A Guide to Providing Mental Health Services to Immigrants Impacted by Changes to DACA and the COVID-19 Pandemic

Germán A. Cadenas, PhD, Lehigh University College of Education
Liliana Campos, MS, Immigrants Rising and University of San Francisco
Laura P. Minero, MA, UCLA Semel Institute for Neuroscience and Human Behavior
Cheryl Aguilar, LICSW, LCSW-C, Hope Center for Wellness

This guide was written by a group of mental health providers and scholars who identify as immigrants, who are current DACA recipients or formerly undocumented, and who have experience working with DACA recipients through clinical work, community organizing, and academic research. The development of this guide was supported by organizations that advocate for humane immigration policy and provide services to immigrant communities (FWD.us and Immigrants Rising). We recognize that the availability of education and training on immigrant mental health is limited. This guide serves to begin to close that gap. It provides mental health providers who wish to work with DACA recipients, or who are currently providing services to them, with introductory content to develop competencies to work with this community. The guide was reviewed by a group of current DACA recipients who are leaders in immigrant rights, and who provided feedback on the guides’ contents.

Together, we acknowledge that the immigration status of those who are temporarily protected by the Deferred Action for Childhood Arrivals (DACA) program represents a social determinant of health. The temporary and limiting nature of the status poses significant constraints such as lack of access to opportunities, inability to plan for the future, and constant preoccupation with sociopolitical stressors. Furthermore, environmental stressors such as systemic oppression, xenophobic policy changes, past and current trauma, family separations or fear of family separations, uncertainty about the future, may lead to heightened mental health distress and concerns.

Based on clinical experience, we recognize that most commonly reported and observable psychological stressors experienced by many DACA recipients include: grief and loss, depression, anxiety, post traumatic stress disorder (PTSD), complex trauma, adjustment difficulties, and low-self esteem or self-worth. Along with these potential concerns, the strengths, resilience, and resourcefulness of DACA recipients are undeniable and represent protective factors that augment wellbeing. The role of mental health providers is to understand what causes pain and suffering, and to work towards helping clients alleviate these while simultaneously highlighting client’s agency, capacity, and qualities to bring about change and enhanced wellbeing.

Amid a decision by the Supreme Court of the United States that can potentially implicate the future of DACA recipients, stress, fear, and anxiety may be predominant emotions and states among DACA recipients. The COVID-19 pandemic further complicates the mental health experiences of DACA recipients, as they cope with a crisis that adds further uncertainty to their futures. Mental health providers can respond to the distress experienced by DACA recipients. This guide aims to support providers in understanding the multi-layered and ever-changing environmental stressors that hinder DACA recipients’ emotional wellbeing, as well as resources and strategies to help providers deliver effective services to this community.

This guide was written for those providing or planning to provide mental health and human services to individuals who benefit from DACA. This might include but is not limited to: mental health counselors, school and career counselors, social workers, marriage and family therapists, and psychologists, as well as other health providers. The guide is centered on the real-life narratives of undocumented immigrants who are protected by DACA¹, and it was constructed to include educational content that has been found effective in boosting competencies for working with individuals who have undocumented immigration status^{2 3 4}. The guide is also written in a way that is critical of current immigration policy and enforcement, acknowledging that its current practices foster psychological harm⁵. Additionally, this guide is affirming of the social advocacy by individuals who are undocumented and who are protected by DACA⁶.

The guide is meant to be practical and useful in clinical practice, particularly for providers working with immigrants who are impacted by stressors related to the Supreme Court decision on DACA as well as the COVID-19 pandemic. The guide contains 10 steps that providers can take in order to improve their cultural responsiveness and clinical knowledge on supporting individuals who benefit from DACA. Each step in the guide includes introductory information as well as a list of resources for further reading and education. This guide is not exhaustive, nor sufficient in and of itself for developing competencies for working with individuals who benefit from DACA, but it represents a starting point towards clinical responsiveness in providing services to this population. The guide can be shared widely to reach those who may be providing services to individuals who benefit from DACA, but who have not had access to in-depth and specialized training in serving this population.

The guide was written using “people-first” language, thus referring to individuals who benefit from DACA recipients or holders, instead of using other common terms such as DREAMers or DACAmented youth.

What is DACA?

Deferred Action for Childhood Arrivals (DACA) is a type of discretionary administrative relief from deportation, which was enacted in 2012. The purpose of the program is to protect immigrants who arrived in the United States when they were children from deportation and provides the right to work legally in the United States. DACA has helped recipients go to school and purchase a home/vehicle. DACA status expires every two years with the option to renew, providing that all requirements are still met.

On September 5, 2017, the Trump Administration announced that it was terminating the DACA program. In the months following, there were multiple lawsuits filed across the country that challenged the administration’s actions to terminate the program, and federal courts ordered that DACA renewals continue to be accepted and processed while the cases advance through the legal process.

Are DACA and The Dream Act the same thing?

DACA allowed nearly 800,000 recipients⁷ of the program to live and work in the U.S. free from fear of deportation. The DREAM Act was a bipartisan legislation that would allow an estimated two million individuals to better contribute to their families, their community, and society. In June of 2019 the U.S. House of Representatives passed the American Dream and Promise Act (HR 6), vital legislation that would provide an earned pathway to citizenship for more than two million Dreamers and TPS holders. The Senate has yet to bring this legislation to a vote.

How do DACA recipients become citizens?

The DACA program does not provide a pathway for recipients to become U.S. citizens or even legal permanent residents. In fact, there is no legal pathway for these individuals to earn citizenship at all, despite 86 percent of American voters supporting giving DACA recipients pathways to legal status.

DACA at the Supreme Court

On November 12, 2019, the Supreme Court of the United States heard oral arguments on three consolidated Deferred Action for Childhood Arrivals (DACA) cases. The hearing came after the Department of Justice (DOJ) requested to fast-track the three cases that were pending at the lower federal courts (New York, Washington, D.C., and California), leap-frogging the standard legal process in an effort to expedite final review of the matter.

A Decision Can Come Any Day

Now that the Supreme Court heard oral arguments for the DACA case, we are expecting a decision any time between now and June of 2020, when the Supreme Court usually ends its term to break for the summer. A decision could potentially end DACA renewals. We don’t know when exactly the Court will announce its decision or what that decision will be, but for now DACA recipients can continue to submit their renewal filings until a decision occurs. 

What is going to happen to DACA recipients?

On average, about 25,000 new DACA recipients will lose work authorization¹⁰ and protection from deportation each month for two years following an end to renewals. By the time a new presidential term starts in January 2021, more than 252,000 young people will no longer be protected by DACA, with the total climbing to nearly 620,000, the large majority of DACA recipients, by the end of 2021. Congress must take action before thousands more individuals lose their ability to live, work, and contribute to the only country they know.

Mental health providers can begin to prepare to provide services to DACA recipients by becoming familiar with the real-life stories of DACA recipients as they are portrayed in videos, documentaries, blogs, articles, literature and other media ^{11 12 13 14 15}. By doing this, providers can better understand the positive impact that DACA has had in the education, work, health, and overall lives of undocumented immigrants who qualify for the program. These stories can also sensitize clinicians to the stakes of losing the program, and the distress that this may cause on DACA recipients. 

By listening to these stories, mental health providers can prepare for the complexity of psychological experiences that may arise during mental health sessions. These stories may give providers a sense for the themes that may be common to many DACA recipients, including their strengths, resilience, dreams, and challenges. However, it is also important for providers to keep in mind that the story and experience of each DACA recipient is unique. Additionally, the narratives of immigrants can also be powerful tools for developing empathy and improving attitudes about this group. Providers may wish to share these public stories with others who may not have access to them as a systemic intervention to improve attitudes and boost empathy towards immigrants. 

Mental health providers may also consider that not all undocumented immigrants who are protected by DACA are comfortable with sharing their immigration status publicly. Many immigrants may be very vigilant regarding when, how, and to whom they disclose their status, given the risks associated with this. Providers may wish to proceed with caution when assessing clients’ immigration status, and avoid demanding this information in an interrogative manner. Providers would benefit from creating a safe conversation space and building trust and rapport, where clients may disclose their status if comfortable. Lastly, providers may also consider that there may be shame and stigma associated with holding an undocumented or temporary immigration status, and that there may also be pride and empowerment in this. Providers may play a supportive role as DACA recipients navigate these emotions.

The COVID-19 (Coronavirus) pandemic has undoubtedly shocked the world. The healthcare system has been overwhelmed and the economy has suffered extensively. This crisis is having a deep impact on the U.S., with estimates that thousands will die and millions will lose their jobs. Racial and ethnic groups that most DACA recipients belong to are disproportionately impacted by this crisis. Reports show that Black individuals may be contracting and dying from COVID at very high rates¹⁶, that Latinxs are among the hardest hit economically ¹⁷, and that Asians are experiencing increased discrimination¹⁸
. More than 200,000 DACA recipients are essential workers¹⁹, including nearly 30,000 DACA recipient healthcare workers helping communities survive the crisis. These heroes are risking their lives and also living with the incredible stress and uncertainty around the future of DACA. 

DACA recipients may be more hesitant to seek health services and public assistance due of fear that receiving these services may implicate their statuses now or in the future²⁰. Immigrants are also often amongst the most vulnerable workers, counting on few work-based protections to keep their jobs or work remotely. Mixed-status families and individuals who are undocumented have also been excluded from government aid, which adds additional weight and responsibility for DACA recipients to help undocumented family members look for aid and health care. Additionally, the impending DACA decision might further aggravate DACA recipients’ current mental health, adding enhanced fear and worries about their futures. Providers might wish to devote ample session time to explore the intricacies of these intersecting stressors on the lives of DACA recipients. Additionally, providers may become familiar with resources available to immigrants (e.g., undocumented relief funds, pro-bono services)²¹ and with policies guiding tele-health services to reach clients in the time of physical distancing²².                 

The immigration system in the U.S. is complex and multi-faceted, and can be difficult for anyone to navigate. Beginning with the Naturalization Act of 1790, which limited citizenship to free White Europeans only, excluding people who were enslaved, indigenous people, and women. The immigration system has a history of exclusion towards Black people, people of color, queer people, folks of lower social class background, and those unjustly and inappropriately deemed undesirable (e.g., Chinese Exclusion Act). In the present moment, immigrants who are undocumented likely ended up without an immigration status due to being unable to access other pathways to seek lawful status. Those pathways can include employment-based, family based, and humanitarian migration; but each of those options are very strict and require significant financial, educational, and social resources to navigate²³. 

Having a basic understanding of the immigration system may help mental health providers have a sense for the context and systems that DACA recipients are navigating^{24 25} . Providers do not need to be experts on immigration law, but having familiarity with it and understanding the social context regarding perceptions about immigrants can facilitate clinical rapport building²⁶. Furthermore, immigration policies are constantly changing and can also vary from state to state (e.g., in-state tuition, driver’s licenses). Providers may find it helpful to stay updated on policy changes and news. For example, the upcoming Supreme Court decision for DACA may cause anxiety and provoke other feelings for immigrant families. However, it is important to ensure that sources of information are reputable and reliable. Additionally, displaying an understanding for how immigration policy can be discriminatory (e.g., racist, xenophobic, homophobic, transphobic) and violent may open the space for clients to be able to express their emotions related to changing immigration policies. Additionally, knowing that the provider is aware of these policies may alleviate any pressure for DACA recipients to educate the clinician on the policy and contextual stressors impacting their lives. Providers should be careful not to provide legal advice but do actively connect individuals to legal resources (see Step 9 on this guide).

Everyone is inclined to developing attitudes, implicit biases, and beliefs about entire groups of people, including those who hold minority statuses and those who may be culturally different from the dominant mainstream culture. These biases are usually informed by messages that are received from friends, family, co-workers, institutions, politicians, multiple media platforms (e.g., movies, TV, news, music, social media), among others. These biases can be unconscious and sustained by leaving them unchecked and unchallenged. For this reason, it is important for mental health providers to reflect and identify their biases towards immigrants, and to actively challenge these biases with factual information.

In the current moment, there is a significant amount of misinformation about immigrants being disseminated through multiple avenues. These myths can reinforce false stereotypes about immigrants that serve to dehumanize them²⁷. Examples include the myth that “immigrants take American jobs,” or that “immigrants are a drain on welfare and social programs.”²⁸ Providers may benefit from learning factual information about immigrants, such as the many positive benefits that the DACA program has had on them and on the U.S. as a whole^{29 30}. Addressing these biases may help providers reduce incidental microaggressions and increase compassion and positive attitudes towards clients who are undocumented and are protected by DACA. 

A starting point is for providers to identify their thoughts and feelings about immigrants. Useful questions to reflect upon include: What do I know about immigrants (the facts)? What perceptions and beliefs do I have about immigrants? How did I develop those perceptions? What emotions come up as I think about my perceptions towards immigrants (fear, sadness, guilt, anger)? If providers find this exercise to evoke intense feelings and emotions that you are not able to process yourself, seek support from a professional or seek supervision.

In the past couple of decades, research documenting the psychological experiences of immigrants has significantly grown³¹. This research, as well as clinical experiences in service delivery and theoretical work have informed the creation of new models and recommendations for mental health practice with immigrants³². The American Psychological Association (APA) has gathered a number of resources that summarize the extant research, and that provide recommendations for practice with immigrants³³. The National Latinx Psychological Association (NLPA) developed guidelines for working with undocumented minors as well as for working with detention centers³⁴. The California Psychological Association (CPA) developed the first set of recommendations for mental health practice with undocumented immigrants³⁵. 

Common threads among these guidelines and recommendations include: attention to the way that immigrants’ psychological experiences are shaped by social and contextual factors, being victims of discrimination and multiple forms of trauma, and challenges related to immigrants’ situations pre-migration, during migration, and post-migration. These guidelines and recommendations also stress that mental health practice with immigrants is enriched by using intersectional, ecological, social justice, and critical frameworks, such as liberation psychology. Providers may find it beneficial to review these resources, guidelines, and recommendations, and integrate them into their preferred way of mental health practice. Additionally, there are several effective interventions when working with immigrants, such as increasing clients’ moment to moment awareness and focus using mindfulness, infusing cognitive behavioral therapy (CBT) with cultural adaptations, and fostering a sense of safety by helping clients create safety plans that anticipate their worst case scenarios.

Research and psychological practice with immigrants and immigrants without lawful status have documented that experiences with multiple forms of trauma can be common with this population. Difficulties related to the way they are received and treated post-migration, due to cultural differences once in the U.S., may further complicate their psychological experiences and functioning. For this reason, providers working with undocumented immigrants are recommended to integrate trauma-informed approaches and multicultural competence in their practice. Trauma informed services or trauma-informed care (TIC) involves practicing with sensitivity to the experiences of trauma in clients’ backgrounds, and to foster resilience and healing from trauma³⁶. This approach has been championed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Council for Behavioral Health³⁷. Part of providing trauma-informed services includes sensitivity to adverse childhood experiences (ACEs) and understanding their long-lasting impact. It is important to not assume that immigrant clients’ status or that of their family members’ is a primary stressor for them, and to do thorough assessments of stressors and prior and ongoing trauma that may inform their presenting concerns. Providers may wish to familiarize themselves with techniques that use trauma-informed approaches with immigrant populations³⁸, and seek training in evidenced practices proven effective processing trauma and complex trauma such as EMDR and Somatic Experiencing.

Providers may also develop competencies in multiculturalism and social justice in order to provide services in a way that is culturally humble and responsive to cultural strengths^{39 40}. This includes forming egalitarian therapeutic relationships, seeing client’s culture as strengths, displaying an awareness that clients are the experts of their own experiences, engaging in learning about client’s cultural heritage, understanding the role of power and privilege in therapy, and practicing in a way that includes advocacy with and on behalf of clients with undocumented status when needed.

DACA has allowed beneficiaries to better cope with daily immigration related stressors such as fear of deportation, uncertainty about the future, financial burdens, and family separation. The level of psychological stress related to the uncertainty of DACA’s future can be chronic, especially when this threat is constant and creates fear about the loss of employment, financial security, access to higher education, and health care. Mental health providers can strive to understand how DACA recipients cope with this chronic stress, such as by displaying strong cognitive flexibility in their ability to negotiate multi-tiered possible outcomes when navigating racial and discriminatory situations intersecting with their immigration status. Their unapologetic political advocacy and activism are action-based and solution-focused efforts that may also result in burn out, fatigue, and hopelessness. Providers may also support DACA recipients in developing new coping strategies⁴¹.

Meditation can be incorporated in therapy to explore social change and to foster self-regulation and self-compassion. When incorporating meditation, providers may draw from historical political activists who used meditative practices as a self-regulation practice. In addition, it is important that providers normalize clients’ experiences. Oftentimes, clients may feel as if “there is something wrong” with them. Their cognitive, emotional and behavioral responses are a normal reaction to the environment in which they live in and how they perceive their experiences to affect them. Psychoeducation can also be central in this work, and in this context it means helping the client understand their experience by naming the psychological response being activated during this time (for example: fight, flight, freeze response, grief and loss), by naming and acknowledging the symptoms and mental health distress they may be experiencing. As a subsequent step, providers may support clients in processing emotions and utilizing adequate therapeutic skills (providing guidance on how to verbalize emotions, identify emotions stored somatically or as sensations, providing validation and empathic, mindful and reflective listening, reflection, etc)^{42 43}.

Wisdom is characterized as having good decision-making judgement through the integration of knowledge and experience. Resilience is defined as having the capacity to cope with adversity or stressful situations. The individual and collective wisdom and resilience that undocumented individuals demonstrate⁴⁴, in spite of the constant levels of uncertainty faced in their daily lives, are key protective factors that need to be celebrated and reinforced. It is important to celebrate the factors that contribute to the unique resilience of undocumented individuals, while also addressing the psychological effects of contextual stressors that often put the nervous system is distress. Highlighting the resilience and coping strategies among DACA recipients should not invalidate the need for social change nor suggest that undocumented individuals adapt to stressful and oppressive environments without experiencing psychological distress, or that they accept racism, discrimination, and other forms of social oppression.

Western mental health fields (i.e., psychology, social work, counseling) are beginning to incorporate ancestral wisdom into clinical practice as this reflects culturally sensitive practice. Mental health providers can integrate ancestral wisdom and cultural humility into your practice and therapy sessions by reflecting on the Eurocentric implications of the therapeutic modalities and interventions you are integrating in session^{45 46}. Drawing from liberation psychology and narrative therapy, which are collaborative and egalitarian forms of therapy, providers can create opportunities to explore clients’ identities and values, which contribute to their wisdom and resilience. Many undocumented individuals may struggle with forms of care that seem individualistic, especially if collectivistic and communal values have been highly reinforced in their families or communities. Providers may consider facilitating the tree of life exercise⁴⁷ which uses a visual metaphor of a tree representing various aspects of the person’s past, present, future. This exercise is trauma-focused and combines identity exploration and story-telling by encouraging individuals to explore their resilience and wisdom by reflecting on their identity as well as that of their community.

Considering the multiple challenges, oppression and marginalization that immigrants face in the United States, clients may benefit from being connected to legal^{48 49}, educational^{50 51 52}, health, financial, and advocacy resources⁵³ that may not be immediately available to them or their family members. DACA recipients may worry about the well-being and health of their undocumented family members. Consequently, even if DACA recipients have access to certain resources, their family members may not. Thus, providers may play a pivotal role in providing information about resources and advocating for DACA recipients to be able to access these. Providers may also consider the potential that clients may hold negative views related to receiving help and support services. 

Having a general knowledge of the kinds of barriers that exist for immigrant and mixed-status families may help inform the kinds of resources that may be useful for a provider’s immigrant clients. This may also relieve some of the pressure that clients might feel to fulfill these needs on their own. However, it is important that assumptions are not made, that providers inquire with curiosity, and offer resources without any expectations and without over-imposing their own preferences. Providers may mindfully listen to clients’ needs and pay attention to opportunities to suggest a resource, such as when a client shares about a challenge being experienced. Providers can simply ask if a particular resource would be helpful and provide it according to the client’s needs. Providers also want to ensure that the resource is reputable and that clients are eligible for services based on their status.

Providers may work towards learning about other mental health resources in their area in case they need to refer a client out or refer their family members. There are emerging services outside of traditional settings such as schools, churches, and online services at low cost for people who are uninsured through services such as Open Path Collective and Latinx Therapy⁵⁴. Lastly, providers may wish to become familiar with crisis support hotlines to clients for crisis support between sessions. 

Mental health licensing and professional boards call on providers to operate from a place of competence and to seek ongoing support and consultation when needed. For mental health providers this means ongoing self-evaluation to determine when they need to enhance their skills or consult and process with other experts. As a starting point, identify other colleagues in the clinical space who are also working with DACA recipients or immigrants who can provide consultation or short-term/long-term supervision. In addition, providers can identify professional networks that specialize in working with the population they are working with, and that can provide peer support training and a sense of community⁵⁵. As part of providers’ continuing educational licensing renewals requirement, they may attend training and conferences focused on immigration, culture, or diversity. 

The mental health work that providers do is essential to the growth and healing of the individuals and communities they serve. This work requires providers to engage in self-care as well as radical healing that addresses collective trauma and systemic inequities^{56 57}. Mental health professional institutions call on providers to tend to their own impairment as an ethical practice. To provide the best care for themselves and their clients, and to prevent and manage vicarious trauma, compassion fatigue and burnout, providers must practice personal and professional self-care ongoingly. As part of provider’s mental health work with immigrants, DACA recipients and all clients, they would benefit from making self-care a central part of their practice. Hence, providers can serve as models for wellness.

Germán A. Cadenas, Ph.D. is an Assistant Professor of Counseling Psychology at Lehigh University’s College of Education. His academic research focuses on the psychology of undocumented immigrants and underrepresented minorities, particularly their critical consciousness development as they seek educational equity, career development, and wellbeing, as well as on strategies for training mental health providers and educators to serve the immigrant community. He received his PhD from Arizona State University and completed a doctoral internship and postdoctoral fellowship at the University of California Berkeley. He currently leads an immigration collaborative project across several Divisions of the American Psychological Association, and chairs the Immigration Special Task Group with the Society of Counseling Psychology and the Society of Peace, Conflict, and Violence. He is an immigrant from Venezuela and is formerly undocumented, with a background in community organizing and advocacy at the local, state, and national levels. 

Liliana Campos, M.S. Liliana was born in Mexico City and crossed the border to the U.S. with her family at the age of seven. She grew up undocumented until obtaining LPR status through a U-Visa in 2018. Liliana is a doctoral candidate in Clinical Psychology at the University of San Francisco (USF). Her clinical and research interests are grounded in community organizing and activism from a liberation psychology lens: she seeks to understand how social, political, physical, and psychological consciousness can strengthen the existing resilience of historically oppressed communities by creating and nurturing empowering, radical, and liberating narratives. Liliana is a Mental Health Advocate for Immigrants Rising’s Mental Health Connector program, a probono matching mental health program for undocumented young people.

Laura Patricia Minero, M.A. Laura is a doctoral candidate in the Counseling Psychology department at University of Wisconsin-Madison and Ford Dissertation Fellow. As an undocumented, queer, muxer of color, advocate and social justice researcher, Laura examines how policy impacts the lived experiences of undocumented immigrant and LGBTQ+ communities to identify how to better-serve these populations through more inclusive implementation of policy and distribution of services. Laura worked on national, consensus scientific studies that were utilized to influence and inform policy as a 2019 Christine Mirzayan Science Policy and Technology Fellow with the National Academies of Sciences, Engineering, and Medicine. She weaves her interest in reforming policies and creating inclusive and equitable systems and environments into her provision of trauma-informed, affirming, and evidenced-based clinical care as a current Stress, Trauma and Resilience clinical intern at UCLA’s Semel Institute for Neuroscience and Human Behavior.

Cheryl Aguilar, LICSW, LCSW-C, a licensed independent clinical social worker, is founding director and lead therapist at Hope Center for Wellness, a Washington, DC based multicultural behavioral health practice focused on holistic healing. She specializes in working with immigrants and refugees and has designed, and implemented several culturally competent groups including Emociones y Política, a support group and workshop for immigrants facing anxiety due to the political climate. She co-launched the first TeleMental Health program for Spanish speaking Latinos in Washington, DC. Cheryl combines her passion for micro, mezzo and macro work advocating for the communities she serves. She founded and co-leads Social Workers United for Immigration, a network of social workers committed to the wellbeing of immigrants and advancement of immigrant rights. She serves as committee member of the National Association of Social Workers’ mental health specialty practice, as board member of the Congressional Research Institute for Social Work Policy and as advisory board member for WETA’s Well Beings/Mental Health project. Raised in New Jersey, Cheryl migrated from Honduras as a teen. Her immigration experience has shaped her mission to uplift communities, give back and empower others to reach their full potential.