Applying an Antiracist Approach to Promoting Health Equity and Psychological Well-Being in Unaccompanied Immigrant Minors

Diversity & Inclusion Statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list.Unaccompanied immigrant minors (UIMs) are a fast-growing demographic in the United States, doubling in population since 2014.1Office of Refugee Resettlement. acf.hhs.gov.https://www.acf.hhs.gov/orr/about/ucs/facts-and-dataDate accessed: August 22, 2022Google Scholar According to the Office of Refugee Resettlement, a UIM is someone under the age of 18 years who enters the United States without lawful status and an accompanying guardian.2Office of Refugee Resettlement. acf.hhs.gov.https://www.acf.hhs.gov/orr/programs/ucs/aboutDate accessed: August 22, 2022Google Scholar Most UIMs in the United States originate from the Central American northern triangle (ie, El Salvador, Guatemala, Honduras), with violence, extreme poverty, and family re-unification as the top 3 reasons for migration.1Office of Refugee Resettlement. acf.hhs.gov.https://www.acf.hhs.gov/orr/about/ucs/facts-and-dataDate accessed: August 22, 2022Google Scholar,3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar Repeated exposure to stressful and/or traumatic events at home, during migration, and upon arrival increases UIMs’ risk for psychological distress and mental disorders.3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar UIMs’ repeated encounters with race-based trauma (eg, racism, discrimination) further heightens this risk.3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar The repercussions of these events are compounded by the fact that UIMs lack the adversity buffering effect that is traditionally associated with the presence of a caregiver.3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar Furthermore, UIMs’ mental health risk is augmented by their interaction with US systems (eg, legal, immigration, child welfare, educational, healthcare) that have policies and practices that are discriminatory, exclusionary, propagate the view of UIMs as racialized threats to society, and fail to consider their developmental context.3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar,4Romero L.A. Unsacred children: the portrayal of unaccompanied immigrant minors as racialized threats.Am Behav Sci. 2022; 66: 1-19https://doi.org/10.1177/0002764222108352Crossref Google Scholar Considering these risks, it is imperative to the well-being and positive development of UIMs that they have access to quality mental health services (MHS). Diversity & Inclusion Statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. However, UIMs’ likelihood of service use is limited because UIMs do not access services via traditional pathways or in traditional clinical settings. Furthermore, conventional approaches to MHS do not offer the sufficient contextualization of mental health concerns needed to effectively address UIMs’ unique mental health needs. Racism and discrimination perpetrated by mental health providers or organizations, whether implicit or explicit, is another deterrent to UIMs’ ability to engage with MHS. Finally, continuity of care is of great concern for UIMs because significant environmental instability makes it difficult for them to engage in long-term MHS. Thus, the combination of high mental health risk, MHS underutilization, and persistent systemic racism aggravates existent mental health disparities among UIMs. To date, efforts to address mental health disparities in historically marginalized populations, including UIMs, have focused primarily on increasing workforce diversity, cultural competence trainings, and culturally adapting evidence-based interventions.5Legha R.K. Miranda J. An anti-racist approach to achieving mental health equity in clinical care.Psychiatr Clin North Am. 2020; 43: 451-469https://doi.org/10.1016/j.psc.2020.05Crossref PubMed Scopus (0) Google Scholar Although these strategies are important for reducing mental health disparities, they do not fully consider the unique environmental, systemic, and structural factors that limit UIMs’ engagement with MHS. An antiracist approach offers guidance for identifying alternative strategies to promoting the mental health of UIMs because it recognizes that (1) health disparities are a manifestation of larger race-based social inequities, and (2) health systems are structured to benefit those with race-based historical power (eg, White, US-born, middle-to-upper class).6Haeny A.M. Holmes S.C. Williams M.T. Applying anti-racism to clinical care and research.JAMA Psychiatry. 2021; 78: 1187-1188https://doi.org/10.1001/jamapsychiatry.2021.2329Crossref PubMed Scopus (5) Google Scholar Applied to mental health practice, an antiracist approach calls clinicians to adjust how they provide MHS so as to be most responsive to patient needs in the context in which they exist.5Legha R.K. Miranda J. An anti-racist approach to achieving mental health equity in clinical care.Psychiatr Clin North Am. 2020; 43: 451-469https://doi.org/10.1016/j.psc.2020.05Crossref PubMed Scopus (0) Google Scholar,6Haeny A.M. Holmes S.C. Williams M.T. Applying anti-racism to clinical care and research.JAMA Psychiatry. 2021; 78: 1187-1188https://doi.org/10.1001/jamapsychiatry.2021.2329Crossref PubMed Scopus (5) Google Scholar To that end, we provide specific antiracist clinical practices that clinicians can use to be maximally effective at promoting the psychological well-being of UIMs. An antiracist approach demands that clinicians push beyond their comfort zone, recognize the unequal distribution of power and privilege between themselves and their patients, and critically examine their positionality with regard that of their patients. This includes evaluating their own beliefs about UIMs, the source of these beliefs, and how these beliefs influence their provision of services. In doing so, clinicians must acknowledge their influence on the lives of UIMs while also centering themselves in the systems that proliferate systemic racism against UIMs. Common blind spots for clinicians in this self-reflection process include assuming UIMs’ experiences of adversity and/or trauma, disregarding their beliefs about immigration processes and pathways to citizenship, failing to contextualize UIMs in development, and neglecting to acknowledge their direct or indirect representation of the aforementioned systems. Clinicians can begin this process by reflecting on their own identity and experiences (eg, race, ethnicity, nativity status, acculturation, clinical training, educational background, preferred language). In undertaking this process, clinicians must also recognize that the demands of other systems may put clinicians in competing dual roles that can have an impact on UIMs’ willingness to engage with services. Clinicians should use the insights gained from this self-reflection process to inform their implementation of the antiracist clinical practices recommended below. Conventional MHS often intervene at the individual level - failing to incorporate broader environmental influences into case conceptualizations and intervention planning. Adopting a systems-level approach to working with UIMs means recognizing the individual, their developmental needs, and their race-based experiences within the larger systems. It limits “blaming” the individual, and recognizes that systems can serve as barriers to MHS use.3Silva M. McQuaid J.M. Rojas Perez O. Paris M. Unaccompanied migrant youth from Central America: challenges and opportunities.Curr Opin Psychol. 2022; 47: 1-6https://doi.org/10.1016/j.copsyc.2022.101415Crossref Scopus (3) Google Scholar Clinicians using this approach should begin by building their structural competence. Structural competence is the clinicians’ ability to see health-related issues as the downstream effects of structural and systematic policies/practices.7Metzl J.M. Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality.Soc Sci Med. 2014; 103: 126-133https://doi.org/10.1016/j.socscimed.2013.06.032Crossref PubMed Scopus (888) Google Scholar In building their structural competence, clinicians should ensure that knowledge gained is relevant to the unique experiences of UIMs and considers the multiple levels of influence described in ecological systems theory. This includes developing an awareness of how UIMs interact with numerous systems, how these systems interact with each other, and the impact of these systems on UIMs’ mental health. A systems-focused approach also calls for clinicians to interact with the systems most relevant to the lives of UIMs via regular, interdisciplinary “team” meetings with pertinent stakeholders (eg, immigration lawyers, teachers, case workers, legal guardians) that are scheduled according to the needs of the patient and the complexity of their case. Transparency and education regarding the purpose of communication is crucial to building partnerships between all parties. Securing access to linguistically appropriate interpreters who use terminology that is familiar to both UIMs and stakeholders is essential to ensuring that everyone involved has the information they need to make appropriately informed decisions. Of note, when working with stakeholders, clinicians should seize opportunities to offer their knowledge of antiracist, best practices as a key step toward dismantling systemic health inequities. Most evidence-based mental health interventions require patients to commit to numerous weekly sessions. As previously mentioned, engaging in long-term MHS can be difficult for UIMs; thus, an antiracist approach calls on clinicians to use a needs-driven, integrative therapy strategy to promote the mental health of UIMs. An exemplar model is the integrated behavioral health model, which emphasizes brief, time-limited interventions that prioritize stabilization, psychoeducation, and the development of coping skills.8Wodarski J.S. The integrated behavioral health service delivery system model.Soc Work Public Health. 2014; 29: 301-317https://doi.org/10.1080/19371918.2011.622243Crossref PubMed Scopus (5) Google Scholar This model steers clinicians away from using one specific therapeutic approach (eg, cognitive−behavioral therapy [CBT], dialectical behavior therapy [DBT]) and instead encourages clinicians to use components from a variety of protocols. Because UIMs demonstrate tremendous resilience despite the adversity they experience, modifying these components to acknowledge and to build on this resilience is necessary.9Mercado A. Venta A. Henderson C. Pimentel N. Trauma and cultural values in the health of recently immigrated families.J Health Psychol. 2021; 26: 728-740https://doi.org/10.1177/1359105319842935Crossref PubMed Scopus (17) Google Scholar For this reason, clinicians must simultaneously challenge their assumptions about UIMs’ capacity for resilience, promote resilience by expanding UIMs’ use of existing adaptive coping strategies, and introduce new culturally and contextually sensitive skills when appropriate. Clinicians can also facilitate UIMs’ resilience by helping them to leverage aspects of their identity (eg, cultural, religious, familial) that remind them of their motivations for migrating and that are a source of pride, hope and/or happiness. Using this resilience-focused approach is crucial to recognizing that clinicians play a vital role in building UIMs’ capacity to endure ongoing system-imposed hardships. Traditional clinical training and insurance-driven health care practices emphasize diagnostically driven MHS. Although UIMs experience high rates of DSM-5 disorders, a common driver of psychological distress among UIMs is the persistent uncertainty that transcends multiple facets of their lives. Albeit not a traditional target of intervention, acknowledging and addressing this uncertainty is crucial to promoting UIMs’ mental health. Clinicians should start by validating and normalizing psychological responses to uncertainty and increasing UIMs’ capacity to cope with uncertainty using the aforementioned resilience-focused strategies. Of note, although maladaptive thoughts related to uncertainty may be present, changed-based therapeutic approaches (eg, CBT) can be invalidating of UIMs’ lived experiences and can undermine UIMs’ confidence in MHS’ ability to provide support and symptom relief. As such, value-based protocols (eg, acceptance and commitment therapy) should be explored as suitable alternatives. Furthermore, although trauma histories are common among UIMs, traumatic experiences often persist across much of UIMs’ lives, and fear of future trauma is common. Although clinicians may be inclined to immediately address UIMs’ trauma histories, clinicians are strongly discouraged from doing so because of their time-limited interactions with UIMs. Similar caution should be exercised when prescribing medications for trauma-related symptoms. Clinicians are instead urged to adopt a trauma-informed (but not trauma-focused) approach to address the psychological distress that often accompanies the high degree of uncertainty that UIMs experience. Although policy change is crucial to making the systemic and sustainable impacts required to eliminate mental health disparities for UIMs, clinicians are well positioned to begin this systematic transformation by developing greater self-awareness and intentionally implementing antiracist practices in each clinical encounter. In doing so, clinicians can begin to make a more immediate impact in reducing mental health inequities as they impact UIMs.