Asking for help

Journal of Counseling & Development ■ July 2017 ■ Volume 95 309 © 2017 by the American Counseling Association. All rights reserved.

Received 11/03/14 Revised 11/11/14

Accepted 03/13/15 DOI: 10.1002/jcad.12145

Trauma and Resilience Among Refugee and Undocumented Immigrant Women Rachael D. Goodman, Colleen K. Vesely, Bethany Letiecq, and Carol L. Cleaveland

Migration and resettlement processes are often characterized by stressful and traumatic experiences. Immigrants may experience premigration trauma in their countries of origin and trauma during their migration journey. Furthermore, refugee and undocumented immigrant women navigate unique and ongoing stressors postmigration. In this study, the authors used a phenomenological approach to explore refugee and undocumented immigrant women’s experiences of trauma and stress and the ways in which they develop resilience to cope with these experiences.

Keywords: trauma, refugees, immigrants, undocumented immigrants, resilience

Rachael D. Goodman, Counseling and Development Program, Colleen K. Vesely, Early Childhood Education and Human Develop- ment and Family Science Programs, Bethany Letiecq, Human Development and Family Science Program, and Carol L. Cleaveland, Department of Social Work, all at George Mason University. Correspondence concerning this article should be addressed to Rachael D. Goodman, Counseling and Development Program, George Mason University, 4400 University Drive, Krug Hall 201C, MSN 1H1, Fairfax, VA 22030 (e-mail: [email protected]).

Of the approximately 40 million immigrants in the United States, 51% are women with varying statuses, including naturalized citizens, lawful permanent residents, refugees/ asylees, persons on temporary visas, and undocumented immigrants (Zong & Batalova, 2016). Although there is a growing body of research highlighting immigrant women’s unique lived experiences (e.g., Curran, Sha- fer, Donato, & Garip, 2006; Hondagneu-Sotelo, 1995; Sano, Garasky, Greder, Cook, & Browder, 2011), less is known about refugee and undocumented immigrants, who are particularly vulnerable to trauma because of their marginalized social positioning (Clarke & Borders, 2014; Goodkind & Deacon, 2004). Trauma exposures for refugees may be linked to persecution and violence that cause them to flee their home countries (Martin & Yankay, 2014), whereas undocumented immigrants may encounter assault and life-threatening conditions during the migration journey (Vogt, 2013). Once settled in the United States, immigrant women often endure myriad stressors (e.g., anti-immigrant environment, family sepa- ration) that can exacerbate previous trauma, often without much support (Chung, Bemak, Ortiz, & Sandoval-Perez, 2008; Menjívar & Abrego, 2012). In this study, we exam- ined how refugee and undocumented immigrant women experience trauma and stress in context and the ways in which they develop coping and resilience.

Trauma and Stress Experiences of Refugee and Undocumented Immigrant Women

Trauma has often been conceptualized through the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) definition of posttraumatic stress disorder (PTSD), which focuses on traumatic experiences that involve actual or threatened death or injury, or witnessing such events. However, scholars have advocated for an understanding of traumatic experiences that is ecosystemic, which would enable researchers and coun- selors to identify and address the complex sources of trauma that may not clearly fall within the DSM-5 definition (e.g., Burstow, 2003; Danieli, 2007; Goodman, 2013; Kira, 2010). In this article, our conceptualization of trauma was informed by Burstow’s (2003) definition: “Trauma is not a disorder but a reaction to a kind of wound. It is a reaction to profoundly injurious events and situations in the real world and, indeed, to a world in which people are routinely wounded” (p. 1302). Complex trauma connotes traumas that occur repeatedly, such as sexual abuse trauma (Herman, 1997). Trauma can arise from experiences of discrimination or systemic oppression, such as racism (Carter, 2007; Goodman & West-Olatunji, 2010). Trauma can also be transmitted across generations,

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which scholars have described as intergenerational, trans- generational, or historical trauma (Danieli, 2007; Duran, Firehammer, & Gonzalez, 2008; Goodman & West-Olatunji, 2008). As Kira (2010) noted in his cumulative trauma frame- work, single-incident models do not account for the complex and layered experiences of trauma, particularly when work- ing with marginalized populations who might experience intergenerational traumas that are socially made, such as poverty, discrimination, caste systems, and other social and cultural conditions. Therefore, our understanding of trauma includes the multiple ways in which individuals experience trauma, including single-incident trauma, complex trauma, and cumulative trauma (Kira et al., 2008). For refugee and undocumented immigrant women, an ecosystemic frame- work inclusive of multiple and systemic sources of trauma is needed to understand their multifaceted traumatic experiences that can occur before, during, or after migration, and which contribute to potentially disparate mental health outcomes.

Refugee and undocumented immigrant women are also likely to face ongoing structural and situational stressors that may further complicate and challenge coping and increase their vulnerability to poor mental health (Letiecq, Grzywacz, Gray, & Eudave, 2014). Structural stressors include poverty (Fortuny, Hernandez, & Chaudry, 2010; Kent, 2007), language barriers (Perreira et al., 2012), difficulty accessing resources (Sano et al., 2011; Yoshikawa, Godfrey, & Rivera, 2008), and difficulty obtaining employment (Chung et al., 2008; Wight, Thampi, & Chau, 2011). Family separation is another structural stressor, because it can take years for families to reunite—and some may never reunite—given the dangers back home, tightening of border security, and government backlogs in processing immigration cases (Letiecq et al., 2014). Situational stressors, which are more labile in nature, include perceptions of discrimi- nation and an anti-immigrant climate, worries about family welfare, and limited social supports (Grzywacz et al., 2010). Such exposures may have a kindling effect, in which individu- als with previous trauma and stress experiences may suffer increased negative effects from future exposures (Schumm, Stines, Hobfoll, & Jackson, 2005).

Psychological Sequelae of Trauma and Stress

As noted in the extant research, the question of how traumatic experiences and stressors are interpreted and integrated by survivors is pivotal for effective interventions that can improve coping and resilience (Marshall, Schell, & Niles, 2009; Nor- ris, Perilla, Ibañez, & Murphy, 2001). Although researchers acknowledge that the study of PTSD among immigrant La- tinas is relatively nascent, high rates of exposure to trauma suggest that this population is at high risk (Eisenman et al., 2008; Kaltman, Green, Mete, Shara, & Miranda, 2010; Pole, Best, Metzler, & Marmar, 2005). Researchers have found

conspicuously high rates of posttrauma symptoms (e.g., reexperiencing, arousal, avoidance) and depression among Latina immigrants and refugees from war-torn countries (e.g., Carta et al., 2013; Perez Foster, 2001; Santa-Maria & Cornille, 2007). A meta-analysis of 6,743 studies found that refugees, including Central Americans, now settled in Western countries are 10 times more likely to have PTSD than are age-matched populations in those nations (Fazel, Wheeler, & Danesh, 2005). This research, however, has yet to fully delineate how trauma and stress exposures affect women and how counselors might best intervene.

Coping and Resilience Beyond psychological sequelae, traumatic experiences can also generate unique strengths, coping mechanisms, and sources of resilience (Burstow, 2003; Goodman, 2013; Len- ette, Brough, & Cox, 2012). Resilience, according to Masten (2001), is an ordinary process and basic human adaptation to circumstances that occur in one’s life. Individuals who are secure and functioning well are often better able to tolerate adversity, yet there is no single pathway to positive adaptation. Resilience is dynamic in nature, is not an either–or status, and is influenced by one’s culture and context (Masten, 2001; Masten & Obradović , 2008).

Immigration researchers have begun to use resilience frameworks that are dynamic and contextualized. In 2012, Lenette et al. explored resilience among single refugee women with children; their research demonstrated the multiple ways in which marginalized women developed pathways to resilience in day-to-day tasks and within their social envi- ronments. Cardoso and Thompson (2010) systematically reviewed literature on resilience among Latino immigrant families. Their review revealed a confluence of risk and pro- tective factors, including community, familial, and cultural supports or strengths. Pulvirenti and Mason (2011), in their study of refugee women, concluded that resilience is a col- lective process. Taken together, extant research demonstrates the complex psychological experiences of individuals in stress-inducing contexts and calls for resilience to be con- ceptualized beyond the individual. In this study, we explored the multiple sources of trauma and stress that refugee and undocumented immigrant women experience and how they coped and adapted in context. Specifically, we investigated the following research questions:

Research Question 1: What sources of trauma and stress do immigrant women experience pre- to postmigra- tion?

Research Question 2: What is the psychological symp- tomatology related to women’s trauma exposures and situatedness in the United States?

Research Question 3: How do women express resilience as they cope in a new country?

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Method We used a phenomenological approach to search for and describe shared meanings among immigrant women (Giorgi, 1997). Such an approach is particularly effective when seek- ing to join with and better understand hidden and marginalized populations (Clarke & Borders, 2014). Well-conceived, rigor- ous phenomenological studies proceed on the understanding that researchers are listening to recollections of experiences influenced by culture and social location (Patton, 2002) and are examining how respondents make meaning of their lived experiences (Creswell, 2009). Phenomenological studies must be designed to allow for a “fresh perspective” in which re- searchers seek understanding “through the eyes of those who have direct, immediate experience with it” (Hays & Wood, 2011, p. 291). By bracketing assumptions and using clearly articulated methods, phenomenologists seek to limit personal bias in interpretation (Gearing, 2004). Our overarching goal was to “re-center the multiply marginalized” (Goodkind & Deacon, 2004, p. 721) and give voice to the nuances of im- migrant women’s experiences.

Participants

Participants were 19 immigrant women, of whom 10 were undocumented immigrants and nine were refugees. Criteria for undocumented immigrant women were that they origi- nated from Mexico, Central America, or South America and that they crossed the Mexico–United States border as adults without authorization. The criterion for refugee women was that they identified as having been or were continuing to be persecuted or under threat in their country of origin (COO); refugee women were from the Middle East and Africa and had either refugee status (n = 8) or asylee status (n = 1). We do not include the refugee women’s COOs to ensure these women’s safety from persecution given their reasons for coming to the United States. All women in this study were considered poor based on the federal poverty threshold; the mean age was 35.6 years (SD = 8.3, range = 26.0–62.0), and the mean time living in the United States was 5.2 years (SD = 5.9, range = 0.4–18.0). Women were identified using pseudonyms.

Data Collection

After obtaining institutional review board approval, we purpo- sively sampled participants to ensure some variation in their experiences (e.g., migration experiences, immigration status, parental status; Patton, 1990). This sampling plan ensured that certain information-rich women were invited to partici- pate (Patton, 2002). Undocumented immigrant women were recruited from three social service delivery sites in suburban Washington, DC. The sites are home to support groups for Latinas, food banks, language classes, and referrals for legal aid and social programs. Refugee women were recruited from

a nongovernmental organization (NGO) responsible for their resettlement in the Washington, DC, area. All participants consented to participate by reviewing and signing an informed consent form prior to being interviewed. Participants were made aware that they could ask questions throughout the study and that they could withdraw from the study at any time without consequence.

In line with a phenomenological approach, we conducted individual in-depth interviews. We used a method of structured discovery in which we focused on specific topics but allowed flexibility for other areas of focus to emerge. This method al- lowed us to discover the range of women’s experiences, while limiting the imposition of our own preconceived ideas (Burton, Skinner, & Matthews, 2005; Roy & Burton, 2007). We asked lead questions on topics of interest and followed up with prob- ing questions to gather more detail. Interviews were conducted in women’s homes, public spaces, or community organizations, depending on the participants’ preferences.

The interviews were conducted in different languages based on the participants’ preferences and language abilities. Among the refugee women, participants were given the choice to conduct the interviews in English or with an interpreter who was a native speaker of their preferred language. The first au- thor conducted five interviews in English and four interviews with experienced interpreters. Of the interviews with an in- terpreter, two were conducted in Arabic and one each in Farsi and Dari. The third and fourth authors conducted interviews with undocumented immigrants in Spanish. Both authors have at least a limited working proficiency of Spanish and used a supervision method wherein interviews were led by graduate research assistants who were native-born Spanish speakers. Interviews conducted in Spanish were first transcribed in Spanish by native speakers and then translated into English. Given the differences between written and spoken Arabic, Farsi, and Dari, these interviews were transcribed directly into English by native speakers. Translation and transcription of the interviews were checked by research assistants to ensure accuracy. Probing questions helped ensure understanding of questions and responses while working across several languages. All interviews were coded in English by the first and second authors.

Role of the Researchers

All four researchers are women, identify as White from Euro- pean American backgrounds, and are full-time faculty mem- bers. All have spent time both personally and professionally with refugee and/or undocumented immigrant communities. Philosophically, the researchers are all committed to conduct- ing research that is culturally competent and that addresses the social injustices and structural inequalities that marginalized communities face. Therefore, we assumed that participants in our study were likely to have experienced social injustice and inequalities both in their COOs and in the United States;

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manifest psychological symptoms of stress and trauma given their situatedness; and possess unique personal-, familial-, and cultural-based strengths. Although we are not members of these communities, our connections and our varied identi- ties as women, mothers, and scholar-activists sensitized us to the unique challenges likely faced by the study participants.

Trustworthiness of the Data

Throughout data collection processes, specific strategies were used to increase credibility, transferability, dependability, and confirmability—all indicators of trustworthiness in qualita- tive research (Guba, 1981; Hays & Wood, 2011; Krefting, 1991). Strategies included spending lengthy time in the field; collecting rich, thick descriptions of women’s experiences; consulting with multiple sources to verify meanings; and triangulating our data sources and methods. We spent ap- proximately 6 months in the field engaging with refugee and undocumented immigrant women in their communities and homes. This extended field engagement enabled us to become familiar and trusted among the women and to observe their experiences over a period of time. We used audio-recorded interviews to gather quotations from participants, which of- fered direct evidence and allowed for rich, thick description of their lived experiences (Krefting, 1991).

We also attended to trustworthiness of the data throughout the process of translation and interpretation. As Polkinghorne (2005) wrote, researchers should “understand that translations of gathered data from one language to another may distort meaning . . . [and] that participants vary in their facility to ex- plore experience and to express the exploration in language” (p. 139). We understand that language is only a representation of human experience and is influenced by the positionality of respondents and the reflexive nature of qualitative inquiry (Polkinghorne, 2005; Temple & Young, 2004). Therefore, we often verified meanings with native speakers. We consulted with multiple sources, including refugee and undocumented immigrant women and research team members who were natives of the participants’ COOs and/or fluent in their native languages. Such strategies have been recommended by quali- tative methodologists to avoid idiosyncratic interpretations of data (Forsyth, Stapleton, Levin, Lawrence, & Willis, 2007).

To ensure data quality and, in turn, trustworthiness re- garding study findings, we also used various methods of triangulation. We used multiple data sources and methods, including field observations and in-depth interviews. We turned to women in our targeted communities and research team members to gain cultural insights about our findings. We triangulated investigators, given that there were multiple interviewers of the participants, and we discussed and pro- cessed our fieldwork experiences during weekly research team meetings. Two of the four authors coded the data inde- pendently, verified the other’s codes, discussed discrepancies, and reached agreement on final codes used to identify study

themes. Together, these methods of triangulation increased the credibility, dependability, and confirmability of the study findings, and aided our ability to tell more nuanced stories about the women’s experiences.

Data Analysis

Data were stored, managed, and coded in ATLAS.ti (Version 7.5), a software program designed to assist researchers in managing qualitative data. Given the sensitive nature of these women’s stories, we worked diligently to ensure that their identities were protected by using identification numbers and pseudonyms throughout the study. We kept the data in password-protected files within password-protected comput- ers. Guided by our phenomenological approach, we conducted three waves of coding. First, we began with bracketing our bi- ases and assumptions through the development of data-driven, literal codes, which are argued to be more true to the “raw” (Boyatzis, 1998, p. 30) information than are thematic codes. Only after this first wave of coding and the creation of parent trees were codes examined for patterns. During this second wave of coding, the parent trees most salient to the research questions (e.g., psychological experiences, traumatic events, coping) were read across all of the interviews to understand the various dimensions of each category. For example, in ex- amining the parent tree related to stress and worry, we found that both structural and situational stressors were associated with family separation and economic marginalization. Dur- ing the third analytic phase, we made connections among the parent trees to tell the story of participants’ experiences of trauma, stress, coping, and resilience.

Results Four themes and several subthemes emerged from our analyses. In the first theme, experiences of trauma, women described three particularly salient types of trauma: (a) sociopolitical-based trauma (i.e., trauma related to the sociopolitical contexts in which they were situated), (b) status-based trauma (i.e., trauma related to their immigra- tion status), and (c) postmigration trauma (i.e., trauma that occurred once in the United States). In our second theme, we explored women’s experiences of structural and situ- ational stressors, some of which were fixed or very difficult to change whereas others were more labile in nature, and two emergent subthemes: (a) family separation and (b) em- ployment, economic, and situational stress. The third theme, psychological symptomatology, focused on women’s mental health concerns, including posttraumatic stress symptoms, depression, and suicidality. The final theme, processes of coping and resilience, explored the ways in which women persist in difficult environments using both external (e.g., social supports, community resources) and internal (e.g., beliefs about a better future) processes of coping.

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Experiences of Trauma

Women’s traumatic experiences reflected their reasons for migrating, how they migrated, and their situatedness as women and as members of various ethnic, religious, or political groups. Some women reported experiencing premigration trauma, including child abuse and intimate partner violence; however, most participants’ trauma exposures highlighted the intersection of their countries’ sociopolitical context, immigration status in the United States, and postmigration experiences.

Sociopolitical-based trauma. Sociopolitical-based traumas were particularly salient for the refugee women in our study, who all reported leaving their COOs because their lives and/ or the life of a family member were in danger. A few women reported that they were unsafe in their home countries be- cause of military occupation, the presence of armed militias, or general conflict and social unrest. Most of the refugee women reported that they and/or their families were targeted for religious, ethnic, and/or political reasons. For example, Charline’s husband was imprisoned because he became po- litically active in their African country; he was smuggled out of the country to avoid likely death. Charline’s life was also threatened, and she was eventually able to reunite with him in the United States. In Maryam’s case, her husband revealed to coworkers that their family belonged to a religious sect outlawed by the government of their Middle Eastern country. After his coworkers reported him to authorities, the family fled to avoid imprisonment and possible capital punishment. Bisrat’s husband was taken by the military of her African country’s government; he disappeared and she still does not know where he is. Undocumented immigrant women also reported that their COOs were unsafe, particularly because of drug-related gang violence and poverty, and several women discussed their history of fears and threats to their safety and the safety of their families.

Status-based trauma. Crossing borders without papers engendered dangerous journeys that were characterized by traumatic events for many of the women. All of the undocu- mented immigrant women and two refugee women left their COOs without documentation. These women experienced and/ or witnessed at least one of the following during the journey: gang rape, rape by a single individual, extortion, robbery, physi- cal assault, threats of gun or knife/machete violence, hunger, thirst, abandonment in dangerous areas, severe heat, and being held captive. Many of the traumatic experiences were gendered in nature, given that women were raped or threatened with rape. Camila described being gang raped and humiliated during her journey from Bolivia:

One night when we were in the desert three men raped me. . . . They took my clothes and made me walk naked . . . and they made fun of me saying rude things. The worst is that they raped me in front of the other people but no one dared

to defend me because they were scared they would be left in the desert or that they would be killed or raped as well.

Many of the women suffered by virtue of the transportation used in smuggling, including experiencing dangerous heat or lack of water. Gabriela, a Honduran, saw other migrants being assaulted and thrown from a train. Women also spoke of the physical and psychological suffering and their fear for their lives or the lives of their children during their journey. Florencia, a Mexican woman, reported, “That was our fear, that they would hit our children or that they would rape my 11-year-old daughter.” Gabriela noted, “The delinquents and the Mexican police abuse, steal, extort, rape, assault, mistreat, and they even kill people if you don’t give them what they ask of you.”

Prior to receiving refugee status, Bisrat initially fled her African country on foot with the assistance of a paid smuggler. Like undocumented immigrants from Mexico and Central America, she endured an arduous journey and feared for the safety and survival of herself and her two children who were traveling with her. As a part of her journey, she spent 5 years in a refugee camp, which was also characterized by traumatic experiences, including the threat of sexual assault and witnessing others being raped and abused.

Postmigration trauma. Women also reported traumatic experiences following their arrival in the United States, par- ticularly in relation to family and structural violence. Family violence–based traumas were gendered, in that they included physical, verbal, and sexual abuse by a partner or family member and threats of assault or death. Elisa, an immigrant from El Salvador, described her experience: “When I came to this country, my brother received me. [He] is a very violent young man. . . . He drinks, he hits me, he used to kick me.” Marlen, also from El Salvador, described how a pregnancy due to rape affected her experiences of trauma postmigration:

I didn’t know I was pregnant because in all three attempts of crossing I had taken the [birth control] shot. When I arrived here . . . the only thing I wanted was to get rid of the child, but I couldn’t because I was already too far along into my pregnancy. So I decided to have my child, but wanted to give him up for adoption. . . . I felt my child was a mistake. . . . Then I arrived to an uncle’s house and he also wanted to abuse me. He asked me to be with him in exchange for food, because I couldn’t work due to my pregnancy.

Particularly among refugee women, we found partici- pants who were experiencing what Smith and Freyd (2013) referred to as institutional betrayal trauma, or wrongdoing by an institution upon which an individual relies. Most of the refugee women felt that they were made promises by government officials that if they came to the United States, they would be taken care of and offered a better life. However,

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refugee resettlement supports, including rental assistance and other benefits, are short lived and decreasing because of limited resources, often only lasting 8 months at the most. When those resources ended, refugees reported feeling disil- lusioned, abandoned, and let down by the U.S. government. This resource cliff was especially devastating for single mothers with children who were struggling to make ends meet in a high cost of living area, where some had yet to master English, had difficulty securing employment, and had few child care options. Indeed, several women in the study were facing eviction. One woman remarked that the U.S. government “wanted us here and then does nothing to help us.” Bisrat described her experiences adjusting to the United States and particularly the challenges she experi- enced navigating various agencies:

I am happy to come to America. But after 8 months they say, “We’re done [and cannot] help you. When you work, we not do anything.” I say, “Where do I put my children? [It is] only me in this country.”

Structural and Situational Stressors

In addition to the complex trauma exposures, the women in our study experienced myriad stressors during their mi- gration and adaptation to life in the United States. Women experienced both structural stressors (e.g., poverty, lengthy family separation) and situational stressors (e.g., perceptions of discrimination). Structural and situational stressors inter- sected, leading to an accumulation of stressors. For example, language barriers, employment challenges, and economic marginalization were connected to women’s perceptions of discrimination. Here, we detail two emergent subthemes: (a) family separation and (b) employment, economic, and situational stress.

Family separation. Most participants in this study re- ported experiencing stress related to family separation and worry about family members. Because most participants’ extended families remained in their COOs, some participants were permanently separated from their families. Undocu- mented immigrant women reported fears of never seeing their families again, because they would not be able to return if they left the United States owing to the dangerous jour- ney and their lack of legal status. Among refugee women, some had not seen their families for years and could never return to their COOs for fear of persecution. Both groups of women noted that their families could not come to the United States because of the dangerous journey and/or a lack of financial means or migration papers. For the majority of women, connection to their families was through telephone communication. Most women wanted to call home to their families weekly or even daily, but cost and their families’ limited access to phones made this challenging. Bisrat described that in her country “they cut the telephone” on

Sunday and her family cannot charge the phone she got for them because often “they have no electricity.” Some women chose not to call their families as frequently because they were deeply affected emotionally by these conversations or they found their families to be unsupportive (e.g., nega- tively judging their decision to leave) or to make requests (e.g., sending remittances) that were unattainable given the women’s financial circumstances.

Concern about their families, both back home and in the United States, was a salient stressor for all women in the study. With regard to family in their COOs, women were worried about elderly and ailing family members, siblings who were struggling financially, and their children left behind with kin. Women also worried about how the migration process itself would affect their children. For example, Maryam and her family initially traveled to Thailand from their COO to escape persecution while awaiting refugee status. During their 2 years in Thailand, her children were unable to attend school because of high costs. Once in the United States, Maryam was “very scared about my kids’ future” and noted that one of her sons had “lots of problems from reading and writing.” Indeed, many of the women expressed concerns about their children’s exposures to trauma, overall well-being, and adap- tation in the United States; however, many were also hopeful that their children would be better off in the United States than back in their COOs.

Employment, economic, and situational stress. All un- documented immigrant and refugee women in this study were experiencing significant structural stressors related to their ability to meet the economic needs of their families. The chronic stress of living in poverty was evident in every inter- view we conducted; thus, addressing traumatic experiences was often secondary to their concerns about their families’ financial security.

One salient economic stressor that affected both groups of women related to the cost of migrating to the United States, which left many in significant debt. Refugees were required to pay back the cost of their travel from their COO to the United States. Emira reported that her family would like to return to her COO in the Middle East, but they could not af- ford the airfare and still owed around $4,000. Undocumented immigrants, particularly those from Central America, faced even greater costs. To be led by a coyote from El Salvador, Honduras, or Guatemala cost around $10,000; Mexican women paid approximately $5,000 for the shorter journey. Failure to repay the coyotes meant longer and more difficult trips for some women. For example, Elisa’s coyote held her for 2 months while she waited for her family to be able to pay the remainder of what she owed him.

Once these women were settled in the United States, lack of legal documentation made the struggle to find employment even more challenging. Employment available to undocu- mented women was under the table at restaurants or as domestic

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help. In a couple of cases, women were propositioned to work in what they considered to be compromising jobs, such as sex work. Noemi, a Honduran woman who was raised in Mexico, described her experience of looking for work:

I asked everywhere to work. They asked me, “Do you have papers?” I answered “no” and they would tell me that they couldn’t give me a job. . . . [People I lived with] told me I could only work . . . as a prostitute. . . . My supposed “friends” wanted me to work as a prostitute.

The challenge of finding acceptable employment was felt by women with papers as well. A few women who completed higher education and had professional occupations in their COOs found it degrading to work in a minimum-wage or lower class job, such as cleaning houses or working in retail. Women also perceived discrimination, often based on eth- nicity or religion, when attempting to secure work. Emira, who wears a head scarf, described her experience: “And they told me that [the manager] . . . only accepts Hispan- ics. . . . It’s discrimination. . . . [Another manager] looked at me, up and down, he said ‘no.’ They don’t want people that wear [the] hijab.”

For some participants, access to employment was compli- cated by chronic health issues with limited access to health care. Nafy, an African woman whose husband was not in the United States, described how her struggles with rheumatoid arthritis shaped her abilities to be employed:

I have a problem with my bones. I drop the cups. I drop the knife. . . . Here I still don’t have [medical care]. I’m waiting to meet with the doctor. . . . I’m sick. I can’t work right now. . . . If I could have treatment and learn the language a little, I could work.

In addition to employment challenges, women without documentation had limited or no access to social service benefits and in some cases were scared to ask for help. For example, Marlen explained that “it has been difficult because sometimes I’m scared and I worry if they [social service agencies] would ask me about my immigration status. . . . I’m afraid they would probably call immigration and report me.” To make ends meet, some women took risks because they had limited choices. Nafy, who was on her own with two small children, rented out the second bedroom in her apartment to a man who was not related to her because when the 8 months of rent support provided by the resettlement agency ended, she could not afford the apartment that the resettlement agency placed her in. She had only government cash assistance and had not been able to find a job because she did not speak English and had chronic health problems. In these dire situations, women, regardless of their immi- gration status, relied on food banks, donated clothing, and shared housing.

Psychological Symptomatology

Women’s psychological symptomatology reflected the confluence of many complex factors from past and present trauma and stress experiences. Many of the women described symptoms that align with the DSM-5 (APA, 2013) criteria for PTSD, which include intrusion symptoms, avoidance, nega- tive mood and cognitions, and arousal symptoms. Women reported nightmares, an intrusion symptom, related to a specific aspect of their migration story. Camila, for example, described how trauma on her journey affected her: “I arrived sick and lost a lot of weight and it affected my heart. I dreamt about the trip and woke up scared and crying.” Arousal and reactivity were noted in women who reported being mad or easily irritated, which, in some cases, affected their relation- ships. Marisol, a Mexican woman, described how she would become angry and treat her children poorly but that this symptom improved over time through a parenting support program. Avoidance was commonly noted among the women as they described purposefully not thinking about traumatic events. Charline described her experience waiting for the paperwork for asylee status: “Yes, it took long. It was very traumatic. I don’t want to think about it too much. . . . I try to not think about it.” Although avoidance could be viewed from a pathological lens, from a nonpathological lens we inferred that women used avoidance as a means to buffer the psychological pain associated with their trauma histories and current life circumstances.

Participants also experienced negative changes in cognitions and mood, a new PTSD criterion added in the DSM-5 (APA, 2013). When asked about how her past abuse affected her, Marlen described her feelings of shame and negative beliefs about herself:

I always had in my mind that I wasn’t worth anything, I suffered because I felt that after being raped I wasn’t worth anything. I thought that no one would want to marry me. No one would want to pay any attention to me, also for having a child as a result of an abuse.

Maryam, who feared persecution in her COO because of her religion, reported that those fears continued in the United States: “And I am very, very scared. . . . I am scared if I told [my religious sect in] front of Muslim ladies. . . . In America now I know that I am a safe, but I am a scared.” Thus, her fears reflected both negative cognition and hypervigilance, an arousal symptom.

Elisa reported a lack of interest in activities, detachment and isolation from others, and ongoing negative beliefs. She described how the trauma during her journey affected her:

There is always . . . that thing you always think. What you have suffered will never be erased from your mind. . . . I don’t really like to go out, I don’t like to socialize with anyone,

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only watch television, being there. And the depression . . . like, it hurts a lot.

Elisa also felt intense regret and loss related to her relation- ships with her children who she left in her COO when she came to the United States: “Yes, I think I should never have made that trip, because I left my children. You lose the love of your children, you lose many things.” Some women re- ported intense homesickness and ambivalence about being in the United States. Some also reported that their symptoms worsened over time and that they felt worn down by the layering of trauma and stress. Maryam described feelings of shame, sadness, and loss of dignity related to the type of work she had to do in the United States. She remarked on the impact, given that she and her family had attained higher education degrees in their COO that were not useful in the United States.

A few participants expressed suicidal ideation in which they thought about ending their lives or wished to no longer be living. Rahila, a Middle Eastern woman, reported abuse by her former husband. She contemplated suicide because of the trauma and stressors she encountered:

I am tired of this life. . . . First of all I can’t find a job, it’s not easy to find work, because I don’t speak English. . . . Since my marriage to that man and ever since my kids have been born, I faced and had to put up with his tyranny. . . . Now, I am so exhausted and tired of living like this, I don’t know what to do or where to go.

Processes of Coping and Resilience

Women in our study developed ways to persist despite the significant traumatic and stressful experiences that they faced. We focus on both external processes, such as family, social support, and government resources, and internal processes, such as beliefs and faith.

External processes. In developing resilience and coping, women noted the importance of external supports and their situatedness in terms of accessing these supports. Access to resources was influenced by several factors, including geo- graphic location, family circumstances, immigration status, and social networks. The presence of a male partner was a support for several women, who received emotional sup- port or a sense of partnership from their male partners. For Nadira, a refugee from the Middle East, the relationship with her husband provided structural and psychological support, which facilitated her ability to access additional resources that supported her resilience: “We always share. We talk, so that’s really helpful. Especially here, when I am alone here. All the time I share everything about my job, whatever happen to me when sometimes I am sad.” Nadira’s spousal relation- ship also offered support via shared financial and child care responsibilities. Single mothers faced challenges to resilience

given the stressors associated with raising children alone and their lack of institutional supports.

Social supports and interpersonal relationships were im- portant for women in developing resilience. Having access to others who shared the same national origin or language offered the opportunity for some women to develop social support and friendship. Julieta, an immigrant from El Sal- vador, discussed the impact of a support group she attended:

The program here has helped me to improve my relationships, . . . how to treat children, the husband, and how to treat your neighbor, . . . how to ask for help. . . . I also like that they teach us that we have to be independent because there are many people who depend on the man, accept everything . . . the abuse and everything, . . . but I say that is not for me.

Several women were isolated and lacked access to both formal and informal supports. One of these women, Marlen, reported that the interview for this study actually served as an opportunity to receive social support through the sharing of experiences.

Women also noted the resources and social services that they were able to access as important to developing coping and resilience. For example, English classes were available to the refugee women through their resettlement agency. The refugee women also had access to initial resettlement funds from their resettlement agency and a case manager who often bought sup- plies for their homes and helped them navigate social services when they arrived. Having immediate assistance upon arriving in the United States was of great help to many of the women. When Nadira and her family arrived, the caseworker met them at the airport, which made them feel supported. Nadira reported that her coping was also facilitated by the resettlement assistance she and her family received, including help with rent payments and a cultural orientation. It should be noted, however, that refugee women had varied experiences with their resettle- ment agencies, which suggests that the quality of services was not consistent among the agencies. Undocumented immigrant women lacked access to many of these services or had to foster such supports through informal networks and NGOs; therefore, access to support for these women varied greatly.

Internal processes. Women’s beliefs and ways of thinking about and reframing their experiences were part of how they coped with traumatic events and stressors. These internal processes were particularly important for women who did not have access to external supports. Women coped by pur- posefully not thinking about their experiences and distract- ing themselves. Camila used this process to cope with her intrusion symptoms:

I don’t like to talk about that trip with anyone. I never men- tioned what happened to me during the journey to my children because I don’t want them to suffer. Now I almost never think

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about that trip. I take care a lot because I don’t have medical insurance. . . . I eat well and sleep well and always go to these classes to distract myself.

Other women also reported using classes and jobs to distract themselves from emotional pain.

Religious beliefs were also salient for many of the women in this study. Julieta described how she prepared for the dangerous journey to the United States: “The only thing I said was that I was putting myself in the hands of God.” When she encountered danger during her journey, she prayed to a patron saint and believed that this saint protected her and the child under her protection. Other women reported that when they were having hard days they would pray, read religious texts, and remember to have faith. Beliefs about the benefits of being in the United States were also helpful for some women. This belief varied based on their unique situatedness, which reflects the interconnectedness of external and internal processes. For example, women who had children in the United States reported that they believed that it was better for their children in the United States (compared with their COOs) in terms of education and safety. Bisrat described how she viewed the opportunities for her children in the United States: “For my children it’s good here. . . . [In] this country they have the school, they have everything. . . . I am happy for my children. But now for me it is not easy.”

Discussion Taken as a whole, our findings suggest that traumatic experi- ences are rooted in the contexts that individuals encounter, as are stressors, mental health outcomes, and resilience processes. Although there were differences among the women in our study based on their immigration status (i.e., refugee or undocumented immigrant), both groups of women were vulnerable to multiple sources of trauma because of complex and intersecting factors related to their gender, COO sociopolitical context, status, and situatedness in the United States. In line with the work of Schumm et al. (2005), these traumas were compounded by familial separa- tions and other structural and situational stressors that the women encountered postmigration. To cope with hardships, many of the women relied on both external strategies, such as reliance on government supports (if eligible), and internal strategies, such as their faith and their positive beliefs about the opportunities in the United States (e.g., safety and education for their children), thus reflecting the ecosystemic nature of resilience processes.

Intersecting and Overlapping Experiences of Supports and Barriers

Although researchers have examined trauma within immi- grant groups, few studies have included both refugee women and undocumented immigrant women in one study. Early in our work with these communities, we made assumptions that refugee women would be better positioned in the United

States to access resources and mitigate the trauma exposures and stressors associated with relocation. However, it quickly became clear that these two groups of women shared many similarities and that both groups are situated in a matrix of domination and systemic oppression (Collins, 2000) that hinders their abilities to cope as individuals and within their families.

For refugee women, their status offered them access to resettle- ment supports and services, but these services were extremely time limited, which created a resource cliff that was financially and emotionally jarring. Furthermore, these services varied in quality and type depending on the particular resettlement agency assigned to a refugee. During this study, many resettlement agencies’ budgets were unexpectedly cut to divert funds to the thousands of unaccompanied minors who journeyed to the United States to escape danger in Central America. This change illuminates the precarious position of refugees who, when they arrive in the United States, encounter support that is much less than what was expected and, as a result, experience acute feelings of institutional betrayal (Smith & Freyd, 2013).

For both refugee and undocumented immigrant women, their inability to find employment and develop financial security in the United States was a chronic stressor. As has been noted, im- migrants come to the United States often perceiving this country as the land of opportunity, where hard work and determination can lead to a better life and even economic prosperity (Vesely, Goodman, Ewaida, & Kearney, 2015). Women in this study, however, were rendered economically insecure and experienced challenges in meeting their families’ basic needs because of high living costs coupled with limited or no income or government assistance. Women faced limited job prospects because of the economy as well as their lack of legal immigration status and/ or language barriers. Even women who had access to job search assistance faced barriers such as needing child care or bus fare, which suggests that economic security must be addressed from a multisystemic perspective. Women’s economic needs were so high that despite facing severe mental health issues, their main focus was on securing employment and navigating edu- cational, social welfare, health, and child care systems on behalf of their families. For both groups of women, their encounters with systems of care often exposed them to poor treatment and discrimination because of their social status, race/ethnicity, and English language skills. Such encounters and institutional betrayals likely exacerbated stressors and poor mental health, while also deterring help seeking.

The Ecosystemic Nature of Trauma, Stress, and Resilience

The sociopolitical context and violence, such as war and political unrest, of immigrant-sending countries have been documented in other studies (e.g., Gonzalez-Barrera, Krog- stad, & Lopez, 2014), as have women’s vulnerabilities to violence and trauma during their migration and postmigration

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journeys in the United States, especially when lacking papers (Hass, Dutton, & Orloff, 2000). Although this study did not capture all sources of trauma experienced by refugee and undocumented immigrant women, our findings point to the complexities of trauma exposures across ecological layers. The intersections of sociopolitical context, gender, legal sta- tus, and economic marginalization rendered women vulner- able to traumatic experiences across contexts, in their COOs, along their migration pathways, and in the United States. The lack of external resources once in the United States rendered women particularly vulnerable to an accumulation of stress- ors, which appeared to exacerbate past traumatic experiences or expose women to new traumas.

Women’s descriptions of their psychological states dem- onstrate the significant and often overwhelming impact of trauma and stress experiences. In addition to confirming the presence of PTSD symptoms found in other studies (Fazel et al., 2005), this study reveals how women experienced the specific sociopolitical context in which they were situated and confirms the need for an ecosystemic perspective on trauma that goes beyond the DSM-5 (APA, 2013) criteria for PTSD. For example, refugee women who believed that they would be supported in the United States felt an acute sense of institutional betrayal (Smith & Freyd, 2013) when they encountered inad- equate government and social service support once they were in the United States. Long-term stressors and the confluence of traumatic events appeared to lead to worse psychological symptoms for some women. However, given the variance among refugee and undocumented immigrant women in terms of the severity of their psychological symptoms despite having seemingly similar trauma and stress experiences, more research is needed to understand these women’s psychological outcomes.

Findings also demonstrate the ecosystemic and layered nature of resilience processes. Women noted the confluence of individual, familial, and social supports and resources that they were able to garner as important to developing coping and resilience. When faced with barriers to external sup- ports, some women appeared to muster internal resources, which suggests the need to explore the relationship between these two facets of resilience processes. There was also variance among women in terms of the ways that family connection fostered resilience processes. Women in this study developed ways to cope with family separateness and to navigate family connections given a complex set of circumstances, including financial barriers, emotional pain of being connected or disconnected, and their own deci- sions to migrate. Some women opted to limit or cut ties rather than endure the pain and hardships of maintaining them. This finding challenged extant assumptions about immigrant informal support networks (Leslie, 1992) and suggests that some refugee and undocumented immigrant women experience feelings of isolation even when living in densely populated immigrant enclaves.

Limitations Participants in our study were recruited via agency connec- tions and snowball sampling, which may limit transferability to refugee and undocumented immigrant women who are not connected with agencies or others in their communities. Therefore, we may not have reached the most marginalized among this population, such as women who are without homes. Furthermore, participants’ experiences are influenced by a number of factors, including their COO, their family situ- ation, and their education or language abilities. Therefore, the trauma, stressors, symptomatology, and coping reported in this study may differ among refugee and undocumented immigrant women with different backgrounds. Location and context in the United States should also be carefully considered, given that access to resources, cost of liv- ing, and other context-specif ic factors likely influence women’s experiences.

Implications Our findings point to the critical importance of a multifocal approach in the work of counselors. The women’s experiences clearly indicate the manifestation of systemic forces (e.g., immigration policies, government resources) on the lives of refugee and undocumented immigrant women. Ecosystemic factors influence women’s vulnerabilities to trauma, the types of trauma exposures and ongoing stressors, and their abilities to access both external and internal mechanisms to promote resilience. Thus, counselors must be prepared to understand and address the ecosystemic factors that affect the clients they serve, especially those who are vulnerable to sociopo- litical and status-based violence and have limited access to resources. On the systemic level, counselors must advocate for changes to policies, laws, and practices that negatively affect clients. Such advocacy may involve addressing discrimina- tion and nativistic aggressions from the majority culture that generate and sustain anti-immigrant sentiments and policies.

In addition to this broad-based advocacy work, coun- selors must also use their understanding of structural factors in their work with individual clients, families, and communities to include traditional and more innovative counseling approaches. Outreach to marginalized com- munities can build partnerships with community leaders and natural healers that can enable counselors to provide services that are aligned with the needs and worldviews of community members (Goodman, 2014). Community-based participatory research is one such model of engagement in which communities and researchers develop partnerships that might include research (e.g., survey of community needs) and action steps, such as resource drives or social events (Letiecq & Schmalzbauer, 2012). Assisting clients with meeting immediate economic and resource needs and

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accessing language classes, child care resources, or job op- portunities can help facilitate women’s resilience. Increas- ing connections among community members can increase information and resource sharing, as well as build social supports and solidarity for potential advocacy work on a broader scale. Counselors can facilitate the development of communities of resistance in which women can come together to question/reject oppressive narratives, cultivate empowerment, and generate advocacy action (Watkins & Shulman, 2008). Building links across other institutions and service providers who have connectivity with refugee and immigrant families can support immigrant families as they build their social networks among other parents in similar situations and learn how to navigate institutional supports in a new country (Vesely, Ewaida, & Kearney, 2013).

Finally, there is a critical need for counselors to offer culture-centered mental health services to immigrant women. Although some women reported that some symptoms less- ened over time, other women reported serious and ongoing psychological outcomes that affected their emotional well- being, their familial and social relationships, and their ability to access or develop resources. Counseling services need to be made available to women in ways that are accessible in terms of cost, location, and language. Furthermore, counsel- ing services need to address the specific needs of women by incorporating an understanding of systemic factors, adhering to individual and/or cultural beliefs and values, and address- ing common and unique psychological outcomes. Because discrimination can be a form of trauma, culture-centered models of healing, such as the culture-as-treatment approach (Gone, 2013), offer a promising modality for counseling clients, particularly those facing trauma and stress related to their cultural, ethnic, or religious identities.

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