Caring for Families Separated by Changing Immigration Policies and Enforcement: A Cultural Psychiatry Perspective

Although the forced separation of families at the U.S.-Mexico border and the mental health impact on separated children has received recent media attention, the ongoing plight of families within the United States being forcibly separated and the mental health consequences have been largely neglected. The mental health community can play an important role in addressing the psychological and psychiatric needs of children and families undergoing forced separation within the United States. In the wake of changing immigration enforcement and new policies under the current administration, the number of immigration-related arrests has increased by 43%, and the number of arrests of noncriminal immigration violators has increased by 300% (1). In addition, temporary protected status (TPS) for legal residence, which was established in 1990 for persons fleeing natural disasters and political conflicts, has been revoked for 200,000 Salvadorans, 60,000 Hondurans, 2,500 Nicaraguans, and 46,000 Haitians. Protection is also ending for TPS recipients from South Sudan and Nepal. Thousands of Liberians, who were granted TPS in the 1990s during widespread warfare in East Africa and who were subsequently transitioned to deferred enforced departure (DED) status in 2007, have also had their residential status revoked. The administration plans to terminate residential protection for 90% of all TPS and DED recipients by 2019. In addition, the hundreds of thousands of young people formerly protected by the Deferred Action for Childhood Arrivals (DACA) program have lost their status and are now at risk of deportation.

For many families, these changing practices and policies place relatives at risk of forced separation. This is especially the case in mixed-status families that may include a parent with TPS, another parent without legal residential status, and children who may be either DACA recipients or U.S. citizens. Among Salvadoran families with TPS, 192,000 U.S.-born children could legally remain after their parents are deported. In these mixed-status contexts, families face painful decisions about whether to leave their children in the United States when other family members are deported. TPS is being revoked for the countries with the highest homicide rates in the world: Honduras, El Salvador, and Haiti rank first, third, and 12th globally, with murder rates in Honduras and El Salvador 600% greater than the global average (2). Therefore, many adults being deported may prefer that their children or other family members stay behind in the United States.

We are deeply concerned about this forced separation and its impact on the mental health of families, especially the short- and long-term consequences for children. The American Psychiatric Association’s (APA, May 30, 2018) statement about mental health consequences of forced separation at the border is equally applicable to families in the United States who are now being torn apart: “Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder (PTSD). The evidence is clear that this level of trauma also results in serious medical and health consequences for these children and their caregivers.”

Separation from caretakers shatters children’s emotional security and may elicit symptoms associated with stress-related disorders, such as the perception of a foreshortened future and an increased risk of suicide (3,4). In a study of 500 children whose relatives were detained in immigration raids, common acute symptoms included loss of appetite, nightmares, anxiety, anger, withdrawal, speech delay, and behavioral and academic decline (5). In this sample, some of the symptoms abated, but anger, aggression, and withdrawal did not improve over time. A vicious cycle can develop wherein older children who have a detained or deported family member are at risk of substance abuse and disruptive behavioral disorders, which increases risk of engagement with law enforcement and subsequent immigration detention and deportation (3). For caregivers, there may be a sense of hopelessness, demoralization, anxiety, and depression, which may decrease their emotional availability, further jeopardizing children’s sense of safety.

In a study of Latino parents of adolescents affected by the current administration’s policies and practices regarding permanent residency status, TPS, and undocumented status, parents with high levels of psychological distress were five times more likely than parents with low psychological distress to not seek medical care; four times more likely to warn their children to stay away from authority figures; and twice as likely to avoid asking police for help when needed (6). In the study, parents who had been stopped, questioned, or harassed by authorities were eight times more likely than others to have high psychological distress. Similar studies report that families fearing separation are at increased risk of major economic, health, and social difficulties because they are less likely to continue enrollment in Medicaid; the Women, Infants, and Children supplemental nutrition program; food stamp programs; and other social services (7). Although some states and organizations have attempted to address the needs of these families, the advice is often generic and can lead to false assurances among children. For example, in March 2017, the Connecticut governor’s office released the Family Preparedness Plan: Preparing Your Family for Immigration Enforcement (8), recommending that adults discuss potential deportation and separation: “Talk to your children about your plan: Without worrying them, assure your children that they will be taken care of if for some reason you are unable to care for them, even for a short period of time. Let them know who will care for them until you can.”

This recommendation introduces a paradoxical statement: the separation is presented as a plan of the parents when in fact it is experienced as an external imposition. It addresses neither the difficulty in communicating the risk of separation with children nor the mental health implications of forced separation for the family. In contrast, the Center for Law and Social Policy finds that many families affected by the current circumstances resist such empty platitudes to their children: “I don’t feel comfortable saying it’s going to be okay,” explained one caregiver (7).

As health practitioners, we need to address the psychological needs of families experiencing or at risk of forced separation. The following considerations are intended to help mental health care professionals fulfill this role.

Understanding the Origins and Nature of Distress in the Context of Family Separation

Clinicians should clarify which aspects of anticipated or current forced family separation are most distressing. For many families, the emotional toll of ruptured attachments, loss of regular communication, and feeling of isolation may be the most overwhelming. For some families, the economic hardship of losing a family member who is the breadwinner may be the primary concern. For other families, losing extended-family members who provide child care may threaten employment opportunities. Others worry about the safety and security of family members being deported. Rather than making assumptions about how forced separation affects a family, clinicians should explore the range of impacts and how they translate into distress for adults and children in the family.

Work with refugee families supports a strengths-based approach in which therapists identify and reinforce current and past healthy coping strategies. Therapists should consider different effects across developmental ages. For toddlers and preschoolers, attachment issues predominate. In the absence of stable and warm substitute caretakers, they may develop insecure attachments; an attachment disorder; or emotional, behavioral, and cognitive problems interfering with their development (3). School-age children will be very sensitive to the meaning of the separation. They often experience conflicts in their loyalty toward the host society, which they may perceive as responsible for the family separation, and these conflicts may be expressed through anger and acting out. Separation during adolescence may complicate the separation-individuation and identification processes that are primary for this age group. This may lead to parentified and overresponsible positions or to risk taking and boundary crossing (for example, substance abuse and delinquency), which are compounded by the absence of legitimate parental figures.

Understanding Family Structure and the Impact of Separation

Clinicians should understand each family’s structure and how separation or fear of separation affects family roles and responsibilities. From the perspective of policy makers, the definition of family is often limited to nuclear households. The relationship with grandparents, aunts, uncles, and honorific kin (for example, godparents) is often neglected in policies and programs. For example, the Supreme Court upheld Presidential Proclamation No. 9645, restricting travel from Muslim countries, North Korea, and Venezuela, which explicitly defines family as “a spouse, child, or parent” (case-by-case waivers, section ii.D). News media coverage of the travel ban repeatedly reported that in many sociocultural groups, grandparents, aunts, uncles, and other relatives are often the primary caregivers for families affected by this ruling. For most cultures in the United States and around the world, bonds and expectations focus on relationships, affiliations, and practical assistance that extend far beyond the nuclear model of family.

Mental health care professionals need to move beyond this nuclear model for effective care. For example, cultural adaptation of Parent-Child Interaction Therapy for American Indian and Alaska Native families has shown the mental health benefits of child-centric and culture-centric approaches to defining families (9). Clinicians also should identify traditions and rituals that are associated with cultural and family identities. For example, when working with separated families, one priority may be finding ways to symbolically and emotionally engage in events where physical presence would have been expected, such as children’s rituals of passage into adulthood (for example, quinceañeras), marriages, and other milestones that create continuity of family narratives across the life course.

Developing Communication Strategies to Strengthen Family Interaction

Clinicians can have a positive therapeutic impact by considering culturally congruent communication practices for families undergoing forced separation. Communication is crucial to bonding and identity formation in families, communities, and cultural groups. Barriers to communication should be identified, including language issues (for example, the inability to access English-based communication resources among those with limited proficiency) and the terminology used by a family to describe distress. Severed communication is one of the greatest risks of immigration detention and deportation. Family Forever: An Activity Book to Help Latino Children Understand Deportation includes practical advice to plan ahead for risk of deportation through case studies illustrating key themes and coping processes such as writing postcards to deported family members (10).

Lessons learned from children who have incarcerated parents can be useful to health workers helping family members communicate with relatives in immigration detention. Research among children with incarcerated parents has shown that contact with incarcerated parents is associated with better mental health outcomes, especially when it is structured through an intervention that guides family members on how to have effective dialogue (11). A common feature is structured visits, which involve preparation for the visit, support of the child during and after the visit, and activities promoting caregiver coping before, during, and after visits. Children also have better mental health outcomes when the parent providing care and the incarcerated parent have a parenting alliance and communication, which can be fostered through interventions focused on these processes (11).

Preparing for Decisions Regarding Family Separation

Many families migrated to the United States for better educational and quality-of-life opportunities for their children. Thus, when adult members are being deported, they are faced with the question of leaving their children behind in the United States or bringing them to a country where they may never have been and where they are at high risk of violent death. These decisions lead to distress within families that can be discussed with their mental health provider. Addressing sources of distress, definitions of family, communication pathways, and political, legal, and health system resources can help families better address this distressing topic of children’s fate in the process of forced separation. We strongly recommend that these issues be discussed to help families best face this major decision and that caregivers be offered support to address the short- and long-term meaning of the family decision for children and youths.

Conclusions

We have provided general recommendations to guide clinicians working with patients affected by family separation. Mental health problems among separated families can in part be addressed through framing specific pathways of distress, elucidating family structures and roles, strengthening communication practices, linking with legal and economic resources, and facilitating decision making through distress reduction. Mental health professionals can play a role in addressing distress associated with forced family separation and guide collaborative approaches to treatment and services to help families cope with this traumatic experience that is increasingly commonplace in the United States.