead et al., 2020). Counselors that were aware of the stress associated with working with these clients showed resilience and compassion for clients and other counselors, and wanted to share their own experiences to help their peers deal with these often difficult cases (Whitehead et al., 2020). In addition, counselors who practice self-care can act as models for their immigrant clients (Cadenas et al., 2020).

Diagnostic Profile

Research regarding the prevalence of specific mental health disorders in DACA-eligible immigrants is limited. This is likely influenced by existing barriers many immigrants face when seeking physical and mental healthcare treatment, such as difficulties in communication, lack of knowledge or resources, or cultural factors (Sue & Sue, 2015). Counselors should be aware of this and other significant effects of immigration on one’s mental and/or emotional well-being. Immigrants often struggle with difficult feelings such as isolation, helplessness, anxiety, and depression (Sue & Sue, 2015) and may also worry about facing marginalization and lack of success in their futures (Rosenberg, Robles, Agustín-Méndez, Cathell, & Casasola, 2020). These feelings, in combination with additional life stressors, all have the potential to develop or affect pre-existing symptoms of GAD (Cadenas et al., 2020). DACA-eligible immigrants report both positive and negatives in their immigration experiences. For example, Latinx young adults who were eligible for and received DACA report many benefits, such as increased social integration, a sense of community with their peers, and a decrease in shame about their undocumented status (Siemons, Raymond-Flesh, Auerswald, & Brindis, 2016). At the same time, some reported detrimental psychological effects of DACA, including stress, shame, fearing deportation of loved ones, and self-isolation motivated by low self-esteem from having grown up undocumented (Rosenberg et al., 2020; Siemons et al., 2016). These psychological effects can have a negative impact on MHWB over time.

Epidemiology

Immigration is a heated topic in politics and public discourse. Much of the stress DACA-eligible immigrants face stems from external factors, including immigration policies, politics, and the state of the social climate (Cadenas et al., 2020). It is necessary to evaluate these external factors for possible implications. The macro- and micro-level impacts of changes to immigration policies under the Trump administration have had numerous effects on immigrants, especially those who are DACA-eligible (Raymond-Flesch, 2018; Rosenberg et al., 2020). Among these effects is a marked increase in symptoms of GAD (Cadenas et al., 2020). Other external factors, such as social health determinants, which include finances, food, shelter, education, and healthcare, also affect immigrant MHWB (Cadenas et al., 2020; Chang, 2019; Getrich et al., 2019). The fragile and temporary nature of these social health determinants in the US today provides insight as to why rates of anxiety and stress among this population are high. Compounded with stigmatization, marginalization, fear of deportation, barriers to healthcare, and pressure to assimilate, the two-year relief that DACA provides from deportation worry is not always enough to avoid distress (Getrich et al., 2019; Kuczewski, 2021). Research shows that longer-term, less precarious policies would have fewer negative implications on undocumented immigrants (Pappas, 2020; Raymond-Flesch, 2018; Siemons et al., 2016). A more holistic view is necessary to encapsulate the varying external factors that influence the lives of DACA-eligible immigrants.

Research provides insight on how navigating the federal immigration system can incite anxiety in DACA-eligible immigrants, demonstrating that even though DACA is meant to be inclusionary, it still promotes anxiety and alienation (Lauby, 2018; Raymond-Flesch, 2018). Simply applying for DACA can be equally as anxiety- and fear-inciting as experiences such as realizing the structural limitations intrinsic to their immigration status, racist taunts, and physical/verbal assaults (Rosenberg et al., 2020). With this in mind, uncertainty and ambiguity about the future under DACA (including the threat of deportation or policy change) could lead to avoidance or hesitation to seek healthcare services (Getrich et al., 2019; Sue & Sue, 2015). Within the DACA application process, applicants run into issues such as strict eligibility requirements, having to find and provide their own application assistance, financial issues, processing issues (processing time and lack of communication), and anxiety about the ambiguity and uncertainty of their future with or without DACA (Lauby, 2018). It is also important to note the possible distress that could result from the level of vulnerability required when disclosing personal and familial information throughout the DACA application process (Lauby, 2018). Some DACA-eligible immigrants choose not to seek services for fear of being “outed” as undocumented (Sue & Sue, 2015). This suppression of identity to avoid rejection, discrimination, or deportation, and the realization that they are not given the same benefits as “real” citizens and the unattainability of their life aspirations can be psychologically harmful (Rosenberg et al., 2020). Additionally, some immigrants express that the inherent risk of being vulnerable could be worth less than inclusion in societal processes (Lauby, 2018). The variation in applicants’ experiences regarding these issues, and the potential lack of resources to help alleviate them, highlights the flaws that exist in the implementation of DACA.

Although DACA provides undocumented immigrants with temporary relief, living their lives two years at a time does not provide adequate stability to improve their mental health outcomes. There is a need for more long-standing policies or immigration reform that take a more comprehensive perspective in addressing social determinants of immigrant health (Getrich et al., 2019; Raymond-Flesch, 2018). Many external factors are completely out of the DACA-eligible immigrant’s control, but there has been a movement among those who receive DACA to get involved in politics to help those who do not have the temporary relief that they do. Political engagement demonstrated a lessening effect on some of these issues, including, by inspiring agency and meaning in their lives (Lauby, 2018; Pappas, 2020; Rosenberg et al., 2020). Latinx DACA-recipients demonstrated a high degree of resilience by reframing their struggles into developmental experiences leading to high hopes and positive views of the future, despite the uncertainty and ambiguity they face (Rosenberg et al., 2020).

Role of the Family

When deciding whether or not to apply for DACA, immigrants need to keep not only themselves, but also their families, in mind (Lauby, 2018). Latinx and Hispanic people are often family-oriented, group-centered, and practice familismo, which is characterized by interdependence with, cultural loyalty to, and prioritization of the needs of family and close friends (Sue & Sue, 2015). These collectivist and community values (Cadenas et al., 2020) influence all aspects of DACA-eligible immigrant’s lives and the decisions they make. Some research participants even disclosed allowing their insurance to lapse, losing it, or canceling it to take care of other life changes, including family obligations, work demands, or school schedules (Getrich et al., 2019). Health insurance also varies within families, influenced by the variation in immigration status (Getrich et al., 2019). Many families engaged in collective decision-making around whether or not to visit the doctors to avoid medical bills they could not afford for members who had no insurance or minimal insurance (Getrich et al., 2019).

Statistics of Generalized Anxiety Disorder (GAD) and DACA-eligibility

GAD is seen in about 264 million adults globally, with the majority being female (SingleCare Team, 2021). In both the US and around the world, anxiety is twice is common in females than in males (SingleCare Team, 2021). Additionally, rates of anxiety are likely to be higher among the immigrant population (Siemons et al., 2016). These statistics are reflected dramatically in a study by Suárez-Orozco & López Hernández (2020), in which rates of anxiety were found to be higher for female than male DACA-eligible immigrants, and nearly 4 times higher for female and 7 times higher for male DACA-eligible immigrants than for the general population sample.

Statistics regarding the prevalence of GAD in DACA-eligible immigrants by specific location are limited. Approximately 40 million US adults are affected by an anxiety disorder, with 6.8 million (about 3.1% of the US adult population) suffering from GAD specifically (SingleCare Team, 2021). As of 2018, there are over 44.8 million immigrants living in the United States, or about 13.7% of the population (Budiman, 2020). Of this 13.7%, approximately 1.3 million (or 2.9%) were immediately eligible to receive DACA as of December 2020 (Batalova et al., 2021). In the US, the percent of children diagnosed with adjustment or anxiety disorders during the post-DACA period (2013 to 2015) dropped by about 4.5% (P = 0.037; local linear regression) at the birthdate cutoff where mothers become eligible for DACA (Hainmueller et al., 2017). This reduction, from 7.8% to 3.3%, provides evidence that mothers’ DACA eligibility sharply improves their children’s mental health (Hainmueller et al., 2017).

Florida has the lowest reported rate of mental illness in the US by state (16.03%) (SingleCare Team, 2021), however, in recent times, 32.7% of Florida’s population reported symptoms of GAD (Centers for Disease Control and Prevention, 2021). The 2017 Census showed that about 25,500 DACA recipients (or 4%) live in Florida (Svajlenka, 2019), but an estimate of just under three times that amount (71,000 people) are immediately eligible (Migration Policy Institute, 2021). With an estimate of 4.4% of Florida’s population (957,775 people) living in Duval County in 2019 (US Census Bureau, 2019), based on the statistics for DACA-eligible immigrants living in Florida, we calculated that at least 0.0033% (or about 3,166 DACA-eligible immigrants) live in Duval County. This is a rough estimation extrapolated as if these DACA-eligible immigrants were evenly spread throughout Florida. However, because statistics show that concentrations of DACA-recipients exist in cities (López & Krogstad, 2020), such as Jacksonville (which comprises all of Duval county), this number (0.0033% or 3,166 people) is most likely lower than in what the amount is in actuality.

Evidence-based Treatments

Therapeutic Orientations and Evidence-based Treatments

GAD is responsive to a wide variety of therapeutic orientations and treatments in counseling. Possible evidence-based treatments include acceptance and commitment therapy, cognitive-behavioral therapy, and applied relaxation with behavioral therapy (Jongsma, Peterson, & Bruce, 2014). To apply this to DACA-eligible immigrants, using these with an emphasis on multicultural and culture-specific practices are necessary. Trauma-informed care, narrative therapy, liberation psychology, attention and sensitivity to ACES, and a focus on radical healing and self-care are suggested for working with DACA-eligible immigrants, especially in relation to symptoms of GAD (Cadenas et al.,2020).

DACA-eligible immigrants need more opportunities to access mental health services, insured and otherwise, because DACA itself impacts health on multiple levels (Siemons et al., 2016). By establishing a culturally-relevant therapeutic relationship with DACA-eligible immigrants, counselors can occupy multiple roles, including educator, advocate, and psychoeducation geared toward education and training, employment and financial information, language requirements and strategies for conflicts within the family (Sue & Sue, 2015). The fear associated with seeking mental health services, and the cultural stigma surrounding this, can be alleviated through a transparent, collaborative, flexible, and culture-centered approach (Sue & Sue, 2015). To address the cultural identity of these clients, counselors need to demonstrate cultural competency, incorporate the family, and be cognizant of safety concerns.

Because DACA-eligible immigrants are able to attend higher education institutions, this is an effective setting to provide services and resources to this population. Higher education institutions can use data to know how they can improve mental health outcomes for these students on both the stressor and the protective levels. These students would likely benefit from greater financial assistance and greater social and academic support from both their educational institutions and from their professors (Suárez-Orozco, & López Hernández, 2020). Positive relationships with professors are also seen to have a positive impact on anxiety levels, while positive relationships with peers had no effect (Suárez-Orozco, & López Hernández, 2020). On the other hand, some researchers recommended possible benefits of providing peer-led counseling resources (Siemons et al., 2016). Peer support was shown to have a positive impact on their mental health by creating a sense of community with their peers, thereby increasing support for identity formation and well-being (Siemons et al., 2016).

Data Sources

Quantitative

Suárez-Orozco, C., & López Hernández, G. (2020) used an embedded mixed-methods research design to assess the ways in which various experiences of legal status, stressors, and potentially protective factors affect anxiety levels of undocumented Latinx undergraduates. Quantitative data (3 questions) were analyzed using frequencies, an independent samples t-test, and a four-step hierarchical multiple regression with a sequential approach (Suárez-Orozco & López Hernández, 2020). Qualitative data (2 questions) were analyzed using inductive (reading and coding) and deductive (collapsing codes into the quantitative model) methods (Suárez-Orozco & López Hernández, 2020). The study also compared participants’ self-reported experiences/rates of anxiety on the GAD-7, a Generalized Anxiety Scale, to those of a standardized norm population (Suárez-Orozco & López Hernández, 2020). The GAD-7 was reported to have good reliability (intraclass correlation = 0.83) and validity, with high internal consistency (Cronbach α = .92) (Spitzer, Kroenke, Williams, & Löwe, 2006). This study found several factors which could be used to predict symptoms of GAD, such as the negative impacts of the immigrant experience on school, stigma/social exclusion, financial concerns, and worry about deportations or detainment (Suárez-Orozco & López Hernández, 2020). Of these factors, financial concerns contributed the most to symptoms of GAD (Suárez-Orozco & López Hernández, 2020).

Qualitative

Lauby (2018) investigated the challenges Latinx DACA-eligible (and some non-eligible) immigrants encountered during the application process for DACA. Through 60 semi-structured interviews with this population living in New York City and northern New Jersey metropolitan area, they found variation among applicant experiences (Lauby, 2018). The location of these participants is important as this area is more “immigrant-friendly” than many areas in the US (Lauby, 2018). Much of the research on GAD among DACA-eligible immigrants is qualitative. These studies present with a limitation that respondents may not be entirely truthful, or may hesitate to disclose personal information because of the fear or avoidance of vulnerability. Recruitment with an online survey and direct contact, then snowball sampling was used due to the vulnerability of this population (Lauby, 2018). Using cross-sectional analyses and alternative interpretive perspectives, they also investigated the use of any other resources that may have affected their ability to do the DACA application (Lauby, 2018). This study used questions that explored the challenges of qualification and application requirements for DACA, the type of resources/assistance they had available to them and those they used, their political engagement, financial issues, processing issues, symptoms they experienced during the application process, and their thoughts on the future of DACA (Lauby, 2018). These questions established links between data, including positive/negative contacts and urban/suburban environment, as well as the possible outcomes of status disclosure, educational unavailability, and isolation/alienation (Lauby, 2018). They argued that the detached approach of immigration services regarding DACA and the decentralized method of execution led to an increase in GAD symptoms, which shows that the manner of enactment of a policy can threaten its intended outcome (Lauby, 2018).

Secondary Data Sources

Many resources are available for additional data and information about DACA-eligible immigrants. Migration Policy Institute (Batalova et al., 2021) and Pew Research Center (Budiman, 2020) are both nonpartisan international resources, which provide statistical research and initiatives as well as news and information on immigration and anxiety. National level resources, such as US Census Bureau (US Census Bureau, 2019), Center for American Progress (Svajlenka, 2019), and USCIS (U.S. Citizenship and Immigration Services (USCIS), 2021), provide current and archived statistical data, information, and news pertaining to immigration and anxiety within the US today. Some of these organizations, such as US Census Bureau and Pew Research Center, can also be resources for local (state and county) information (Budiman, 2020; US Census Bureau, 2019).

Resources/Referrals

Community Resources

DACA-eligible immigrants’ MHWB may improve with the help of legal, educational, health, financial, advocacy resources (Cadenas et al., 2020). In Duval County, Project for Healing, a program created by Beyond 90, provides immigrants with counseling and psychiatric services, immigration evaluations, behavioral case and medication management, referrals, and barrier reduction services (Beyond90, 2021). Florida Association of Community Health Centers (FACH) is another resource available specifically for immigrants in Florida which provides a comprehensive list of informational resources and organizations for immigrant health and public charge rules (Florida Association of Community Health Centers, n.d.). On a more national scale, immigrants can utilize resources like Coalition for Immigrant Mental Health (CIMH), which promotes access to mental health services through education, outreach, research, and advocacy, regardless of immigration status (Coalition for Immigrant Mental Health, 2021). It is important for counselors to keep in mind that immigrants, including those who are DACA-eligible and non-eligible, may also choose to seek support within their close social circles of family or friends who can relate to the immigrant experience (Sue & Sue, 2015).

Government Agencies

The Florida Department of Health (FDOH) provides many state-wide and community-specific public health programs and services for Florida residents (Florida Health, 2020). While these resources are not guaranteed to be accessible to all DACA-eligible immigrants, FDOH is a credible source for about services, regulated professions, diseases, and the environment all over Florida, which may be useful for immigrants seeking more information about their communities (Florida Health, 2020).

Non-government agencies

The Immigrant Legal Resource Center (ILRC) is a non-profit resource center comprised of law professionals and community advocates seeking to make government change (Immigrant Legal Resource Center, 2021). The ILRC works with immigrants all over the US and aims to make improvements to immigration law and policy, train and educate legal service providers, and advocate for immigrant rights (Immigrant Legal Resource Center, 2021). This could be a resource for DACA-eligible immigrants seeking to engage in political activism.

Recommended References

Informed Immigrant is a collective of immigrant-serving professionals and allies that provides up-to-date and accessible online resources, information, and guidance for both immigrants and service providers (Informed Immigrant, 2021). Online organizations such as this can play an important role in providing free services and support for both DACA-eligible immigrants and mental health professionals.

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