Implications of Undocumented Status for Latinx Families During the COVID-19 Pandemic: A Call to Action

ABSTRACT

Background

A disproportionate number of COVID-19 cases and deaths have been reported among Latinxs in the U.S. Among those most affected by the pandemic are marginalized families, including those that are undocumented and mixed-status, in which some, but not all members are undocumented. Undocumented and mixed-status families face multiple and chronic daily stressors that compromised their health and wellbeing. Salient stressors faced by undocumented Latinx families include poverty, social disadvantage, discrimination, dangerous living and working conditions, and limited access to healthcare. These stressors are frequently compounded with trauma, fear of detention, deportation, and family separation.

Purpose

Informed by the literature and insights from our community-based work to address the health needs of undocumented and mixed status Latinx families during the pandemic, this paper uses a social determinants of health lens to present a narrative summary that highlights four primary psychosocial stressors faced by these families and their implications for mental health.

Discussion

These include stressors pertaining to (a) anti-immigrant rhetoric and actions; (b) family stressors and disruptions in family dynamics; (c) economic changes and financial losses; and (c) limited access to healthcare. Implications of the aforesaid stressors on the mental health of undocumented families and youth are also discussed. In addition, recommendations are provided for the provision of mental health services, best practices, and resources from a strengths-based approach.

Resumen

Introducción: Latinxs en los EE. UU. han experimentado un número desproporcionado de casos y muertes por el virus del COVID-19. Entre aquellos más afectados por la pandemia están las familias marginalizadas, incluyendo las que son indocumentadas y de estatus mixto, de los cuales algunos miembros, pero no todos, son indocumentados. Las familias indocumentadas y de estatus mixto enfrentan estresores múltiples y crónicos diarios que comprometen su salud y bienestar. Algunos de estos estresores incluyen la pobreza, la desventaja social, la discriminación, las condiciones residenciales y laborales peligrosas, y el acceso limitado a los servicios de salud. Frecuentemente, estos estresores son amplificados por el trauma, el miedo a la detención, la deportación, y la separación familiar.

Propósito: En este artículo, empleamos la literatura científica y nuestras perspectivas a partir de nuestro trabajo comunitario para abordar las necesidades de salud de las familias Latinxs indocumentadas y de estatus mixto durante la pandemia, y nos enfocamos en cuatro estresores psicosociales principales usando una perspectiva de determinantes de la salud.

Discusión: Estos estresores incluyen: (a) la retórica y acciones anti-inmigrante; (b) la adversidad y disrupciones de las dinámicas familiares; (c) los cambios económicos y pérdidas financieras; y (d) el acceso limitado a los servicios de salud. También se discuten las consecuencias de estos estresores en la salud mental de las familias y juventud indocumentada. Adicionalmente, usamos una perspectiva basada en las fortalezas para ofrecer recomendaciones para la provisión de servicios de salud mental, mejores prácticas, y recursos.

A disproportionate number of COVID-19 cases and deaths have been reported among Latinxs people in the United States (U.S.), with those most affected being families that have been historically marginalized including those with undocumented immigration legal status (Lau & Sosa, 2022). For parsimony, we refer in this article to undocumented families as also including those of mixed-status in which some, but not all members are undocumented. Undocumented status refers to immigrants who have entered the U.S. without proper authorization or entered with a nonimmigrant visa but remained within the country after the visa expired (Legal Information Institute, 2022). Undocumented families often face multiple and chronic daily stressors, including but not limited to poverty, social disadvantage, discrimination, dangerous living and working conditions, and limited access to healthcare (Garcini, Daly, et al., 2021). These aforesaid stressors are frequently compounded with fear of detention, deportation, and family separation (Garcini, Daly, et al., 2021). Many undocumented families also experience traumatic events that occur at different stages of the migration process, including pre- and post-migration (Garcini, Daly, et al., 2021). Despite being a highly resilient population, research shows diminished physical and mental health effects the longer time that immigrants reside in the U.S. (Alegría et al., 2008). Addressing the complex health and social needs of undocumented families is essential to reduce risk and prevent further harm among a vulnerable group that comprises a significant proportion of the U.S. population.

Positionality Statement and Contextual Background

This manuscript was written by six interdisciplinary scholars affiliated with research universities and academic medical centers that are dedicated to studying and serving the health needs of historically marginalized and medically underserved Latinx communities, including undocumented families. The author’s interdisciplinary backgrounds include expertise in the fields of psychology, public health, policy studies, and medicine. All of the authors are of immigrant background. Three of the authors, including the first and senior authors, are Latinxs and have considerable expertise in conducting studies with undocumented families that are used to inform policy and advocacy. Four out of six of the authors identified as women, and three out of six speak Spanish as their first language. The gender make-up of the team may have sensitized the authors to the experiences of undocumented immigrant women. All of the authors are actively engaged in community-oriented scholarship, clinical services, and/or advocacy efforts for immigrant health, which may have helped attune them to the themes discussed in this manuscript.

Over the course of the COVID-19 pandemic, the authors conducted several needs assessment community projects with undocumented immigrant families residing in South Texas, near the U.S.-Mexico border region. In these mixed-methods projects, the authors used a social determinant of health (SDOH) framework to identify salient socioeconomic stressors and factors of the neighborhood and built environment affecting the health and wellbeing of undocumented families during the pandemic. In their projects, the authors also identified culturally and contextually relevant coping strategies used by undocumented families to cope with stress during the pandemic. SDOH refers to the environments, conditions, and social structures that affect health outcomes in the face of adversity (Maani & Galea, 2020). The use of an SDOH lens to inform the mental health of undocumented families facilitates a deeper understanding of systemic inequities faced by immigrant families with the goal of informing intervention and policy that can improve community health. In this manuscript, the authors provide a narrative summary informed by the literature and insights from their COVID-19 community projects to highlight four primary psychosocial stressors faced by undocumented families over the pandemic. These prevalent stressors include anti-immigrant rhetoric and actions; family stressors and disruption in family dynamics; economic changes and financial losses; and limited access to healthcare (Garcini, Rosenfeld, et al., 2022). The authors also elaborate on the implications of the aforesaid stressors on the mental health of undocumented families and provide recommendations for the provision of mental health services and best practices for working with undocumented families during and beyond the COVID-19 pandemic.

Psychosocial Stressors Faced by Undocumented Latinx Families in the Face of COVID-19

Anti-Immigrant Rhetoric and Actions

Anti-immigrant rhetoric and actions have been prevalent in the U.S. for many years; yet, recently and throughout the COVID-19 pandemic, the sociopolitical climate in the U.S. has fueled growing anti-immigrant discourse and policies that increased distrust and fear among undocumented families (Chavez-Dueñas et al., 2019). Negative depictions of undocumented families, along with polarizing views on immigration in mainstream media displaying divisive rhetoric and anti-immigration sentiments, have magnified hostility and the prevalence of discrimination, marginalization, and isolation experienced by undocumented families (Garcini, Cadenas, et al., 2022). Unaccompanied minors and adult undocumented immigrants have been portrayed as criminals, invaders, and potential terrorist threats (Finley & Esposito, 2020; Romero, 2022). Also, political rhetoric has increasingly framed undocumented immigrants as an economic burden and a threat to job security in the U.S. (Finley & Esposito, 2020). This is ironic as undocumented immigrants largely bared the burden of engaging in essential services that others did not want to do, which maintained the functioning of society during the pandemic (Garcini, Rosenfeld, et al., 2022). Another salient stereotype includes portraying undocumented families as carriers of disease across borders, which increases marginalization (Riggirozzi et al., 2020). Framed as a “public health hazard” due to limited access to healthcare that would stop the spreading of contagious diseases, undocumented families have faced an even steeper uphill battle in addressing their most basic health needs during the pandemic compared to pre-pandemic times (Garcini, Rosenfeld, et al., 2022).

Existing federal and state anti-immigrant policies have resulted in increased punitive actions against undocumented families. For example, a widely criticized immigration policy was implemented in 2019 known as the Migrant Protection Protocols (MPP or Remain in Mexico policy) that allowed the U.S. Department of Homeland Security (DHS) to return non-Mexican migrants in immigration court proceedings to await the decisions in Mexico. The program sent nearly 70,000 immigrants to Mexico (Mayorkas, 2021). The anti-immigrant sentiment was particularly apparent in U.S. immigration policy early in the pandemic. By March 2020, the spread of the coronavirus had accelerated rapidly and prompted some of the most stringent immigration restrictions, among them the suspension of MPP hearings, and implementing agreements with Canada and Mexico to limit all non-essential travel at ports of entry (these measures were repeatedly extended until November 2021; U.S. Department of Homeland Security, 2020). Arrest, detention, and removals of undocumented immigrants increased year over year during the Trump presidency, including at the start of the pandemic (arrests in 2017 = 323,591, detention = 37,931, removals = 226,119; arrests in 2018 = 396,448, detention = 43,746, removals = 256,085; arrests in 2019 = 510,854, detention = 50,922, removals = 267,258; U.S. Immigration and Customs Enforcement, 2019). Indeed, immigration raids continued to be conducted during the pandemic, despite the risk of exposure to the virus among detainees (Lopez & Holmes, 2020). In March 2020, the Trump administration also implemented a public health order known as Title 42 that turned back legal asylum seekers without due process and suspended court hearings for those awaiting hearings under the pretext of preventing COVID-19 transmission (American Immigration Counsil, 2022). Travel bans were also imposed in response to the pandemic, further stigmatizing immigrants from banned countries (Kanno-Youngs, 2021). Another example of increased punitive actions is the Trump administration’s public charge rule enacted in February 2020, which counted the use or future use of health and human services by immigrant families as a negative against their immigration applications (Sanchez, 2022). The Trump administration also attempted to terminate the Deferred Action for Childhood Arrivals (DACA) program, which was later overturned by the U.S. Supreme Court in June 2020 (Totenberg, 2020). In many instances, the aforesaid actions and policies separated immigrant families, returned undocumented immigrants to home countries under dangerous conditions from which they were attempting to escape, discouraged the use of health and social services during a global pandemic, and exacerbated trauma-related distress among undocumented parents and their children (Solheim et al., 2016).

With the election of the Biden administration, there was hope for needed immigration reform. However, the Biden administration has only recently begun to end the Trump era Title 42 policy. Efforts to push for immigration reform have also stalled in congress, which has increased uncertainty and feelings of deceit, mistrust, and stress among undocumented families (Levine et al., 2022). Indeed, the anti-immigrant rhetoric that has prevailed over the course of the COVID-19 pandemic, combined with anti-immigrant actions and policies, has conveyed a public message that undocumented families are unwanted and undeserving of protection and assistance (Crudo Blackburn & Sierra, 2021). The negative effects of discrimination and ethno-racial trauma among undocumented parents put their children at-risk of experiencing internalizing symptoms (e.g. fear, withdrawal, separation anxiety) and externalizing behaviors (e.g. impulsivity, disruptive behaviors; Barajas-Gonzalez et al., 2022; Chavez-Dueñas et al., 2022). Importantly, anti-immigrant rhetoric and actions cause unintentional impact not only to undocumented parents and their children, but also to others such as U.S. children who may vicariously experience the punishment faced by their undocumented relatives, friends, neighbors, or anyone around them (Solheim et al., 2016). The lack of legislative federal and state solutions for undocumented families only points to continued risk of further trauma, including mental health problems and with little to no access to mental health treatment, support, and services (Ayón, 2020).

Anti-immigrant rhetoric and harmful stereotypes about undocumented immigrants can increase feelings of rejection, particularly among children and adolescents, which may lead to internalize the negative labels placed on them (e.g. portraying immigrants as criminals, rappest, and killers; Caballero et al., 2022; Finley & Esposito, 2020; Solheim et al., 2016). Internalization of the aforesaid stereotypes may result in shame, embarrassment, diminished self-esteem, and increase identity confusion (Garcini, Daly, et al., 2021). Undocumented children, or children of undocumented parents, may be keenly aware of disparities and discriminatory practices, which can contribute to the development of mental health disorders (i.e. depression, anxiety; Kim et al., 2018). Also, discriminatory, abusive, and/or unpleasant encounters with law enforcement or other figures of legal authority can create a sense of otherness among undocumented families and children that can have a detrimental impact on these immigrants’ sense of self and perceived identity (Kim et al., 2018). Certainly, anti-immigrant rhetoric and actions inflict wounds on the mental health of undocumented families and youths (Crudo Blackburn & Sierra, 2021).

Family Stressors and Disruptions in Family Dynamics

Intricately linked with the anti-immigrant actions and sentiment rising during the COVID-19 pandemic, undocumented families have faced a growing fear of family detention and separation. These fears have been cultivated by U.S. federal and state governments, which have used the threat of family detention and separation as a deterrent to unauthorized border crossings in the past. For example, many families were impacted by the U.S. “Zero Tolerance” policy enacted in April 2018, which prosecuted any individual apprehended crossing the border unlawfully, with no exceptions for asylum seekers or families (Frye, 2020). It is estimated that nearly 4,000 children were separated from their parents from June 2017 to June 2021 as a result of this policy (Southern Poverty Law Center, 2022). The aforesaid family separation policy has exposed many undocumented families and youth to trauma, while increasing distrust of authorities (Barajas-Gonzalez et al., 2022; Lovato et al., 2018). Fears of family detention and/or separation affect all aspects of life for undocumented families. To reduce the risk of detention or deportation that may lead to family separation, undocumented families engage in concealment of their identity on a daily basis and live under constant fear (Solheim et al., 2016). For instance, to minimize exposures to situations that may place them at risk of detention and/or deportation, undocumented families avoid seeking health services (i.e. mental healthcare), evade educational and job opportunities that may provide them economic stability, stay away from financial investment (e.g. homeownership, banking) and/or avoid denouncing crimes or abuses against them, all of which undermines their mental health and wellbeing (Valentín-cortés et al., 2020).

Family ties and familismo (or familism), that is the emphasis on strong family relations and loyalty as essential to wellbeing, are especially important for undocumented families (Kapke & Gerdes, 2016). As the requirements for shelter-in-place orders and social distancing measures went into effect to prevent the spread of COVID-19, undocumented families faced changes in family dynamics that led to significant difficulties maintaining family connections and harmonious family ties (Solheim et al., 2016). For instance, many undocumented families experienced rising tensions during the pandemic related to multiple members living under one roof and having to share limited resources, which resulted in tensions associated with a lack of privacy and struggle to share needed resources such as the family computer for school or work activities (Garcini, Rosenfeld, et al., 2022). Also, the pressure to adapt to changing economic and social circumstances throughout the pandemic forced family members to perform multiple roles while grappling with potential intergenerational conflicts and disagreements over cultural values that were being compromised (Garcini, Daly, et al., 2021). The changing nature of family relationships, expectations, and obligations resulted in reports of increased irritability, distress, and interpersonal violence among undocumented families (Garcini, Rosenfeld, et al., 2022). Furthermore, many undocumented families experienced sudden or unexpected deaths due to the pandemic, which coupled with the family’s inability to travel home to care for or attend funeral/burials, left many undocumented families to mourn at a distance with limited support, strained family dynamics, and little to no resources to facilitate the healing process (Garcini, Rosenfeld, et al., 2022). The pandemic has also led to changes and losses in social networks outside the family (e.g. church, community) that left many undocumented families isolated from important sources of support, including those that could have facilitated access to needed mental health, social, and legal services, or resources (Đoàn et al., 2021).

Complicating family dynamics for undocumented families has been school closures aimed to reduce the spread of the virus and the mass migration to online learning (Kim & Padilla, 2020). Limited access to technology and financial hardship have added stress to existing social and educational disadvantages faced by undocumented families (Jalongo, 2021). For instance, generational differences in digital literacy have limited the ability of undocumented families to support the learning of their children during the pandemic (Bastick & Mallet-Garcia, 2022; List, 2019). Learning lost during the pandemic may negatively impact the academic trajectories and outcomes of these youths (Jalongo, 2021). Also important is that children of Latinx immigrants often act as brokers who help navigate culture, language, and healthcare systems for monolingual speaking parents and adults in their households, which increases family distress and challenges traditional family roles and expectations that disrupt family dynamics (Kam & Lazarevic, 2014). The aforesaid brokering demands put a significant strain on immigrant children as they serve as a bridge for their parents navigating life in a foreign context during a global pandemic (Kam & Lazarevic, 2014). Indeed, cultural brokering burnout has been a significant stressor for many Latinx immigrant youth who have helped their families navigate complex healthcare and educational systems during the pandemic (Todd & Martin, 2020).

Given the importance of the family as an essential source of support for undocumented families, the loss of family ties and harmony is extremely distressing and harmful to their wellbeing (Barajas-Gonzalez et al., 2022; Kapke & Gerdes, 2016). As immigrants separate from their loved ones, they lose contact with social, emotional, and cultural resources that are essential to facilitate coping with adversity and uncertainty (Barajas-Gonzalez et al., 2022; Solheim et al., 2016). Unable to visit or be near family members has left many immigrant families feeling helpless, lonely, and demoralized (LeRoy et al., 2020). Given the wide-ranging impact of the pandemic, many undocumented families have had to grapple with the pain of being unable to visit sick or dying relatives in their homelands. This has resulted in transnational loss and bereavement, which is associated with increased psychological distress among undocumented families (LeRoy et al., 2020). Consistent with the concept of disenfranchised grief, losing a loved one from afar is distressing for undocumented immigrants who either have to stay home or risk capture, separation, and deportation to be with their family. Research shows that the distress suffered by these immigrant families as a result of transnational death is often accompanied by guilt, which often remains long after the loss (Bravo, 2017). Bereavement and grief can have a direct impact on the ability of parents to provide adequate support to and care for their children. Bryant et al. (2021) found that greater grief among refugee parents was associated with worse mental health outcomes among youth. Parents experiencing severe grief are likely to form anxious relationships with their children, which can contribute to the development of mental health disorders among youths.

Economic Changes and Financial Losses

The economic burden of the COVID-19 pandemic has not been equitable, and significant economic losses and rapid changes have had a detrimental impact on undocumented families, which has led to the widening of existing socioeconomic gaps in the U.S. (Salinas & Salinas, 2022). While all areas of life for undocumented families have been impacted over the course of the pandemic, economic instability has been identified as a salient stressor affecting the health and wellbeing of undocumented families (Gonzalez et al., 2020). Many undocumented immigrants lost their jobs during the pandemic and had to rapidly reinvent themselves and take on new jobs, often with low-pay and in hazardous conditions (i.e. essential services; Gonzalez et al., 2020; Salinas & Salinas, 2022). Undocumented immigrants helped carry the burden of maintaining the U.S. economy through provision of essential services that others did not want to provide. These services were rewarded with low wages, long work schedules, limited availability of protective equipment, difficulty maintain social distancing guidelines, denial of paid time off when sick, and lack of health insurance coverage, which have contributed to financial instability, health risk, and stress among undocumented parents that is transmitted to their children (Gonzalez et al., 2020; Jewers & Orozco, 2020; Solheim et al., 2016).

The ramification of job instability and loss of regular income for undocumented families has led to many unmet basic needs including housing, food security, and the ability to care for loved ones abroad. For instance, many undocumented immigrants rely on their jobs and income to send remittances to their countries of origin to support family members in need, those that have been left behind, been deported, and/or are no longer able to work (Garcini, Rosenfeld, et al., 2022). In 2020, approximately 75% of remittances in Latin American and Caribbean countries originated in the U.S. (Jewers & Orozco, 2020). The pandemic is thought to have caused at least $10 billion in loss of remittances within those countries (Jewers & Orozco, 2020). Similarly, the loss of income has led many undocumented parents and children to face food and housing insecurity, including having a growing fear of homelessness (Solheim et al., 2016). Undocumented families face constant housing challenges. For instance, it is not uncommon for undocumented families to fall prey of unscrupulous landlords and have a high-rent burden that forces them to pay more than 50% of their income on rent. As a result, undocumented families often have to cut back on necessary expenses (e.g. food, medicine, health services), which has cascading negative effects on the family’s finances, mental health, and wellbeing, including increasing symptoms of anxiety among youth (Solheim et al., 2016, 2022).

Despite experiencing significant economic loss and challenges, undocumented families have been excluded from economic protections. Recognizing the serious economic toll of the pandemic, the U.S. government authorized several stimulus payments to U.S. citizens to ease the burdens of unemployment and furloughs. Despite working in services deemed essential to maintaining the economy during the pandemic, undocumented immigrants were not eligible for financial assistance from the Coronavirus Aid, Relief, and Economic Security Act (Garcini, Rosenfeld, et al., 2022). The requirement of a social security number as a prerequisite for payment effectively eliminated any possibility that undocumented immigrants would qualify for financial help through the stimulus checks (Lajka, 2021). In addition to the stimulus payments, the increase in unemployment insurance funds, of an additional $600 per week, was solely designated for those with U.S. work authorization (Congressional Research Service, 2020). Though the economy of the U.S. continued to stay afloat in part due to the labor of undocumented immigrants in essential sector jobs, undocumented families have been excluded from social safety net programs and other government provisions.

When compared to people born in the U.S., undocumented immigrants are at a greater risk of developing psychosocial challenges related to economic instability (Chhabra et al., 2022). Chronic stress during the pandemic related to securing basic needs such as housing and food security is associated with greater risk for substance abuse and diminished mental health outcomes among adults, and anxiety among youth (Fong & Iarocci, 2020; Turner et al., 2022). Unable to provide housing stability, food security, and financial support for their families in the U.S. and abroad leads many undocumented parents to feel despair, guilt, and shame for being unable to uphold the familismo value that entails an unrelenting commitment to care for family. Undocumented parents can be particularly susceptible to anxiety, irritability, and feelings of guilt and shame, as well as marital hardship and family tension resulting from conflicts between the demands of work and family (Fong & Iarocci, 2020; Solheim et al., 2022). In turn, stress from economic hardship experienced by undocumented parents is known to reverberate throughout the household with children becoming aware of the family difficulties related to financial insecurity (Loria & Caughy, 2018; Solheim et al., 2022). The negative impact of economic hardship on the mental health of youth has been documented and is often attributed to changes in parenting practices (Gonzales et al., 2013; Solheim et al., 2022). Research shows that economic hardship contributes to decreasing warm parenting and increasing harsh parenting practices among Latinx parents, which can increase the risk of externalizing problems among youth (e.g. defiance, aggression; Gonzales et al., 2011). Other negative effects of financial instability among immigrant youth include excessive worry, fear, frustration, depression, and increase in suicidal thoughts, as well as poor academic and social outcomes including greater school drop-out rates (Gonzales et al., 2013).

Limited Access to Healthcare

A primary stressor over the course of the COVID-19 pandemic for undocumented families has been lack of or limited access to healthcare (Galvan et al., 2021). Lack of health insurance and inability to purchase insurance in the marketplace, as well as financial hardship that makes it difficult to pay for health services out of pocket, are two salient barriers limiting access to needed health services for undocumented families (Garcini, Rosenfeld, et al., 2022). The Latinx Immigrant Health Alliance (LIHA) recently found that 32.9% of Latinx immigrants surveyed during the pandemic did not have health insurance (i.e. undocumented, mixed-status families, DACA recipients; Latinx Immigrant Health Alliance, 2021). This lack of insurance was further compounded by fear and mistrust of how personal information would be handled, which made it difficult for undocumented families to seek needed health services, including mental healthcare (Garcini, Pham, et al., 2021). Throughout the pandemic, many undocumented families have been hesitant to seek mental health services due to fear that their personal information may be used to facilitate their deportation, detention, and/or family separation (Finnigan et al., 2022). For instance, Caballero et al. (2022) found that when it comes to healthcare access for undocumented children, parents reported feeling hesitant about bringing their children to the emergency department despite acknowledgment that hospitals have been inclusive and protective of people with undocumented status. These concerns are magnified in regard to mental healthcare for immigrant youth due to fear that the disclosure process or a bridge in confidentiality may lead to parental deportation, family separation, or removal of the youth from the household (Finnigan et al., 2022).

Testing and vaccination for COVID-19 have been important strategies to prevent the spread of the virus. Yet, undocumented families have faced many significant barriers in accessing screening services and COVID-19 vaccination (Garcini, Pham, et al., 2021, Garcini, Ambriz, et al., 2022). In a recent study of Latinx immigrant communities residing near the U.S.-Mexico border, researchers identified undocumented immigration legal status as a salient barrier to COVID-19 testing and vaccination due to fear of deportation and family separation (i.e. children being taken away due to positive test). This study also found fear among undocumented families that a positive COVID-19 test result may lead to loss of income from missing work, stigma associated with being infected, and inability to access needed healthcare due to cost (Garcini, Pham, et al., 2021). The aforementioned barriers impacting COVID-19 testing and vaccination have contributed to the greater risk for COVID-19 infection, hospitalization, and complications among many undocumented families (Cleaveland & Waslin, 2021). Weighing the pros and cons of seeking needed health services in the face of the current anti-immigrant climate and financial instability has been difficult and frightening for many undocumented families. Moving forward, recommendations for policymakers and advocates should move not only to ensuring access to testing and vaccination for COVID-19 and any other emerging health threat but must particularly consider creating equitable universal access to medical services among vulnerable populations such as undocumented families (Matlin et al., 2022).

Undocumented families are also in a position of vulnerability as a result of numerous compounded psychosocial stressors that magnify physical and mental health risk from the COVID-19 pandemic (Galvan et al., 2021). Anti-immigrant rhetoric and policies, family loss, economic hardship, and limited access to healthcare may have long-lasting mental health effects for undocumented families. Prior research has documented the detrimental effects of toxic chronic stress on mental health (Lupien et al., 2018). Indeed, toxic stress from a life history of trauma, along with compounded stress from the pandemic, while living and working under challenging conditions with limited access to health services and resources can significantly increase distress among undocumented families (Keller & Wagner, 2020). Uncertainty associated with their legal process, the possibility of family separation, and/or deportation to places that they fled from may exacerbate existing trauma, worsen depression, increase anxiety, and interfere with the functional ability of undocumented parents and their children (Galvan et al., 2022). The constant threat of deportation and family separation led many undocumented families to mistrust and to live in the shadows, which increases the risk of isolation and marginalization, while restricting the building of support networks that are essential to maintain wellbeing.

In the face of compounded stressors from the COVID-19 pandemic, many undocumented families are in need of mental health services and resources, yet access to mental healthcare is limited and in many cases lacking (Benuto et al., 2019). Common barriers to accessing mental health services among undocumented families include mental health stigma, concerns over cost, lack of health insurance, language barriers, and limited services tailored to their needs (Bridges et al., 2012). Additional barriers to mental healthcare that have been exacerbated by the pandemic include mistrust, fear that information would be mishandled, fear that undocumented family members would be deported, misconceptions or limited knowledge about mental health services, concerns that services would disrupt the family dynamics, fears that families will be separated if a member is committed to a hospital, discrimination, and stigmatization (Garcini, Pham, et al., 2021). The aforesaid barriers contribute to greater dependence on informal sources of support and/or result in forgoing formal mental health treatment (Garland et al., 2013).

The lack of adequate access to mental health services during the pandemic raises concerns regarding the long-term impact of unmet psychological need among undocumented Latinx families and youth. Indeed, the pandemic has contributed to increases in the prevalence of mental health problems, while limiting access to in-person mental health services and community-based support for undocumented families (Latinx Immigrant Health Alliance, 2021). While telepsychology services have been scaled up to address restrictions on in-person gatherings during the pandemic, disparities in access to technology, variations in treatment preferences, inability to afford services, fear, and mistrust are some of the many factors limiting access to telehealth services among undocumented families (Rothe et al., 2021; Vázquez, Culianos, et al., 2021, 2021). Unmet mental health needs raise concerns regarding the functional impairment associated with worsening psychological problems and increased risk for suicide among undocumented adults and youth who face significant marginalization, economic hardship, and compounding stressors with limited access to services and resources (Negi & Siegel, 2022). Importantly, high levels of stress related to the pandemic and stay-at-home orders have also contributed to increased risk for domestic violence and child abuse, while reducing the chances that the abuse would be detected and reported outside the home (Rosenthal & Thompson, 2020). Child abuse, domestic violence, and household mental health disorders are known risk factors for the development of youth mental health problems (Petruccelli et al., 2019). Furthermore, isolation and alienation from valuable social support networks throughout the pandemic may have long-lasting effects on the developmental trajectories of Latinx immigrant youth (Garcini, Pham, et al., 2021). Efforts are needed to facilitate access to psychological services and resources for undocumented families that are affordable, accessible, convenient, and culturally and contextually appropriate.

Yet, despite the many stressors faced that pose a risk to the mental health of undocumented families, these families are extremely resilient. Garcini, Cadenas, et al., 2022 identified numerous effective coping strategies used by undocumented Latinx families to deal with compounded stressors on their everyday lives. For instance, many undocumented families seek respite from faith-based organizations that provide support, which helps them build hope and find meaning in the face of adversity (Garcini, Cadenas, et al., 2022). Through cognitive reframing, undocumented families reappraise adversity in their lives and build a more optimistic perspective. Interpreting challenges as temporary obstacles within a brighter future serves respite from stressors and situations that families perceive to be out of their control (Garcini, Cadenas, et al., 2022). Also, behavioral adaptations (e.g. routine changes, information seeking, behavioral activation) undertaken by undocumented families help open doors to a renewed sense of self-confidence and flexibility that fosters resilience and resourcefulness (Garcini, Cadenas, et al., 2022).

Recommendations for the Provision of Mental Health Services and Best Practices for Undocumented Families and Youth

Our recommendations for the provision of mental health services for undocumented Latinx families focus on building resilience, leveraging support networks, increasing access to technology-assisted interventions (e.g., telepsychology and self-guided mental health intervention), and increasing cultural competency among health service providers. While these recommendations can apply to each of the four primary psychosocial stressors faced by undocumented families during the COVID-19 pandemic, specific recommendations for each challenge and related consequences are provided in Table 1.

Table 1. COVID-19 stressors, challenges, mental health consequences, and recommendations for working with immigrant Latinx families.

Stressors	Challenges	Mental health consequences	Recommendations
Anti-immigrant rhetoric and actions	a) Hostility b) Discrimination and marginalization c) Isolation d) Fear and mistrust	a) Feelings of rejection b) Internalization of stereotypes c) Shame and embarrassment, d) Diminished self-esteem and increase identity confusion	a) Use of strength-based approaches to foster healing, resilience, and family cohesion b) Asserting, preserving, and/or regaining cultural pride and pride in the immigrant experience c) Foster social networks to build support and sense of belongingness d) Use of testimonials or life narratives to increase support, sense of community, and collec tive pride that are passed on as interge nerational gifts. e) Increase awareness of and coping with systemic oppression.
Family stressors and disruptions in family dynamics	a) Distrust of authorities. b) Difficulties maintaining family connections and harmony. c) Transnational death and bereavement. d) Child strain from cultural brokering.	a) Distress and lose of an important source of support. b) Feelings of helplessness, loneliness, and demoralization. c) Grief that negatively impacts caregiver health and effective parenting.	a) Bolstering familial and social supports. b) Supporting development of beneficial parenting skills. c) Considering familial responsibilities and time commitments to foster family bonds. d) Maintain connections with family in country of origin (e.g., via online, phone).
Economic changes and financial losses	a) Low wages, long work hours, limited access to protective equipment, denial of paid time off, lack of health insurance, and ineligible for federal financial relief. b) High risk for infection. c) Difficulties maintaining remittances. d) Housing instability and food insecurity.	a) Chronic stress b) Feelings of despair, guilt, and shame. c) Risk for substance abuse and mental health problems. d) Decrease in warm parenting and increase in harsh punishment. e) Risk for youth internalizing and externalizing problems.	a) Dissemination of financial alternatives and information that may help prevent scams and reduce financial burden. b) Leveraging non-traditional sources of support to reduce economic hardship. c) Evaluating existing financial resources and need for case management.
Limited access to health care	a) Lack of health insurance and service access. b) Hesitance to seek health services due to mistrust of authorities. c) Mental health stigma, language barriers, and limited access to culturally competent mental health service providers.	a) Toxic stress impacting physical and mental health. b) Impact of untreated illness on wellbeing and quality of life. c) Increased risk for suicide, domestic violence, and child abuse.	a) Culture and context sensitive strength-based interventions. b) Telepsychology services and self-guided interventions. c) Use of non-traditional sources of service delivery (e.g., pastoral care, use of community health workers) to deliver mental health information and resources.

Building Resilience

Despite being resilient, there is an urgent need to address the mental health of undocumented families and youth during and beyond the COVID-19 pandemic. Of primary importance is the training of a mental health workforce and allied non-traditional sources of service delivery (e.g., faith-based leaders, lay health promoters, community grassroot organizations) that can facilitate the provision of culture and context-sensitive services to the needs of undocumented families. In this regard, incorporating the use of strength-based approaches that focus on helping undocumented families build upon their existing resources, values, talents, skills, and motivation can be valuable to foster healing, resilience, family unity, and cultural pride (Smith, 2006). Evidence supports the effectiveness of strength-based approaches in increasing positive feelings (i.e., happiness) and diminishing negative affectivity (i.e., depression; Rashid, 2015). Indeed, it is important to assist undocumented families and youth in asserting, preserving, or regaining pride in their culture and immigrant experience. This can help foster feelings of belongingness that can be reassuring to their self-esteem, self-efficacy, creativity, bravery, and the building of strong family ties to offset negative media/political messages. Inviting undocumented families to tell their life stories and passing them to their younger members can also be a powerful way of strengthening collective pride, wisdom, and resilience within a hostile context (Cadenas et al., 2021). In learning to connect the stories from their past to their present, parents can provide an intergenerational gift to their children that can facilitate healing and bonding through stories of struggle and resilience, which can foster identity formation and can help families see things in a new light with a renewed sense of meaning, purpose, and hope.

It is important for mental health service providers to support undocumented families in healing from ethno-racial trauma and psychological distress stemming from fears of discrimination, persecutions, and threats of physical harm (Chavez-Dueñas et al., 2019). Providers should incorporate recommendations from Chavez-Dueñas et al. (2019) the Healing Ethno and Racial Trauma (HEART) Framework into the assessment and treatment of mental health problems among immigrant Latinx families. The HEART Framework conceptualizes ethno-racial healing as progressing across four sequential phases. In phase one, mental health service providers focus on stabilization and provide relief from ethno-racial trauma by creating a space where the experiences of Latinx immigrants are respected, validated, and affirmed. This may include helping Latinx families build stability (e.g., maintaining routines, building support networks, consistency with expectations for children), develop a plan in case a family member is deported (e.g., identify guardians for children, provide legal resources) or are detained (e.g., case management for immediate needs, psychological first aid). In the second phase, providers help Latinx immigrants develop awareness of the impact of oppressive systems across multiple levels (e.g., individual, family, community) and support the development of skills to cope with psychological responses to these stressors. This may involve psychoeducation, processing, and development of culturally consistent coping responses (e.g., building support networks, spirituality). In the third phase, providers support Latinx immigrants in connecting to their cultural traditions, strengths, and healing practices. This may include developing an understanding of individual and family responses to ethno-racial trauma, identifying culturally relevant coping skills by eliciting historical examples of Latinxs that have faced and overcome challenges, maintaining cultural traditions, and identifying and celebrating the psychological strengths of the Latinx community. In the fourth and final phase, providers support Latinx immigrants and communities in building critical consciousness to collectively resist against systemic oppression and to achieve psychological liberation. This may involve helping Latinx immigrants identify the ways in which they can support systemic change through advocacy, volunteering, activism, and/or seeking leadership positions within their communities.

Support Networks

As pandemic restrictions are lifted and access to community resources return, it is important to tap into support networks that undocumented families can leverage. Latinx immigrant families utilize a wide array of services to support the emotional and behavioral development of their children (Benavides et al., 2021). For instance, a primary source of support for undocumented families are faith-based institutions that provide religious or spiritual gatherings and peer support groups, along with an array of psychoeducational and legal resources and services (Garcini, Daly, et al., 2021). Similarly, school systems, grassroot organizations, and community advocacy agencies are helpful avenues of collaboration for the delivery of mental health resources and low-cost referral services (Vázquez, Alvarez, et al., 2021). Building collaborative alliances or partnerships with the aforesaid institutions can facilitate the delivery of affordable, accessible, and convenient mental health services to undocumented families and youth, while providing a safe environment to overcome fear and mistrust (Garcini, Daly, et al., 2021). The provision of peer support family groups, psychoeducation, and English as a Second Language (ESL) classes may also help promote positive developmental trajectories among youths within undocumented families, although time constraints due to work and family responsibilities need to be considered in planning and scheduling. Public health messaging targeting the benefit of the aforementioned programming may promote interest in these services, particularly when using testimonials from community members who have benefited from the services offered.

Telepsychology and Self-Guided Interventions

In response to restrictions to in-person gathering, there has been a massive migration to telepsychology services during the COVID-19 pandemic (Burgoyne & Cohn, 2020). While restrictions on gathering have loosened, telepsychology is expected to remain an important avenue for delivering mental health services (American Psychological Association, 2021). Prior to the pandemic, this format had shown promise in reducing barriers to accessing mental health services among Latinx families (e.g., transportation, language, childcare; Stewart et al., 2017). Yet, despite apparent advantages and rapid scaling of telepsychology services, Latinx families have experienced significant disparities in access to teleservices (Cowan et al., 2019; Vázquez et al., 2021). Devising innovative ways to facilitate low-cost access to teleservices for undocumented families is needed, including leveraging videoconferencing, online forums, and social media to build support groups and a sense of community, along with bringing people together to raise mental health awareness (Falicov et al., 2020). Advances in self-guided mobile mental health interventions in Spanish may also present an avenue for increasing access to psychoeducation and the building of coping skills for undocumented families. Mobile mental health interventions are scalable, accessible, may be perceived as less stigmatizing than formal mental health services, and are promising in reducing psychological distress in a short amount of time (Ebert et al., 2017; Lui et al., 2017; Schleider & Weisz, 2016). The decentralized and private nature of mental health smartphone applications, along with its low-cost may help overcome salient barriers (e.g., fear, mistrust, cost) to mental healthcare faced by undocumented families. Further research is needed to adapt the aforesaid interventions to the mental health needs of undocumented families and youth, as well as to determine their efficacy and acceptability within this population.

Culturally Competent Service Providers

Mental health and medical providers, social workers, counselors, public health workers, and other allied health professionals serving undocumented immigrants may find it helpful to read the recently published Guide for Providing Culturally Competent Mental Health Services (Cadenas et al., 2022). The guide provides practical information on best practices and the use of valuable skills for working in the provision of mental health services to undocumented Latinx families and children. For instance, the guide highlights strategies for how mental health providers and allied professionals can make use of trauma-informed care, multicultural and social justice competencies, develop their understanding of legal and political contexts, and develop communities of support to bolster resilience among undocumented families. Important recommendations from these guidelines include increasing awareness of cultural factors that impact treatment (e.g., adjustment to new culture and language; access to social supports; anti-immigrant political messaging and policies), knowledge regarding contextual risk factors for developing mental disorders (e.g., discrimination, persecution), and focus on promoting resilience and growth. For providers conducting forensic immigration evaluations for court proceedings, the recently published Professional guidelines for psychological evaluations in immigration proceedings provide a discussion of foundational issues inherent to immigration evaluations and present nine essential guidelines for conducting psychological evaluations with immigrant families (Mercado et al., 2022). It is also important to emphasize that undocumented families are highly heterogeneous and that attention needs to be given to their multiple intersectional identities, which is essential to consider when evaluating and addressing their mental health needs (Chavez-Dueñas et al., 2019; Minero et al., 2022).

Conclusion

The adverse effects of chronic toxic stress, anti-immigrant climate, lack of legislative solutions, and limited access to healthcare in the face of compounded stressors from the COVID-19 pandemic have concerning implications for the mental health of undocumented parents and youth (Garcini, Rosenfeld, et al., 2022). Identifying innovative ways to address the complex mental health and social needs of undocumented families is essential to reduce risk and prevent further harm in this vulnerable, yet resilient population. It is essential that mental health, medical, and other allied health professionals become aware of the systemic oppression faced by Latinx immigrant families, provide culturally competent services, and support policies that would increase equitable access to health services.

Author Contributions

All authors contributed to the manuscript conception, material preparation, and writing. All authors commented and edited on various versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgments

This article is part of the special issue “Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Latinx Children, Youth, and Families: Clinical Challenges and Opportunities” edited by José M. Causadias and Enrique W. Neblett, Jr.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was funded by a grant from the National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI; K01HL150247; PI: Garcini). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.