When I work with immigrants and refugees, I often think of my late aunt Pragna’s words: Human immigration is the basis of human evolution. It is how we evolve as a species. It is how life flows. I was in my early teens at the time and had scarce knowledge of global events, human psychology, or the capacity of our own species’ ability to persecute and consume its own soul. Twenty years later, those words feel heavy, laden with the pain, suffering, blood, and tears of millions who have escaped trauma and persecution. Some for being gay, some escaping the threat of honor killing for loving someone outside of their caste and religion, poverty, quality of life, political unrest, war and genocide.
My work with immigrant and refugee clients has come full circle back to myself. Little did I realize my own privilege of being born into an upper middle class Hindu family in the middle of Mumbai and how disconnected I really was from the challenges in rural India. Despite my own struggle of being a lesbian in India, I woke up to the rude shock of how privileged I was that my family unequivocally had accepted me. Sure, there was plenty of news about honor killings, and persecution of gays in India, but in my mind that happened elsewhere in those villages, far from me. I find it ironic that I have learned so much about my own identity and my own privilege here in Oregon. It would be fair to say I have learned more about India and myself here in Oregon than in India itself. What I have found is that there is a parallel process – while I grapple with the realities of being a woman of color here in Oregon, I also now walk with a new understanding of my own privilege back in India. Both of those realities can co-exist in an integrative fashion. It is true that all our stories – no matter how different – bind us together. Tightly and inexplicably, together. I feel honored to be the holder of the stories my clients have brought to me. I strongly believe that our role as counselors is to bear witness to the human story as a whole.
Almost every sixth adult in the United States is foreign born. Approximately 12 million immigrants are undocumented and approximately 60% have been in the United States for over 10 years (Baker & Rytina 2013). Working with this diverse population presents a unique set of legal, sociopolitical and clinical considerations (Sue & Sue 2016).
From a legal standpoint, laws governing immigration have been unfair. For example, until 1952 only White people were able to gain naturalized citizenship. This law changed in 1965 with credit going to the Civil Rights movement. Another policy called “Controlled Application Review and Resolution Program” (CARRP) makes it legal under certain circumstances (which the ACLU terms as over-broad criteria) to deny or delay citizenship and visas of people from Middle Eastern, Arab and Muslim countries. Some state laws specifically target immigrants, which essentially legalizes racial profiling. With regard to undocumented immigrants and the possible ending of Deferred Action for Childhood Arrivals (DACA), the implications for millions of immigrant families living in the United States are enormous. Adults who have been here since 2 or 3 years of age are facing the possibility of being deported to a home they have never known. The fear in this population is palpable. All of the above would need to be considered as part of the complex clinical landscape.
The role of a therapist while working with this population is somewhat adaptive and multifaceted in nature. The therapist may need to wear different hats. For one, it is important to stay abreast of current affairs and keep a keen eye on new laws that govern the legal status of. Partnering with legal professionals and coordinating client care can also be helpful. Taking the time to understand the current legal status of the individual will help immensely with building a therapeutic alliance so a clear understanding of the fear, anxiety and anticipation can be established. Counselors may find that providing psycho-education, advocacy and knowledge of community resources, such as agencies like Immigrant Refugee Community Organization (IRCO), resources for interpreters, and barriers to or ways of accessing institutional structures such healthcare, education and housing can be extremely helpful.
From a broader clinical standpoint, many immigrants and refugees find that seeking mental health treatment can be anxiety-provoking. What can be easily be misinterpreted by a therapist as noncompliant may be a lack of understanding of the process. Therefore, taking a lot of time to explain the process is key. When using interpreters, it’s important to keep in mind that most are not formally trained in mental health and translations in this context could be rife with bias or distress at hearing the information disclosed. On the other hand, interpreters are often a source of comfort and support for the client, especially with language barriers and feeling understood. Sometimes interpreters are the only constant person clients see since case managers and counselors change (if working in an agency). However, it is still recommended that interpreters are oriented to the nature of the work being done in order to adhere to best practices.
It’s important for therapists to consider that most immigrants come from countries that are collectivist in nature. This means that interdependency is valued over independence. Western capitalistic culture places an increased value on individualism, while collectivist cultures do not. This fundamental difference should be explored as it has far reaching implications for the quality of the therapeutic alliance between therapist and client. Extended family and community play a very important role in the health of many clients and involving family should be considered. In general, the practice of psychotherapy and counseling is primarily a Western philosophy and, therefore, inherently is influenced by Western thought. Having an operational understanding of that could prove beneficial for the counseling process. This area of practice can become rife with value-based conflicts, judgments, assumptions, and biases. Seeking regular supervision and consultation to clarify values-based questions that may come up for a therapist is highly recommended. In addition, many immigrants and refugees come from cultures with more defined gender roles and that is also a clinical consideration to be attended.
There are numerous special considerations for therapists working with refugees that have escaped persecution. The experience of trauma being the foremost. Refugees tend to experience more stress than immigrants due to the nature of their circumstances and the acute threat they experienced which led to them fleeing for their lives. Some may have witnessed their families being murdered or raped, or they themselves may have been beaten and had near death experiences. One of the clients I worked with was threatened to be killed by his own family for marrying outside his caste – a term called honor killing, a practice still active in the more rural parts of India. Another client was tortured and beaten up by corrupt law enforcement for being gay. His family and the police worked in tandem by threatening to kill both him and his partner.
They both escaped India together, but got separated in the jungles of Columbia and now months later, he has not yet seen his partner and does not know if he is alive or dead. Post-Traumatic Stress Disorder (PTSD) is common in this population. However, not all suffer from PTSD and most can adapt well to their new home country given time and support. Complex grief and loss may be experienced due to abrupt separations and loss of their culture and homeland.
Coping with the level of trauma and grief could prove debilitating for some.
Establishing an understanding of the narrative and pre-migration story (Sue & Sue 2016) of the refugee – assessing how their life was before they fled, the circumstances that led up to them fleeing, and where they find themselves now is extremely important. Exploring how they perceive their story is also key to the assessment process. Inquiring about their life in their own country and getting a sense of how they lived, what they did on a daily basis, people they were attached to could prove helpful. For example, one of my clients was extremely close with his mother. His mother had accepted him being gay but was unable to speak up for him against her husband. As such, my client has not spoken to his mother for over a year.
Attachment trauma of such nature should be a part of the assessment as that experience will need to be woven into the larger experience of traumatic grief and loss. The initial process of developing a narrative of a client’s journey from their own homeland to the United States can help them develop a comprehensive view of their own story and landscape they have navigated and will be navigating. Exploring the client’s own understanding from the context of their own culture will likely lend itself to providing culturally competent services.
In our current contentious political environment, visceral fear of immigrants and refugees has at times reached fever pitches. Negative stereotyping has further marginalized an already marginalized population. While the counseling profession has made great strides to become culturally competent as a whole, there is still much work for all of us to do in this area through learning, challenging and overcoming our own assumptions and biases. This area of practice, especially in the Pacific Northwest, is still developmental in nature due to the demographics of the region. Therefore, it is increasingly important that we as a counseling community come together and share our knowledge, ideas and resources and support each other in this complex work.
Kalindi Kapadia, LPC, CADC III blends western as well as contemplative, insight-oriented Buddhist teachings into her work. With over 14 years in the field of mental health and addictions, she’s been fortunate to work with a very diverse population. She maintains a private practice specializing in working with dual diagnosis, LGBTQI, ethnic minorities, immigrants and refugees and people with cultural adjustment issues.