Attfances tn Nursitif- SiifnceVol. i«. No. 5, pp. 24O-2'il© 2(H)5 Lippimoii Williams S Wilkins. Inc.

Mental Health of UndocumentedMexican ImmigrantsA Review of the Literature

Margaret M. Sullivan, FNP, MSN; Roberta Rehm, PhD, RN

The Latino population in the United States, the majority of whom are Mexican, is one ot thefastest growing. Similarly, the niimht r ol undocumeiUcd Mexican immigrants (lIMIs) contin-ues to swell. However, little is known about UMIs livinj- in the United States, and much lessis known ahout their mental health status. This interdisciplinary review of the iiteniture aimsto outline the eurrent state of knowledj^e regarding the mental health of tJMIs in the UnitedStates. Themes isolated from the literature include failure to sueeeed in the country of origin:dangerous horder crossings; limited resources: restricted mobility; marginalization/isolation;blame/stigmatization and guilt/shame; vulnerability/exploitability; fcar/fear-based behaviors;and stress, depression, and health implications. Key words: illegat immigrant. Latino, men-tal health, undocumented Mexican immigrant

PURPOSE

Mexicans have a lon^ ant! historical pres-ence in what is now the United States, pre-dating the vast majority of ancestors of US cit-i7.cns. Tlic 2()()()-milc long US-Mexico borderwas delineated hy governmental acts in 1848and 1853, and initiated today's constructs of"legal" and illegal personhood. Mexicans "W-legally • cross this border or overstay immigra-tion visas despite risks of border patrol, detec-tion in the United States, and separation fromfamily, primarily for ecotiomic purposes.' Yet,very rarely are the psychological implicationsof illegal" identity considered.

Research has suggested that undocu-mented Mexican immigrants (UMIs) havedistinct characteristics compared to eithertheir documented or Mexican Americancounterparts.-"^ As a result, these dilferences

FfYJWj thf Ptcuined tkirvnthuod Golden Gate. .SunI'rancisai. Calif (Ms .Sulliran): und the pof Family Health Can- Stirsing. Vtiirersity ofCalifornia - San lYumisco (Dr Rehm).

author Mar}>atet M. Snltivan. h'.\'P. MSKC/O A. Atfurado. 2200 Adetine .SI, Suite 2^5, (kiktand.CA 94607 (e-mail: ctiniLmaggie@hotmait.iom).

240

can relegate UMIs to a "second class" statusor a "pariah" group.^"'""* This stigmatiza-tion raises questions ahout the effects ofliving under such stress. In the wake ofacknowledging that health disparities arerelated to race and ethnicity,"̂ "̂ additionalquestions arise. Ihese include the following:Is documentation status related to mentalhealth, and, if so, why and how? Is "un-documentedness" a higher-risk category incomparison to documented imtnigrants? andShould documentation status be consideredin the assessment of health? Tliis literaturereview aims to appraise evidence about themental health of UMIs living in the UnitedStates and to begin to consider answers to theabove questions in light of existing research.The review also aims to assist clinicians andscholars in nursing to better understand themental health status, needs, and challengesof UMIs.

INTRODUCTION

In professional literature, the fields of men-tal health and undocumented Mexican immi-gration rarely converge. Research in the for-mer generally excludes any formal discussion

Mental Health of Undocumented Mexican Immigrants 241

of legal status, while research in the lat-ter is typically addressed by disciplines ofanthropology, sociology, public polic-y, andeconomics, where the focus is seldom onhealth. As a result, it remains largely un-known if documentation status plays a rolein the determination of Mexican immigrants"mental health. The studies that have beenconducted on IJMIs demonstrate thai theyare a distinct population unto them.selves, ora "class within a class." '̂i'̂ '̂ "* For example,compared lo their documented counterparts,UMIs are pervasively affected by exploita-tion and vulnerability'"''; physical, mental,and emotional hardships'"; lower and uncer-tain wages, lower employment status, fewerkinship networks, less English proficiency,less education, and poorer housing" " ' ' ; lesshealth insurance coverage, access to care, andquality of care\ a fear of deportation that pre-vents some from seeking medical care' '^•'^;and the leading of "secret lives. "̂ - '•*^^^'' How-ever, despite their unique profile and differ-ent set of stressors, UMIs are rarely specificallyidentified or addressed in the mental healthliterature.

The primary reason for the paueity ofmental health data specific to the undocu-mented population is the difficulty of eth-ically soliciting such sensitive information.Some researchers avoid studying this popu-lation entirely, because they presume UMIswill he reluctant to give answers that mayresult in self and/or family incriminationand persecution.^ ' ' Related barriers to gen-erating; research are the uncertainty ahoutcensus data, general lack of informationabout the population, and mistrust of the re-search process.'''' ' As a result, the physicaland mental health consequenees of undocu-mented migration have not been systemati-cally studied."'

Despite these barriers, there have beenstudies published about other health topicswith UMIs as participants.'^" '^'"•'"'"-" In ad-dition, a few researchers have successfully as-sessed the stress associated with being undoc-umented without directly asking about legalimmigration status.^'"^* Therefore, it follows

that mental health research on UMIs is indeedpt)ssible. However, because of the ethical im-plications and concerns raised in conductingresearch with an tmdocumented population,researchers must pay particular attention tosampling methods and participant protection.

The health status of Mexican Americansin general reflects their laek of health insur-ance and poor linkage to programs designedto serve them."' Although they die of heartdisease and cancer at rates comparable to theoverall US population, they have higher mor-tality rates from diabetes, homicide, chronicliver disease, and human immunodeficiencyvirus infection than the general population."^Moreover, Mexican Americans are dispropor-tionately affected by 2 additional risk fac-tors linked to negative health outcomes bythe Surgeon General: low educational attain-ment (S0% of Mexican Americans 25 years ofage and older have not graduated from highschool), and the lowest per capita income ofany minority' group (27% of Mexican Ameri-cans live in poverty).^' Significantly, for eacli ofthese statistics, Mexican-born immigrants fareworse than their US-born counterparts.'' "̂ '̂ '̂ 'However, despite these statistics, foreign-born Latinos exhibit a better overall healthprofile than their US-born counterparts.-' Forexample, though epidemiological data arelacking for the mental health of UMIs, it isestimated that foreign-born Mexican Ameri-cans have both lower rates and lower risk ofpsychiatric disorders than US-born MexicanAmericans.-" Researchers suggest this to betlie result of selective niigratit)n, more favor-able health behaviors, and the protective tac-tors of strong family and cultural ties.̂ *^""-̂ ^Furthermore, it appears that the longer Latinoimmigrants reside in the United States and themore acctilturated they hecome, the greaterthe risk of negative health t)utcomes."'^''This is thought to be due to the decreasein their protective factors over time, as wellas the effects of long-term poverty and "thestress associated with the continual processof integration into U.S. society."'""''^'^' In ad-dition, the Surgeon General reports discrim-ination to he a contributing factor to adverse

242 ADVANCES IN NURSING SCIENCE^ULY-SEPTEMBER 2003

health outcomes."^ Thirty percent of Latinos inCalifornia reported they, a family member, ora close friend had experienced discriminationduring the last 5 years because of their racialor ethnic background.•^'' Tbese stresses are es-pecially pertinent to the mental health sta-tus of UMIs and merit inquiry. As Hall et al'''claim, the future of the nursing profession de-pends on its ability to reach out to diversecommunities and meet the healthcare needsof tbe most vulnerable.

IMPUCATIONS AND SIGNIFICANCE

In 2000, the US Latino population num-bered more than 35 million (13% of the to-tal US population), an increase of nearly 58%since 1990.^" In 2001, tbe US Census Bureaufound that more than 7%. of the nation's to-tal Hispanic population identified as Mexican,greater tban any other Latin American coun-try outside of Mexico.̂ ** As of March 2005,the Pew Hispanic Center (PHC) estimatedthat nearly 11 million undocumented immi-grants live in tbe United States, 6 million ofwbom are from Mexico. '̂̂ In fact, the PHC es-timates 80% to 85% of migration from Mexicois undocumented.^*' Sixty-eight percent of tbenation s undocumented immigrants live in 8states (in decreasing order: California, Texas,Florida, New York, Arizona, Illinois, NewJersey, and North Carolina).^''

Latinos are less likely to have health in-surance than any other race/ethnicity.^ Fur-thermore, lack of insurance is a predictorof not seeking healthcare.^" Consequently,Mexican Americans are believed to bave manyunmet bealthcare needs. ̂ ' Additional barri-ers to outpatient bealth services are lan-guage, lack of knowledge regarding availableservices, and fear regarding legal status.'^^^^Cultural barriers to mental bealth servicesinclude somatization of psychiatric distress,versus a more typical clinical presentation ofaffective symptoms,^^ as well as perceivedstigma and differences in illness perception.^^As a result of tbese barriers, Mexican immi-grants in general are underserved by health-

care resources, especially mental healthcare,and underrepresented in healthcare research.

Tlie area of mental health is the sixthof 10 leading health indicators identified byHealthy People 2010.^^ Mental illnesses af-fect an estimated 20% of the US populationin a given year, depression being the mostcommoti. '"̂ Depression can be incapacitating,rendering individuals unable to fulfill daily re-sponsibilities. It is also associated witb othermedical conditions, anxiety, eating disorders,and use of alcohol and illicit drugs. ̂ "̂ For thesereasons, the Surgeon General has urged theprevention, identification, and treatment ofmental illness. Despite tbis priority, little isknown regarding specific effects of documen-tation status on psychological distress, and nocurrent figures on the incidence of specificpsychiatric disorders are available for UMIs.

PROCEDURE

Criteria for the publications reviewed intbis article (Table 1) include tbe following:(1) a .specific focus and/or discussion ofthe immigration documentation status ofcommunity-dwelling (neither detained norunder order of deportation) adult Mexi-can immigrants living in tbe United States;(2) articles specific to mental health fromthe disciplines of medicine, nursing, anthr(^pology, public health/policy, and psychology;(3) research published since 1980; (4) peer-reviewed articles or dissertations.

The databases PubMed, CINAHL, andPsycINFO were searched for the terms Mex-ican Americans, Mexicans, mental health,emigration and immigration, depression.,psychiatric illness, undocumented, immi-grants, illegal, and Hispanics.

LITERATURE REVIEW

Definition of terms

Many studies do not offer operational defi-nitions of key terms, which results in the useof multiple descriptors of this population. Inthis article, Mexican American and Mexican

Mental Healtb of Undocumented Mexican Immigrants 243

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246 ADVANCES IN NURSING SCIENCE/JULY-SEPTEMBER 2005

will be used whenever possible; however,when data are not specific, Latino will beused instead. Alien refers to a noncitizen oftbe United States residing in this country. Thisincludes foreign nationals (ie, Mexican citi-zens) with Green Cards, or Permanent Resi-dent Visas.̂ '̂ Illegal aliens lack US citizenshipand reside in the United States without hav-ing followed established immigration proce-dures. However, this term is imprecise andunofficial as legal status can only be deter-mined by an immigration judge." *̂* Undoc-umented may either focus on tbe lack of writ-ten proof of identity (driver's license, ID card,birth certificate) or immigration documenta-tion (asylee/refugee status, Green Card, tem-porary visas). Labels sucb as Mexican Ameri-can and Mexican immigrant, both frequentlyused in the health and mental healtb litera-ture, are not specific about documentationstatus or citizensbip. Immigration status andmigrant status cannot be used to imply doc-umentation status as tbey are sometimes usedin the iiterature to indicate whether a personhas ever immigrated to the United States. Nei-ther can they be used to imply immigrationdocumentation status.

UMIs and mental health

Although the scant research in this areasuggests Mexican immigrants as a wholeare not at higher risk for psychiatric symp-toms or disorders tban US-born MexicanAmericans,̂ '̂̂ *̂ documentation status is sel-dom addressed. In addition to findings be-ing metbodologically difficult to compare be-tween studies, a lack of systematic researchabout the health effects of documentation sta-tus makes it difficult to draw definitive conclu-sions about Mexican immigrant mental healtbstatus. Nevertheless, within the limited re-search that does exist about tbe mental healthof UMIs, recurrent themes appear Still miss-ing, however, is an exploration of how thefollowing themes specifically translate to themental healtb status of UMIs.

Failure to succeed in tbe country of ori-gin: Although it is largely accepted that UMIs

come to tbe United States for economicopportunities,' rarely is an emotional an-tecedent mentioned. The stresses and strainsthat lead to immigration are important to bearin mind.̂ '̂ Emotional effects may result froma sense of failure or inability to create sus-tainable lives for one's self or family."*" Al-though currently residing in the United States,it cannot be assumed that each person wants,prefers, or hopes to stay here."^

Dangerous border crossings: As a result ofUS immigration policies, UMIs inherently facedanger in crossing the border by virtue of be-ing undocumented. UMIs, especially the verypoor, face the possibility of deprivation, rape,and murder ̂ ^ There is an emotional toll fromfeeling hunted at tbe border by helicopter andhovercraft surveillance as well as motion de-tectors and infrared scopes."" These fears arenot unfounded given that more than 2000 mi-grants bave died crossing tbe border in thepast 10 years.'*''*^ A UMI recalled, "We knowhow difficult is the crossing ... how peoplerun and how they [Border Patrol] let the dogsloose to catcb them, and how tbe airplanesfly really low. It is very hard, and yet peoplecontinue crossing."*"f* '̂

Limited resources: Tbe limited resourcesof many UMIs precede tbeir arrival to theUnited States. This economic push factor"is first and foremost in most UMIs' deci-sions to cross tbe border. Being undocu-mented is .specifically associated with lack oflegal protection, social security, employmentopportunities, and access to information/assistance or healthcare.^ UMIs arc morelikely to receive less pay than even their doc-umented counterparts.^'* Although being un-documented restricts financial resources, itsbroader restriction of resources in general hasfar-reacbing health consequences. Unique toundocumented immigrants is difficulty in ac-cessing healthcare in the United States as a di-rect result of documentation status. Not onlydoes legal status affect eligibility for certainbealth services and insurance requirements,but undocumented immigrants may be reluc-tant to even seek or accept healtbcare for fearof deportation.̂ '̂'*^ For example, an entire

Mental Health of Undocumented Mexican Immigrants 247

family may deny themselves health servicesthough only one member is undocumentedfor fear of initiating an Immigration andNaturalization Service (INS) investigation.'^Wben medical attention is infrequent, de-layed, or absent, there is an inherent riskof poorer healtb outcomes. Primary care istbe most common route to accessing neededmental health services.-^^'^ If primary care isnot being accessed by UMIs, mental health-care may also remain inaccessible. UMIs maybe more likely to be ineligible for or forgoneeded mental healtb services for fear ofdetection.

Restricted mobility: A unique aspect ofbeing an undocumented immigrant in tbeUnited States is the inability to freely crossthe US-Mexico border. Many UMIs, havingcrossed the border initially, are reluctant toattempt another crossing for fear of phys-ical danger and risk of apprehension. Thedifficult)' of entry in the United States pre-vents and restricts the undocumented frombeing able to return home to Mexico to visitfamily.'''* Ihis inability of UMIs to freely en-ter and leave the United States creates anemotitmal distance between adults who cometo the United States for work and any chil-dren who remain behind." As it is commonto retain emotional ties to friends and familyin Mexico, many UMIs hope for immigrationdocumentation so as to reguiarl) and freelycross the border.** However, when hopes fordocumentation are not realized, the remain-ing options arc to risk danger and apprehen-sion with each crossing, not return home un-til ready to do so permanently, or only returnhome in cases of family emergencies. Thereare subsequent emotional burdens and conse-quences lo each option.

Marginalization and isolation: In addi-tion to dangerous border crossings, limited re-sources, and restricted mobility, UMIs expe-rience a unique sense of marginalization andisolation. They have reported loneliness, dis-orientation. isolation, feeling trapped, separa-tion from children, depression, sadness, andsuffering.^' Their marginality is reinforced

by the ambiguousness of being "illegal" onone hand, while being unofficially welcomedthrough the economic "back door" on theother.̂ "r*^* Although barred from full integra-tion into society, their presence and ability toearn a livelihood in the United States signals adegree of connectedness, demonstrating theirintermediacy. the essence of marginalization

as defined by Hall et ah'̂ ^̂ P̂ "**Despite completing the initial transition

phase of crossing the border, many UMIsnever fully complete the process of soci-etal incorporation as do documented im-migrants because they are viewed as soci-ety s Other.**'̂ ^ Rather than transition fromthe liminal space inherent in crossing bor-ders, many UMIs instead retain a permanentlymarginalized status, reinforced by their in-ability to demonstrate a sense of societal in-corporation through fmancial and employ-ment stability, language capacity, or familyformation." "' In addition to being ostracizedby societj', many UMIs see themselves asoutsiders to their own communities becauseof their undocumented immigration status.^However, with time, as undocumented im-migrants establish networks of employmentand family/friends, and gain language skillsand education as well as cultural experience,some become incorporated within their lo-cal communities despite their undocumentedstatus.*^'" When this occurs, they demon-strate resiliency against marginalization, defy-ing what Chavez calls society s perception ofthem as "transient and rootless aliens.*'f'^''

Blame/stigmatization and guilt/shame:Undocumentedness implies discrimination,blame, illegalit). and guilt.•***'"*" UMIs are re-ferred to in derogatory terms, portrayed asexploiting public assistance programs, takingneeded jobs from US citizens, and therebybenefiting unfairly.' '̂ ^" In some instances,community members have been hostile to-ward undocumented immigrants who havebeen faulted for count>' or state budgetaryproblems.** For example, in 1994. California'sProposition 187 barred the undocumentedfrom access to state-funded nonemergency

248 ADVANCES IN NURSING SCIENCE/JULY-SEPTEMBER 2005

health Sfrviccs and required that healthcareproviders report suspected undocumentedimmignmts to the INS.'^ The US media andsociety play such a large role in stigmatiz-ing UMIs that it can erode self-worth and po-tentially lead to depression.^" Stigmatized asdeviants, UMIs are consequently scapegoatedand discriminated against.'^ ''' The effects ofsuch stigmatization effectively "[change| theconcrete realities of everyday situations [ofUMIs]."^ '̂!""'̂ ' The psychological burden ofbeing blamed and stigmatized hy media andthe larger society is manifested in the daily ex-periences, perceptions, and actions of UMIs.They are at risk of low self-esteem, guilt,shame, fear, and insecurity.^'''"

Belonging to a politically and economicallycontroversial group and being made the ob-ject of stigma and blame by the host soci-ety may result in shame, guilt, the need forsecreey. or attempt to pass as documented.However, the psychological and health ef-fects of stigmatization and blame of UMIs hasneither been fully studied nor addressed byhealthcare researchers.

Vidnerabtlity/exploitcibility: As a result ofUS immigration policies and lack of US immi-gration documentation, UMIs are legally \T.ii-nerable and therefore potentially exploitable.Given that most come to tbe United Statesfor economic purposes, a sense of desper-ation for work renders many vulnerable tounscrupulous employers.**'̂ '̂ '̂ '̂̂ Inherentlylegally vulnerable, the undocumented areless likely to speak out against injustices"'and are subject to blackmail and pressureto work for unjust wages.'** Becau.se theylack the legal benefits assured through im-migration paperwork, they are easy targetsfor exploitation in underground markets offalsified immigration/citizenship papers andsmugglers.•̂ '̂ •̂ '̂

Undocumented immigrants in the UnitedStates are exposed to inadequate occupa-tional safety and health conditions.'" Theselimited resources are specific to legal statusand not simply the result of immigration tothe United States, as fear of apprehension

and deportation prevent the undocumentedfrom requesting training or safety equipment,accessing healthcare, expecting a minimumwage or employment benefits, asking ques-tions, or speaking out. Undocumented immi-grants cannot expect or demand these min-imtim standards and resources by virtue oftlieir lack of legal protection. Mental healthimplications of such conditions are unknown,but chronic stress has been tied to poor healthoutcomes in other situations. '**

fear and fear-based behaviors: The inten-sity and pervasiveness of fear in the lives ofUMIs is nearly ubiquitous in the literature.Fear of detection and deportation is constant,regardless of length of time in tbe UnitedStates, ~̂ '•* It is specifically identified by UMIsas a life-altering concern and is synonymouswith being undocumented. "'-**̂ The experi-ence of fear becomes integrated into daily lifeand shapes the perception of reality. leadingto habitual fear reactions.'̂ ^*'"*^^* Fear is abarrier to receiving bealthcare when patient-provider trust is eroded because of the needfor secrecy.'' One example of fear-based be-havior occurs when an entire tiimily refuseshealthcare because one member is undocu-mented. This places all members at increasedrisk of poor health outcomes. In addition,fear leads UMIs to isolate themselves, furthermarginalizing themselves from society." Tbeidea of home comes to be perceived as arefuge, a sanctuary from the fear of appre-hension and deportation carried throughouttbe day.̂ -̂ ** One UMI states. The most diffi-cult thing about living in the United States isto be undocumented . . . when you don t havepapers the biggest fear about being here isthat tomorrow you could end up across theborder You know tbat no one is free withoutpapers.""*''''*

Stress, depression, and health implica-tions: UMIs stressful experiences include liv-ing in a hostile environment, fear of depor-tation, and states of bypervigilcnce. "'^'""*These ongoing stressful experiences mayexacerbate health risks.'' '"" In addition,UMI s experience of discrimination results in

Mental Health of Undocumented Mexican Immigrants 249

questioning self-worth, whicb may increasetbeir risk of depression.^

In a study of mostly UMIs, Vega et al^''found tbat satisfactory adjustment to life inthe United States was highly associated withinteqiersonal factors, in conjunction witb im-migration itself For example, loss of emo-tional support was important in predicting de-pression. To resolve the stress of disruptedsocial networks from the country of ori-gin, establishing new social networks in thehost-country was necessary for sati.sfactoryadjustment. In addition, depressive symptomswere related to unfulfilled financial expecta-tions, discrimination, perception that migra-tion was a mistake, incompatibility betweencultures, and distance between place of ori-gin and host-country.

In a study of the impacts of accultura-tion stress and social support on immigrants'perceived health status. Finch and Vega^"found "legal status stress" to bave a signif-icant effect.--*'''*'''* Defined as an accultura-tion stressor, legal status stress was meastiredby fear of deportation and its consequences,avoidance of immigration officials, diffictiltyfinding legal .services, and limited contactwith family and friends because of legal sta-tus. Wliile acculturation stressors in gen-eral were moderately associated with poorerhealth, legal status stress alone significantly in-creased the likelihood of rating one s health asfair/poor

CONCLUSION

Gaps in the literature

UMIs are an tinder-researcbed populationand largely excluded from mental health re-search. The mental healtb research that doesexist varyingly examines and compares themental health status of Mexico-born MexicanAmericans, US-born Mexican Americans, andMexicans in Mexico. The sample populationsare nt)t adequately described and documen-tation status is seldom mentioned or consid-ered a variable. Researchers employ inconsis-tent operational definitions, assessment tools.

and variables. Findings about mental healthamong Mexican immigrants therefore are in-comparable on methodological grounds, pre-venting sound conclusions.^'^' Moreover, dif-fering findings on the mental health of UMIshave not been fully investigated. For example,Bacb-y-Rita^" found that other factors relatedto immigration had greater mental health im-plications than documentation status, yet nofollow-up studies bave pursued this finding.

What Ls known from the literature

Despite what is not known about tbemental health of UMIs. tbere are recurrentthemes in the literature. Specifically, thethemes of failure in the cotintry of origin; dan-gerous border crossings; limited resources;restricted mobility; marginalization/isolation;stigma/blame and guilt/shame; vulnerability/exploitability; fear and fear-based behaviors;and stress and depression are specific to un-documented immigrants and have health andmental health implications. The literature sug-gests that tindocumented immignints do havea uniqtie risk profile, wbieb may contributeto different mental health outcomes as com-pared to their documented counterparts. Insum. tbere is an emerging picture in the liter-ature of the increased psychological burdenof being a UMI in American society; yet, tbeexact effects of this burden remain unknown.

Recommendations

Foremost, scholars mu.st specifically andethically address tbe issue of immigration doc-umentation status in mental bealth research.Sample groups and terminology should beconsistentl)' defined. Mental health assess-ment tools and variables should be system-atically tested and utilized. Finally, there isa need to investigate factors within immi-grant groups that may determine relationshipsbetween migration experiences and mentalillness.^'' In tbese ways, the bealthcare es-tablishment could better determine whichgroups of immigrants bave higher mentalhealth risks and accordingly provide targetedquality care.

250 ADVANCES IN NURSING SCIENCE/^ULY-SEPTEMBER 2005

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