6200 Week 8 Assignment: Connecting Knowledge and Research

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p a r t TWO

Immigration and Social Work Practice

Social Work with Immigrants and Refugees, Second Edition : Legal Issues, Clinical Skills, and Advocacy, edited by Fernando Chang-Muy, and Elaine P. Congress, Springer Publishing Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=4102341. Created from waldenu on 2021-07-23 03:32:37.

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c h a p t e r THREE

Culturally competent social work practice (CCSWP) is an ethical responsibility for all social workers (National Association of Social Workers, 2001, 2008) and an absolute necessity when working with immigrant populations. Social workers need to understand the full spectrum of issues faced by immigrants before they leave their country of origin, what they experience immigrating, and what they face on arrival in the United States (Drachman, 1992; Pine & Drachman, 2005). Immigration imposes a sociocultural, economic, and psychological toll on people that does not go away completely over time.

Cultural competence requires a holistic approach that combines biological, psychological, social, and internal spiritual elements in services, allowing for the opportunity to address other major problems clients may have such as depression, low self-esteem, and family problems. Culturally competent practice includes, but is not limited to, knowledge of a range of cultures, histories, worldviews, val- ues, and beliefs; understanding of communication patterns and appropriate inter- viewing techniques; strengths and diff erences among and within diverse racial/ ethnic groups; cultural expectations and help-seeking behaviors; and the integra- tion of traditional, indigenous, and spiritual practices that attend to the spiritual needs of families and children of color (Ortiz Hendricks, 2008).

Th e social work focus on “person in environment” takes on new meaning when working with immigrant populations. Social workers need to be skilled practitioners to work with diverse clients traumatized by poverty, discrimination, exploitation, war, famine, violence, genocide, and a range of physical and emo- tional problems related to leaving their homeland for a strange and all-too-often hostile environment. Social workers may recognize trauma in the lives of their diverse immigrant clients, but they need help to incorporate this knowledge into eff ective practice interventions.

Special attention needs to be directed toward particular immigrant groups in U.S. society that are likely to require a range of human services because of diff erences in (a) addressing physical and mental health issues; (b) customs,

Culturally Competent Social Work Practice With Immigrant Populations Carmen Ortiz Hendricks & Elaine P. Congress

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traditions, beliefs and values; (c) family structures, child-rearing practices, and gender roles; (d) language and literacy; and (e) political ideology and oppressive experiences.

Th is chapter looks at some culturally sensitive and competent ways to serve immigrant clients by examining what is meant by cultural competence in social work practice and how this applies to work with immigrant populations. It examines the institutional arrangements that contribute to ongoing racism and xenophobia and the kinds of responses needed to help integrate immigrants into the fabric of American society. Th ere is an attempt to classify culturally compe- tent interventions and treatment plans that are eff ective with individuals and families from diverse communities. Social workers also need to take leadership in developing culturally competent organizations that advocate for policies, pro- cedures, and practices designed to ensure access to culturally competent services for all in need.

■ IMMIGRATION PATTERNS IN THE UNITED STATES

Immigration patterns dramatically shift and change in the United States. Th roughout the 1800s and the early part of the 20th century, charity workers primarily worked with White European immigrants who were diverse in terms of ethnicity, religion, social class, and political ideology. Much has been writ- ten about this earlier immigration and how it shaped people’s lives, beginning with long sea voyages to crowded urban ghettos, unfair labor practices and the discrimination and exploitation that immigrants faced. Immigration reached a peak at the turn of the 20th century with the mass immigrations of people from southern and central Europe—Italy, Ireland, Germany, and Poland—most of whom were Catholics and Jews. Social workers served these populations in the settlement houses of large urban settings while beginning to forge an identity as a new profession.

Th roughout U.S. history, immigrants have faced both positive and negative attitudes toward immigration. Positive attitudes include the following:

• Immigrants enrich the U.S. culture. • Immigrants can be socialized to be good Americans. • Immigrants contribute to the U.S. economy by taking jobs that most

Americans do not want to hold. Negative attitudes include the following:

• Immigrants take jobs away from Americans. • Immigrants are a drain on the U.S. economy. • Immigrants contaminate American culture and threaten American values.

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• Immigrants bring new political points of view that weaken democratic ideals.

America’s ambivalence toward immigrants continues even today. Since September 11, 2001, a strongly negative attitude and punitive approach to immi- gration has become the norm as the United States confronts terrorism and main- tains homeland security. However, this ambivalence has not stemmed the fl ow of immigration.

According to the Pew Research Center, “If current trends continue, the popula- tion of the United States will rise to 438 million in 2050, from 296 million in 2005, and 82% of the increase will be due to immigrants arriving from 2005 to 2050 and their U.S.-born descendants” (Passel & Cohn, 2008, p. 1). Th e report further states that the Latino/Hispanic population, already the largest and fastest growing minor- ity group in the United States, will triple in size to 29% of the U.S. population in 2050 (compared to 14% in 2005). In fact, by 2050, the non-Hispanic White popu- lation will become the minority or 47% of the U.S. population. Th is is one reason why much of the immigration debate in America today seems to focus primarily on one major immigration stream—Mexican legal and undocumented immigrants.

Huntington (2004) has stated that the “single most immediate and most serious challenge to America’s traditional identity comes from the immense and continuing immigration from Latin America, especially Mexico” (p. 24). Huntington believes that the United States is an Anglo-Protestant nation, and this tradition is being threatened by Hispanics who are trying to make the nation “into two people, two cultures, and two languages” (p. 30). Anti-immigration sentiment like this often overlooks the positive contributions that immigrants make to the United States or the fact that immigrants provide “new energy, new tastes, and new strivers who want to lunge into the future” (Brooks, 2004) and economic advantages (Costa, Cooper & Shierholz, 2014).

Th e sheer numbers of immigrants entering this country, and the debates sur- rounding them, clearly underscore the important role that social workers can play in meeting the needs of immigrant individuals, families, and communities who are not always welcomed members of U.S. society.

■ DEFINING CULTURALLY COMPETENT SOCIAL WORK PRACTICE

In providing human services today regardless of the geographic region in which they work, social workers meet diverse immigrant clients. Broad categories of people—Asians, Hispanics/Latinos, Eastern Europeans, people from the former Soviet Republic, Africans, and Indians—include large numbers of heterogeneous groups with diff erent ethnic, racial, linguistic, historical, political, cultural, and religious identities and experiences. Most social workers may not know (for

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example) where Mali is nor appreciate its cultural traditions but do know how to deal with loss and trauma in its many forms. Sooner or later, clients from many parts of the world will walk into a social service agency, and social workers need to be ready to meet these clients and their myriad needs.

Th e social work profession has been very concerned about defi ning and preparing practitioners to engage in culturally competent practice. A number of documents in professional social work organizations address the issue of culturally competent practice. Th e National Association of Social Workers (NASW) Code of Ethics includes a provision on Cultural Competence and Social Diversity (1.05) that focuses on culture as a strength in the lives of people. “Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures” (National Association of Social Workers, 2008, p. 9). Social workers are also advised to “have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to diff erences among people and cultural groups” and to “obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or phys- ical disability” (National Association of Social Workers, 2008, p. 9).

Th e NASW Standards for Cultural Competence in Social Work Practice spells out in more detail diff erent areas in which individual social workers, as well as agencies, can engage in culturally competent practice. Th e following 10 standards are included (National Association of Social Workers, 2001):

1. Ethics and values 2. Self-awareness 3. Cross-cultural knowledge 4. Cross-cultural skills 5. Service delivery 6. Empowerment and advocacy 7. A diverse workplace 8. Professional education 9. Language diversity

10. Cross-cultural leadership Learning to be culturally competent practitioners is not only important for

professional social workers but also needs to be incorporated into the education of future social workers. To accomplish this goal, the Council on Social Work Educa- tion (CSWE) has incorporated provisions on cultural competency into its Edu- cational Policy and Accreditation Standards (2015) that mandate the integration of curriculum to enable it “to value and respect diversity, and develop a commit- ment to cultural humility” (p. 12). Th e focus is on diversity that includes cultural diff erences as intersecting with “multiple factors of age, class, color . . . ethnicity,

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gender, gender identity and expression, immigration status, marital status, physical and mental ability, political ideology, race, religion/spirituality, sex, sexual orienta- tion, and tribal sovereign status” (p. 12).

To be culturally competent social workers must understand cultural compe- tence the way the client does.

Cultural competence requires hard work, commitment, and experience. It entails more than speaking the language of the client or gaining specialized knowledge about a particular cultural group. Cultural competence means understanding the value of culture as perceived by clients, and appreciat- ing how culture guides behavior and gives meaning to life. Culture shapes and infl uences individual physical and mental health beliefs, family practices, human behavior, and even the outcomes of interventions (Ortiz Hendricks & Fong, 2006, p. 136)

Th e Center for Cross Cultural Health (1997) sees culture as aff ecting all aspects of life, such as one’s relationship with older family members and adoles- cents, as well as one’s own reactions to illness. “Cultural competence . . . implies a heightened consciousness of how clients experience their uniqueness and deal with their diff erences and similarities within a larger social context” (National Association of Social Workers, 2001, p. 8). Th e NASW Standards for Cultural Competence in Social Work Practice defi nes cultural competence as “the process by which individuals and systems respond respectfully and eff ectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affi rms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each” (Center for Cross-Cultural Health, 1997, p. 11).

Fundamentally, cultural competence is the ability and the will to respond to the needs of clients arising from their culture, and the worker’s and client’s ability to use culture as a resource, strength, or tool to meet common human needs. CCSWP involves a range of professional knowledge, skills, and values that address the com- plex cultures emerging in a society from the interplay of power and privilege associ- ated with race and ethnicity, gender and sexual orientation, religion and spirituality, social class and status, and age and abilities (National Association of Social Workers, 2007). Th e emphasis in this defi nition is on power, privilege, and oppression of people based on characteristics that, to a large extent, they cannot control.

CLINICAL ASSESSMENT

Understanding the cultural background of diverse clients may seem like a daunt- ing task. To promote understanding, engagement, and intervention planning with immigrant families, one of the authors developed a visual family assessment

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tool, the culturagram (Congress, 1994; Congress, 2008a). Since its initial devel- opment, it has been used in work with people of color (Lum, 2004), battered women (Congress & Brownell, 2007), children (Congress, 2001), older people (Brownell & Fenley, 2009), families in crisis (Congress, 2000), Mexican families (Congress, 2004a), Latino and Asian families (Congress & Kung, 2013), immi- grant families with health problems (Congress, 2004b; Congress, 2013), refugees (Congress, 2012), and in family development theory (Congress, 2008b).

Th e culturagram grew out of an attempt to dispel bias and stigmatization that occurs in generalizations about immigrant groups. In working in a mental health clinic, it was noted that many clients were simply referred to as Hispanic and Latino, and there were guides about understanding and working with His- panic clients. Although both could be called Hispanic/Latino, a Puerto Rican family who had lived in New York City for 20 years was very diff erent from an undocumented Mexican family that arrived the previous week. Th e culturagram considers culture not as a monolithic concept or national background but as mul- tilayered. To truly understand a family’s cultural background, the social worker is asked to assess a family in the following 10 areas:

1. Reasons for immigrating 2. Legal status 3. Length of time in country 4. Language spoken at home and in the community 5. Health access and beliefs 6. Impact of crisis/traumatic events in the past and present 7. Contact with cultural institutions and holidays, food, and dress 8. Past and current experiences with racism, discrimination, and bias 9. Values about education and work

10. Family values involving gender, age, myths, and rules

Th e template for the culturagram can be found in Figure 3.1. Social workers work with clients in developing a culturagram, a visual dia-

gram of the family (see Figure 3.1). Th is is the client’s story and contains much more information than the social worker’s singular acknowledgment of the client’s national background. As clients participate actively in creating the culturagram, it also diff ers sharply from other diagnostic assessment processes such as assign- ing a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013) diagnosis as clients can participate actively in creating their own personalized cultural assessment.

An important aspect of the culturagram is that it takes a longitudinal approach to working with immigrant families. Although the focus in social work practice is usually on the current situation, Drachman (1992) and Pine and Drachman (2005) have pointed out that a three-stage approach is often more eff ective. To

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3: CULTURALLY COMPETENT SOCIAL WORK PRACTICE ■ 75

understand clients, it is important to consider their situation before migration, in transit, as well as their experiences since their arrival in the United States.

Recognizing power and status diff erences is an important part of becoming a culturally competent social worker. Th ese diff erences often result in bias, preju- dice, and discrimination against those with less economic, gender, and White privilege status. Th e newest version of the culturagram has a focus on a family’s past and present experience with bias, prejudice, racism, and/or discrimination. What has been their experience before migrating? Refugees, especially, may have been subject to discrimination because of their social, religious, or political beliefs in their country of origin. Immigrants are often subject to discrimination while migrating. Bias and discrimination may have continued to occur for immigrant families that have impeded their use of needed educational, social, and health ser- vices. Some of this discrimination may be minor assaults experienced as microag- gressions, which have been defi ned as frequent communications in the workplace, school, or community that serves to denigrate individuals because of their group membership (Sue, 2010). Although these communications are subtle and the perpetrator may not have conscious awareness of their impact, they often have a negative long-lasting impact on immigrants’ well-being.

FIGURE 3.1 Culturagram

Family (list individual

members)

Legal status

Reasons for relocating

Values about family - structure, power, myths and rules

Values about education and work

Language spoken at home and in

community

Health beliefs and access

Impact of trauma and crisis events

Oppression, discrimination,

bias and racism

Contact with cultural and religious Institutions

Holidays, Food and clothing

Time in community

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In addition to helping the clinician become more culturally competent, the culturagram strives to move the worker toward a position of cultural humility. Th is approach to cultural work has been suggested as an alternative to traditional cultural competency methods that rely primarily on clinicians interpreting the culture of their clients. Clinicians who use a cultural-humility approach look at clients as experts who can tell clinicians about their culture. Th ey are open to learning from clients about how they understand their cultural identity (Hook, Davis, Owen, Worthington, & Utsey, 2013) Th ree methods have been suggested to promote cultural humility:

1. A lifelong commitment to self-evaluation and self-critique 2. A desire to fi x power imbalances 3. An aspiration to develop partnerships with people and groups who

advocate for others (Tervalon & Murray-Garcia, 1998)

To truly help immigrant clients, social workers need to understand power and how it is constructed and used to oppress people. Social workers then have to work to change the conditions that continue to oppress immigrants. In the NASW Code of Ethics (2008), social workers have an ethical responsibility to the broader society, which includes social and political action (6.04) in the form of expanding choice and opportunity for all people; promoting respect for diversity; and preventing and eliminating domination, exploitation, and discrimination. Th erefore, understanding of and sensitivity to clients’ cultures is insuffi cient with- out translating this understanding and sensitivity into social action.

■ CULTURAL COMPETENCY IN AGENCY PRACTICE

Furthermore, social agencies have tended to put the onus of responsibility on social workers to be culturally competent. According to Lum (2004), workers can only achieve cultural competence after developing cultural awareness, mas- tering knowledge and skills, and implementing an inductive learning approach. But cultural competence is both a personal and organizational quest. It requires organizational awareness and sensitivity. Agencies spend thousands of dollars yearly training workers to become more culturally aware and sensitive, provid- ing them with knowledge of diff erent client groups, educating them about the impact of cultural diff erences on help-seeking behaviors, and encouraging them to adapt intervention strategies for diff erent populations and needs. However, attention to the worker’s individual growth in knowledge and skills is insuffi cient without simultaneously paying attention to the agency context within which workers serve clients (Fong & Gibbs, 1995; Nybell & Gray, 2004).

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CULTURAL COMPETENCY IN CHILD WELFARE

One of the most challenging and controversial issues facing immigrants is the child welfare system and its disproportionate representation of racial/ethnic minority children and families. “Over-representation of adolescents of color in the juvenile justice system result from decisions made very early on regard- ing the need to remove children from their homes, decisions that are based in some large part on the family’s color or race” (Walker, Spohn, & DeLone, 2000, p. 6).

Immigrant families face numerous challenges when they come into con- tact with the child welfare system. Language barriers, the stress of immigration, sociocultural dislocation, and discriminatory U.S. policies toward immigrants contribute to the likelihood that immigrant families are more vulnerable and therefore more likely to enter the child welfare system. Child abuse and neglect may be the result of failed systems of care that further traumatize parents and children of color, who are at the greatest risk. When parents cannot fi nd adequate help for their own or their children’s problems, they are at a loss as to where they can turn to for help and often lack understanding of the kind of help they will receive (Webb, 2001).

CULTURAL COMPETENCY IN HEALTH CARE

Th ere are tremendous disparities around who gets quality health and human ser- vices in the United States. Immigrant clients may be overrepresented in criminal justice, juvenile delinquency services, and public welfare programs, but they are also underutilizing physical and mental health care services (Fong, McRoy, & Ortiz Hendricks, 2006). Poverty may be the principal underlying reason in these disparities. Social workers should keep in mind several factors that impinge on immigrants’ eff ective use of health services:

• Length of stay in the United States • Size of the family • Emotional and fi nancial support of family • Documented or undocumented status • Minimum-wage or less-than-minimum-wage jobs • Financially supporting family members in the country of origin • Youth of the population • Single-parent households • Lack of marketable skills

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• Residence in inner-city neighborhoods with substandard housing, inad- equate schools, and inadequate services

• Limited English-speaking profi ciency

Racism and discrimination further oppress immigrants in the United States and put all immigrant groups at risk.

■ RECOMMENDATIONS FOR SUCCESSFUL CCSWP WITH IMMIGRANT POPULATIONS

CULTURALLY COMPETENT ORGANIZATIONS

Social workers need to feel competent and eff ective in carrying out very complex roles and functions with regard to services to immigrants. In order to do this, they require the support and guidance of culturally competent organizations. Th ese organizations need to enact a two-pronged strategy: (a) continued recruitment and retention of diverse workers who can understand the language and culture of diverse clients and (b) ongoing preparation of all staff as culturally and linguisti- cally eff ective practitioners.

Cultural competence begins with administrative support and encourage- ment, quality supervision and oversight, strong peer relationships, and manage- able caseloads. It also requires well-educated, well-trained, and experienced social workers who can eff ectively deal with increasingly diverse and troubled immi- grant individuals and families.

Agencies need to do the following:

• Help workers keep abreast of new policies and procedures and changing state and federal laws.

• Train staff to adopt new strategies for dealing with such issues as mental illness, addiction, AIDS, or incarceration. Workers need to be prepared to identify and intervene in these problems and make proper referrals for treatment when indicated, and they have to do this in culturally competent ways that strengthen immigrant communities.

• Reach out and establish connections with immigrant communities, as well as to work with coalitions, councils, or other collaborative boards to examine the issues confronting immigrants and problem-solve ways to ameliorate them.

• Build public and private agency partnerships that can address the range of service needs with which immigrants present and fi nd additional resources to support immigrants, especially as they transition to new ways of life.

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• Provide ongoing and well-crafted training opportunities for all levels of staff . Social workers need and want training in cultural awareness and sensitivity, especially in light of observed incidents of staff bias toward immigrant populations. Sometimes, social workers can make decisions based on race or ethnicity or the socioeconomic background of clients, but if the worker is an immigrant, this bias may be an occupational hazard that aff ects the specifi c merits of a case. More extensive training that focuses on cultural, sociological, and psychological factors of the immigrant experience for specifi c immigrant populations is necessary to address such diffi cult and complex issues as racial or class bias.

Many of these suggestions indicate that human service professionals already know what is needed to help immigrants succeed in the United States and to reduce discrimination and oppression. What is needed is the combination of power and resources to implement these recommendations.

RESEARCH

Th ere is not enough known about successful interventions with immigrant communities. Research is needed to enhance treatment options, to appreciate best practice interventions and outcomes, and to determine the approach that is most successful with a specifi c immigrant population. Research is particu- larly needed on resiliency to determine the factors that keep immigrants intact and healthy. Research also needs to unpack large ethnic groupings by analyz- ing subgroup or intergroup relationships. For example, there are few studies that examine the disproportionate numbers of Central American or Southeast Asian immigrants in child maltreatment reports or their relationship to other groups.

ADVOCACY

Immigrant families and children, and especially immigrants of color, are trauma- tized by multiple factors in the environment that stress and deplete their physical and mental health in this country. Social arrangements and social policies main- tain immigrant families in ghettoized communities plagued by violence. Th e only way to change these social arrangements is to examine the child welfare, social welfare, and physical and mental health care systems while simultaneously work- ing to remedy the problems that bring immigrant families and children into the system in the fi rst place. Poverty, violence, substance abuse, and mental health problems are among the factors fueling the growth of child maltreatment, and,

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as a result, protecting children and reducing the level of trauma that they are exposed to requires more than intervention through child protective services or foster care placements (McRoy & Vick, 2001).

Dramatic social changes and broad responses are needed in many areas, including education, public welfare, child welfare, juvenile justice, criminal justice, substance abuse, and physical and mental health programs that often interact with the very same families but do not collaborate in their care or treatment. Creating safe environments, including adequate housing, nutrition, and health care, is a prerequisite to achieving a notable downward trend in all forms of maltreatment.

It is not hard to understand how immigrants, particularly single individu- als or families, struggling fi nancially with little education and few job skills, with little social support and often enormous social isolation, and with extensive life- long histories of trauma, might be at greater risk of depression and health prob- lems. Culturally competent social workers are central fi gures in the promotion of the health and well-being of countless immigrant populations, now and into the future.

■ CASE STUDIES

Th e following cases illustrate life experiences commonly encountered by immi- grants. You are invited to discuss the following questions about each vignette.

• What social work issues are raised by this vignette? • What legal issues are raised by this vignette? • What aspects of the experience suggest a crisis, and why? How would

you prioritize the immigrant’s needs? • What cultural aspects impact the situation? How would a culturally

competent practitioner address the issue? How might a lack of cultural awareness on the part of the practitioner impact the situation?

• What strengths might the immigrant derive from his or her culture in this vignette?

• What, if anything, could be done on an organizational (mezzo) level to help in this case? What could or should be done on the policy (macro) level?

CASE STUDY 1: MAMADOU AND MOUSSA

Mamadou and Moussa were two immigrants from Mali who came to the United States with a dream of a better life for their children—one forging a path for

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his fellow countrymen, and the other, his cousin, navigating a classic immigrant route behind the wheel of a taxi.

Th eir long road to New York began 20 years ago, when Moussa, a member of the Sinonke tribe, arrived from the Malian capital of Bamako. He was one of the very fi rst to come here from his arid, landlocked nation on the fringe of the Sahara Desert.

Moussa helped his family back home by sending them money whenever he could. Soon, more members of his tribe followed, and, in keeping with their cultural traditions, Moussa opened his doors and helped them get established. Th ese Malian immigrants lived together and shared everything; anyone from the same Sinonke tribe had a guarantee of a home in New York City. Soon, the Bronx neighborhood of Highbridge was home to a large Malian community.

A few years ago, Moussa helped establish a mosque in the Bronx. Th e mosque also had a school to help new arrivals learn to speak, read, and write Eng- lish. Moussa enjoyed giving advice to his countrymen about how to survive in the United States and how to adjust to this society. His vision was for his community to contribute positively and constructively in the United States.

Th at vision was shattered when a fast-moving fi re gutted the four-story apartment building where the men lived with their families, killing fi ve sons of one and the wife and four children of the other. Th e entire community shared in their terrible loss.

Th is true and tragic immigrant story, reported by Williams and Fernandez in Th e New York Times (2007), brought great attention to the Malian community in the Bronx.

CASE STUDY 2: MR. S

Mr. S, a Bangladeshi immigrant, was upset that his 13-year-old daughter was fail- ing in school. He found her diary and although he could not read English well, he could tell that it had something to do with boys and possibly sex, too. Furious, he told his daughter he was going to talk to her teacher. Panicked, the daughter told her friend, who encouraged her to claim that her father was abusing her. Her friend told a teacher, and the family’s three children were immediately removed from the home and placed in a non-Muslim, non-Bangladeshi home. Th e young- est child, age 3, could not speak English. She refused to eat or wash in the foster care home. Th e father was encouraged by his court-appointed attorney to sign an admission of guilt to end the case quickly, although the father did not understand the document or its ramifi cations (Coalition for Asian American Children and Families, 2001, p. 12).

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CASE STUDY 3: MR. Y

Mr. Y is a 49-year-old Chinese male with end-stage renal disease who is receiv- ing hemodialysis. He was born and raised in mainland China. He paid a fee of $35,000 to come to the United States via illegal means 6 years ago. He has not yet paid off the smuggling fee. As a result of the treatment schedule, Mr. Y has diffi culty fi nding and keeping a job with fl exible hours. As his fi nancial situation worsens, Mr. Y is also forced to relocate from place to place, depending on the kindness of strangers.

Mr. Y spent most of his adult life in the Fujian province in eastern China. He grew up in a poor farming family and community. His parents died a few years ago and he has no siblings. Mr. Y married a woman from his village and they have three children. Mr. Y felt he came from a disadvantaged family and married the only person who would have him. He described his wife as angry, depressed, and highly critical and argumentative. She ran the household and she ran him. He worked hard on the farm and did not like to socialize much. Mr. Y appears to have learned to be silent and tolerant of not having his needs met.

Because of poverty, the villagers looked down on his family and they were very isolated. As he grew older, Mr. Y also felt ashamed of his poverty. He could not see any hope of a better future for himself or his children even if he worked his fi ngers to the bone on the farm for the rest of his life. He noticed that many young people took the risk of losing their lives by paying large sums of money with high interest rates in order to be smuggled into a foreign country. Illegal immigration to Mr. Y is not a moral, ethical, or even a safety issue. It is a means of survival and of upward mobility. He borrowed money and made plans to come to America. He fi rmly believed that this was the beginning of a golden opportunity for him to earn money, respect, and a diff erent life for himself and his children.

Mr. Y took a 58-day boat ride from the Fujian province before reaching the shores of the United States. His primary goal upon arriving in the United States was to earn as much money as possible to pay back the smugglers and send money home. He worked very hard, day and night. He agonized over his inability to speak and understand English. He remained close to his Chinatown enclave. He missed his family and his country. He forced himself to work even harder and to send money home regularly to his family. His living arrangements and his jobs were very unstable, unsafe, and substandard. Sometimes Mr. Y had to live with more than 10 people in one basement and worried about them steal- ing his money or what little food he had. He frequently did not have enough money for food and lived on just a bun a day. Eventually, Mr. Y became ill and was admitted to the hospital. Mr. Y’s frustration increased because he could not work and the dream of a better future for his family seemed to be falling apart. He appeared restless, anxious, and angry over his destitute circumstances. When

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the social worker fi rst met Mr. Y, he desperately requested help with fi nding a job and a cheaper apartment. He was also becoming noncompliant with his medical treatment.

■ REFERENCES

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Brooks, D. (2004, February 24). Th e Americano dream. Op-Ed Column, New York Times. Retrieved from http://www.nytimes.com/2004/02/24/opinion/the-americano-dream .html?_r=0

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Congress, E. (1994). Th e use of culturagrams to assess and empower culturally diverse fami- lies. Families in Society, 75, 531–540.

Congress, E. (2000). Crisis intervention with culturally diverse families. In A. Roberts (Ed.), Crisis intervention handbook (2nd ed., pp. 431–449). New York, NY: Oxford University Press.

Congress, E. (2001). Ethical issues in work with culturally diverse children and their families. In N. B. Webb (Ed.), Culturally diverse parent–child and family relationships (pp. 29–53). New York, NY: Columbia University Press.

Congress, E. (2004a). Crisis intervention and diversity: Emphasis on a Mexican immigrant family’s acculturation confl icts. In P. Meyer (Ed.), Paradigms of clinical social work: Emphasis on diversity (Vol. 3, pp. 125–144). New York, NY: Brunner-Routledge.

Congress, E. (2004b). Cultural and ethical issues in working with culturally diverse patients and their families: Th e use of the culturagram to promote cultural competent practice in health care settings. Social Work in Health Care, 39(3/4), 249–262.

Congress, E. (2008a). Th e culturagram. In A. Roberts (Ed.), Social work desk reference (2nd ed., pp. 969–975). New York, NY: Oxford University Press.

Congress, E. (2008b). Individual and family development theory. In P. Lehman & N. Coady (Eds.), Th eoretical perspectives for direct social work practice: A generalist-eclectic approach (2nd ed., pp. 83–104). New York, NY: Springer Publishing Company.

Congress, E. (2012). Social work with refugees. In D. Elliott & U. Segal, (Eds.), Refu- gees worldwide: Law, policy, and programs (Vol. 4, pp. 197–218). Santa Barbara, CA: Praeger.

Congress, E. (2013). Immigrants and health care. In R. Keefe & E.T. Jurkowski (Eds.), Handbook for public health social work: Th e social work section of the American Public Health Association (pp. 103–121). New York, NY: Springer Publishing Company.

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Congress, E., & Brownell, P. (2007). Application of the culturagram with culturally and eth- nically diverse battered women. In A. Roberts (Ed.), Battered women and their families. New York, NY: Springer Publishing Company.

Congress, E., & Kung, W. (2013). Using the culturagram to assess and empower culturally diverse families. In E. Congress & M. Gonzalez (Eds.), Multicultural perspectives in work- ing with families (3rd ed., pp. 2–21). New York, NY: Springer Publishing Company.

Costa, D., Cooper, D., & Shierholz, H. (2014). Facts about immigration and the U.S. economy. Washington, DC: Economic Policy Institute.

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Drachman, D. (1992). A stage-of-migration framework for service to immigrant popula- tions. Social Work, 37(1), 68–72.

Fong, L. G. W., & Gibbs, J. T. (1995). Facilitating service to multicultural communities in a dominant culture setting: An organizational perspective. Administration in Social Work, 19(2), 1–24.

Fong, R., McRoy, R., & Ortiz Hendricks, C. (Eds.). (2006). Intersecting child welfare, sub- stance abuse, and family violence: Culturally competent approaches. Washington, DC: Council on Social Work Education.

Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Jr., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychol- ogy, 60(3), 353–366.

Huntington, S. (2004). Th e Hispanic challenge. Foreign Policy, 141, 30–45. Retrieved Febru- ary 23, 2004, from http://foreignpolicy.com/2009/10/28/the-hispanic-challenge/

Lum, D. (2004). Cultural competent practice: A framework for growth and action. Belmont, CA: Brooks Cole.

McRoy, R., & Vick, J. (2001). Intersecting child welfare, substance abuse and domestic violence. In R. Fong, R. McRoy, & C. Ortiz Hendricks (Eds.), Intersecting child welfare, substance abuse and family violence: Culturally competent approaches (pp. 1–34). Alexan- dria, VA: Council on Social Work Education.

National Association of Social Workers. (2001). Standards for culturally competent social work practice. Washington, DC: NASW Press.

National Association of Social Workers. (2007). Indicators for the achievement of the NASW standards for cultural competent practice. Washington, DC: NASW Press. Retrieved July 20, 2008, from http://www.socialworkers.org/practice/standards/NASWCultural StandardsIndicators2006.pdf

National Association of Social Workers. (2008). Code of ethics. Washington, DC: NASW Press.

Nybell, L. M., & Gray, S. S. (2004). Race, place, space: Meanings of cultural competence in three child welfare agencies. Social Work, 49(1), 17–26.

Ortiz Hendricks, C. (2008). Culturally competent social work practice with immigrant families In F. Chang-Muy & E. Congress (Eds.), Social work with immigrants and families: Legal issues, clinical skills, and advocacy. New York, NY: Springer Publishing Company.

Ortiz Hendricks, C., & Fong, R. (2006). Ethnic sensitive practice with children and families. In N. B. Webb (Ed.), Working with traumatized youth in child welfare (pp. 135–154). New York, NY: Guilford Press.

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Passel, J., & Cohn, D. (2008). U.S. population projections: 2005–2050. Pew Hispanic Center. Retrieved from http://www.pewhispanic.org/2008/02/11/us-population-projections -2005-2050/

Pine, B., & Drachman, D. (2005). Eff ective child welfare practice with immigrant and refugee children and their families. Child Welfare, 84(5), 537–562.

Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. New York, NY: Wiley.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defi ning physician training outcomes in multicultural education. Journal of Health Care for the Poor and Undeserved, 9, 117–125.

Walker, S., Spohn, C., & DeLone, M. (2000). Color of justice, race, ethnicity and crime in America (2nd ed.). Belmont, CA: Wadsworth Publishing Company.

Webb, N. (2001). Culturally diverse parent-child and family relationships: A guide for social workers and other practitioners. New York, NY: Columbia University Press.

Williams, T., & Fernandez, M. (2007, March 10). Horrifi c fi re unites cultures in rituals of belief. Th e New York Times. Retrieved July 20, 2008, from http://www.nytimes .com/2007/03/10/nyregion/10fi re.html?_r=0

■ ADDITIONAL RESOURCES

Administration on Aging, Achieving cultural competence (guidebook): https://archive.org/ details/achievingcultura00admi

Center for Human Diversity: www.centerforhumandiversity.org Th e Commonwealth Fund, Taking cultural competency from theory to action: http://www

.commonwealthfund.org/publications/publications_show.htm?doc_id=414097 National Association of Social Workers, Standards for cultural competence: http://www.social

workers.org/practice/standards/NASWCulturalStandards.pdf National Association of Social Workers, Immigration policy toolkit: http://www.socialworkers

.org/diversity/ImmigrationToolkit.pdf Th e National Center for Cultural Competence, Georgetown University Center for Child and

Human Development: http://nccc.georgetown.edu/

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http://www.centerforhumandiversity.org

http://nccc.georgetown.edu

http://www.pewhispanic.org/2008/02/11/us-population-projections-2005-2050/

http://www.nytimes.com/2007/03/10/nyregion/10fire.html?_r=0

https://archive.org/details/achievingcultura00admi

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=414097

http://www.socialworkers.org/practice/standards/NASWCulturalStandards.pdf

http://www.socialworkers.org/diversity/ImmigrationToolkit.pdf

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c h a p t e r FOUR

Social work practice with immigrant populations poses many challenges related to the multiple issues associated with the immigrant experience, ranging from personal adjustment issues to community impact and regional and federal policy initiatives. Th e sustained growth and visibility of immigrant populations in the United States has captured the public’s attention on immigration in American history, particularly in the early 20th century, the 1920s, and the 1940s. Th e national debate on immigra- tion has featured a climate of antagonism toward immigrants and unyielding eff orts to restrict the participation of undocumented immigrants in the American economy. Although there is some question regarding the actual number of undocumented workers in the United States—whether 12 million or twice that amount—we can expect that social workers involved in service delivery to immigrants will encounter undocumented individuals and thus will have to deal with many challenges.

Th e heightened national attention on the exponential growth of immigrant populations has been framed in the media to emphasize “foreign presence within U.S. borders” with minimal attention to the contribution of immigrant workers to the U.S. economy and American life. Th e presence of immigrants as dangerous pro- motes a monolithic view of this population that emphasizes threat and ignores the population’s heterogeneity. Immigration is a human right supported by the United Nations (2005), yet legalization of the process remains problematic at national levels. As a result, immigrants seeking employment are reduced to labels such as “ illegals” and “aliens,” thus making invisible their economic and social contributions to this country. Th is perspective is illustrated by the labeling of undocumented immigrants as “illegal” rather than distinguishing and recognizing the productive economic role that many immigrants have in American society. Because of the increased inter- national focus on immigration, social workers have an even greater responsibility to engage in critical thinking about immigration and exercise incisiveness in their engagement with immigrants and assessment of their needs.

Successful practice with immigrants is guided by concepts and theories that enhance perception of the presenting concerns and provides a basis for eff ective

Theory and Social Work Practice With Immigrant Populations Betty Garcia

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assessment that leads to relevant interventions, which enhance functioning and expand resources. Th is chapter addresses theoretical and conceptual resources for practice with immigrant populations with the intention of identifying conceptual frameworks and ideas that can serve as guides to assist in the development of practice orientations and skills, which meet the multifaceted needs of immigrants and their communities.

Attention to immigrant and human rights issues is a social work concern in that social workers see the impact of immigrant and refugee polices in their every- day practice and often fi nd that their ability for eff ective practice “is constrained by immigration policies, especially policies that limit family visitation and . . . reunifi cation” (National Association of Social Workers [NASW], 2006, p. 8). Moreover, NASW proposes that policies are needed to provide “relief to long- term resident undocumented families” and to support amnesty and citizenship paths for those who have responsibly dealt with their immigration status (NASW, 2006, p. 8). For these reasons, NASW advocates for an end to human rights vio- lations, provision of fair and humane immigration laws and practices, as well as foreign policies that alleviate the conditions, which lead individuals to emigrate from their countries. Chapter 14 of this book addresses the role of macro advo- cacy in social work practice.

Th e fi rst part of this chapter discusses assumptions about the role of theory as well as implications for skills and interventions. It also addresses concepts that, although distinct from theories in their scope and function, are invaluable in their capacity to provide a basis for eff ective interventions and implementation of prac- tice skills. Identifi cation of “what theory, used in what way, in relation to what life experiences” represents a signifi cant concern. I propose that the complexity and nature of practice with immigrants requires practitioner knowledge of the larger societal debates and perspectives, as well as individual, family, and community needs of immigrant populations.

Th e second part of this chapter discusses theories and concepts that can frame practice with immigrants, beginning with themes and issues currently dis- cussed in the sociopolitical context and the American sensibility about how to respond to immigrant presence. Finally, the chapter concludes with a summary of various perspectives of social work theory, from empowerment to family systems and how these various perspectives can inform aspects of the immigrant experi- ence and address the needs of immigrants and their communities.

■ THE ROLE OF THEORY AND CONCEPTS IN GUIDING PRACTICE

Th e theory of practice curriculum introduces both theories and concepts as frame- works to guide practice. In principle, theories are distinguished by their capac- ity to provide “ideas about the world” that encompass models, which assist in

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implementing practice in a systematic way, perspectives that communicate “views of the world,” and explanatory theory, which addresses the relationship between interventions and outcomes (Payne, 2005, p. 5). Concepts, on the other hand, although more limited, signify dynamics and/or factors associated with a category; that is, they identify the uniqueness and relationship between particular entities. Although not expected to describe reality, theories are expected to “make sense of what would otherwise be inscrutable or unmeaning . . . fi ndings” (Kaplan, 1964, p. 302) and facilitate a “particular way of seeing and acting” (Pozzuto, 2007, p. 79).

Pozzuto’s discussion on the types of theories similarly points out dissimi- lar functions of two general categories of social work theories: technical–rational theories and generative theories. Drawing from Kondrat’s (1992) work, he pro- poses that the technical–rational theory is intended for explanation, whereas the generative theory “is intended for understanding” (p. 69), for the purpose of cre- ating better lives, meeting basic human needs, and changing social structures. Th e postmodern conception of theory, as discussed by Pozzuto and demonstrated by Dean (2001), draws attention to how diff erent theories lead to a distinct, myriad lens that interprets experience from diverse value assumptions that lead to explicit intervention approaches (i.e., techniques and strategies) and attends to the value assumptions underlying various theoretical frames. Th eoretical frames with underlying values that are inclusive, seek complexity, recognize resources within individuals, and articulate real-world barriers as well as transactional dynamics have been selected for discussion in this chapter.

SOCIETAL AND LEGAL CONTEXTS

Th e scope of practice with immigrants requires the use of theories and concepts that assist in the development of accuracy in perceiving immigrants from their point of view and process skills that demonstrate active listening and attunement, which undergird engagement with immigrant populations. Th is requires sus- pension of one’s own biases and beliefs, comprehension of viable theories and concepts, and the ability to draw on theories for the purpose of enhancing obser- vation, recognizing the world of the immigrant, and engaging in a way that cre- ates the foundation for successful professional intervention.

Th e increasingly punitive reactions and intense political debates that cur- rently frame the context of practice with immigrants remain strong. Denial or lack of awareness of these contextual environmental realities by helping profes- sionals can potentially compromise the ethical qualities that distinguish profes- sional practice. Any discussion on the role of theory in social work practice with immigrants would be remiss if it were not to consider environmental factors in the person–environment and transactional perspectives that guide social work formulations and interventions.

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Th e early 21st century has witnessed the intensifi cation of raids, legal initia- tives, and anti-immigrant sentiments unlike any seen in U.S. history since the early 20th century (Montgomery, 2007). Th e legislative and regional reactions to reduce undocumented presence aff ects employers, landowners, and documented and undocumented immigrants alike in ways that threaten to undermine local economies and threaten community life in neighborhoods across the country. Th e focus of eff orts to eliminate nondocumented immigrant presence in the United States shifts and is fl uid; however, certain themes maintain center attention in legislative initiatives and regional responses. At the federal level, current broad policy themes include increased border security, harsher employer/landlord pen- alties, increased severity in citizenship paths, enhanced community surveillance programs, and a modifi ed guest worker program. Proposed methods to address each of these tactics include some of the following:

Increased Border Security

• Fund a fortifi ed southern border fence that would include virtual features.

• Increase the size of the southern border patrol force by almost double and, potentially, hire private contractors (i.e., mercenaries) as part of the patrol force.

• Train more enforcement personnel, including local police. • Detain more undocumented immigrants caught at the border. • Penalize landowners for border tunnels on their properties where

immigrant passage has occurred.

Harsher Employer/Landlord Penalties

• Raise fi nes for employers who hire undocumented workers (e.g., “reck- less” hiring of undocumented workers leading to $50,000 fi nes); make the hiring of undocumented workers a felony rather than a misdemeanor charge; defi ne off enses as criminal rather than civil.

• Require federally funded employers to implement an employment verifi - cation system and to dismiss workers whose Social Security numbers do not match Social Security records within 90 days.

• Impose fi nes on landlords who rent to undocumented residents. • Require registration for a rental permit.

Increased Severity in Citizenship/Residency Pathways

• Establish a three-tier system for immigrants to secure citizenship status that would require, for some, application for immigration in their home country.

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• Require a $370-replacement card for legal permanent residents (i.e., Green Card holders) who were issued their documentation between 1979 and 1989 and do not have expiration dates.

• Increase citizenship fees to $1,000. • Eliminate any legislation that would honor the rights of citizen children,

address issues of mixed-status families, and promote family stability.

Enhanced Sur veillance Initiatives

• Require law enforcement to investigate the citizenship status of individuals arrested for a felony or a driving under the infl uence (DUI) off ense.

• Issue tickets (e.g., $500) to drivers who cannot speak adequate English with police offi cers.

• Conduct informal investigations on immigrants who commit misdemeanors.

• Increase barriers to securing state identifi cation documents.

Modified Guest Worker Program

• Streamline an ineffi cacious agricultural guest worker program. • Create conditions (via an ambiguous legal status for nondocumented

workers) that promote a marginalized underclass comprising nondocumented and legal residents in American society.

Although it may be tempting to limit one’s analysis of the origins of the hostile and exclusionary reactions of some American policy makers to American eco- nomic factors, there is much international evidence to support the role of interna- tional factors, such as a general undermining of workers’ rights around the world (Lee, 2006).

EXPERIENCES OF IMMIGRANTS

Th e experiences of immigrants and their families are fi lled with examples of per- sonal, social, economic, and political issues that require coping, adjustment, and adaptation. Th ese events can be experienced as traumatic and/or may exacerbate past traumas. Th e proposed policies described in the preceding subsections give practitioners a sense of the ongoing hostile sociopolitical climate that immigrants encounter once they arrive in the United States. Recognition and acknowledg- ment of trends in the environment, such as political, economic, and demographic trends, are basic to a transactional approach in practice. Elements of immigrants’

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experiences that are essential to explore during assessment for the purpose of for- mulation and focus of interventions include:1

• Th e process of immigration: Was the move voluntary or involuntary? Anticipated or not anticipated? What were the points of transit on the way to the United States? Who was left behind and what separations occurred with family members? What is the status of immigration documentation?

• Social power changes and coping: Have there been socioeconomic, educational, and occupational adjustments? Shifts in new employment or unemployment status? Shifts in family decision making due to structural family changes? What are the eff ects of language and literacy fl uency in the new country? Is the immigrant facing workplace-related stressors? If so, what types of stressors (e.g., supervisory, interpersonal, xenophobic, immigration authorities)?

• Economic and housing resources: What are the immigrant’s debt commitments and assets? What is the status of housing (e.g., quality), transportation, and access to communication technology?

• Physical and psychological health status: Are the immigrant’s basic needs for food and shelter being met? Can the immigrant utilize and/ or access professional health providers and/or cultural healers? Are there any antecedent health conditions prior to immigration or during the immigration process (e.g., loss of health, limb)? What is the immigrant’s current health status?

• Family system and social networks: What are the family constellations, structures, communication patterns, multigenerational experiences, and coping abilities? What social support systems, if any, is the family involved with (e.g., extended family, friends, religious, community, political, recreational)? To what degree is the individual or family isolated and/or active with social contacts?

• Cultural: What are the profi les and qualities of the individual’s social identity? In what ways and to what degree is the individual identifi ed with his or her traditional culture, with the new American culture, and/ or with other cultures (e.g., religious, people with disabilities, gender orientation)?

Assessment issues to address in practice with immigrants will vary depend- ing on service delivery mission, as will the scope of practice. An all-inclusive review of signifi cant concerns is beyond the focus of this chapter. Other chapters address in more detail topics such as physical health (Chapter 5), mental health (Chapter 6), employment (Chapter 8), and other issues that immigrants face. However, the list presented in the preceding text may be useful to the practitioner in acknowledging the range of multilevel and multisystemic concerns in the lives

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of immigrants and in ensuring that theoretical approaches and concepts are in principle invoked in the helping relationship and in advocacy eff orts.

■ CONCEPTUAL AND THEORETICAL RESOURCES FOR PRACTICE WITH IMMIGRANT POPULATIONS

Th e contextual and experiential issues noted earlier highlight the impor- tance of informed practice with immigrants that is multisystemic (i.e., micro, mezzo, macro) and is based on theoretical orientations that facilitate direct ser- vice based on strong clinical process skills and promote macro-level interven- tions. Frey and Dupper’s (2005) discussion on the need for a “broader clinical approach” in the 21st century due to the presentation of increasingly complex problems articulates a key theory of practice considerations with immigrants. Practice has never been more compelled to require knowledge, values, and skills that include clinical interventions and “multilevel interventions that tar- get both personal issues and social justice concerns” (p. 34). Moreover, there is an increase in the social work practice literature, which addresses the need for theoretical approaches that take into account power diff erentials, empower- ment, and critical thinking as provided (for example) by feminist, postmod- ernist, and oppression theories and concepts. Th is growing literature in social work is direly needed for the multifaceted and trying situations faced by prac- titioners serving this population.

Strong clinical skills that build trust and rapport and demonstrate cultural and linguistic competency are particularly needed with immigrants, who all too often experience adversarial encounters in their new host country. At the same time, macro-level interventions, based on practice insights in interactions with individuals and families, are also needed for advocacy eff orts and/or program and policy development. Practitioners must necessarily demonstrate clinical skill in engaging individuals and families, regardless of the level of intervention. Th e many social work skills that have a vital role in practice with this group can- not all be addressed here. However, the following brief descriptions of diff erent approaches will identify theoretical orientations and concepts that are vital in grounding practice that is curious, inclusive, and collaborative.

Unequivocally, eff ective practice with immigrants embodies a biopsycho- social, spiritual, cultural perspective within a person–environment interaction, and a transactional framework for the purpose of addressing the numerous levels of adaptation (e.g., personal, familial, economic, political) evoked by the immi- gration process. Th e biopsychosocial concept focuses our attention on contri- butions of health status, behavioral (thoughts, feelings, actions), familial, social network, and societal factors in the lives of immigrants. Th e spiritual and cultural aspects focus our attention on immigrants’ beliefs, values, and practices that bring

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meaning to their lives whether they are religious, nonmaterial, or civic in nature. Cultural competence is addressed more fully later.

Th e person–environment interaction, transactional approach (Payne, 2005) emphasizes evaluating the “goodness of fi t” between needs and environmental resources to meet those needs. Discounting or omitting critical assessment infor- mation can lead to lost opportunities to join the client in the refl ection of sig- nifi cant events and exploration of individual choice and environmental resources as promoted in a transactional approach. Th e biopsychosocial, cultural, spiri- tual transactional foundations of social work practice promote looking clearly at strengths, needs, and vulnerabilities of the individual and in the physical and social environment for the purpose of assessment and intervention.

Although national sentiment currently is inclined to understand immigrants’ behavior by exclusively focusing on their behavior as the unit of analysis, the per- son–environment focus suggests factoring in macro-level factors, for example, pov- erty and federal policies, to more fully understand the experiences of immigrants. Overreliance on factors related to individual behavior risks blaming the victim, which can result in social workers colluding with a largely unresponsive and unre- ceptive environment. Likewise, overreliance on environmental factors risks dis- empowering the individual by not recognizing and/or minimizing choices and decisions exercised by the individuals themselves. Th e art of social work practice in this case requires holding several perspectives, individual and environmental, in mind and holding an either/and perspective, rather than either/or approaches.

Acknowledgment of the multifaceted dimensions of human experience is supported by the strengths perspective (Saleebey, 2012) and empowerment approach (Gutierrez, Parsons, & Cox, 1998; Rose, 2000) in that these frame- works promote the exploration of psychosocial resources identifi ed by the immi- grants themselves, from their own subject viewpoint. Th e following will present several theoretical perspectives and associated questions relevant to practice with immigrants.

■ EMPOWERMENT THEORY

Empowerment theory is quintessentially a social work approach in that it promotes social justice and advocacy; addresses the role of social power; normalizes diff er- ence; and occurs on personal, interpersonal, and political levels that encompass power relations (Gutierrez & Lewis, 1999; Payne, 2005). As an advocacy- oriented approach, empowerment concepts promote critical thinking, examination of knowledge construction, and the development of “resources (material and inter- nal), knowledge, and know-how [that build] individual lives and . . . community” (Lee, 2001, p. 31). By taking into account social justice and highlighting the ineq- uity in socioeconomic structures and their eff ects on individuals, this approach

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opens up previously unrecognized alternatives and reduces the isolation and mar- ginalization (Rose, 1990) so acutely experienced by immigrant populations. Th e social justice, problem-solving, and historical perspectives provided in empower- ment concepts address issues related to class, ethnicity, and gender (Lee, 2001). Th us, although driven by social and political factors, the empowerment approach is a psychologically transformative experience that strengthens connections.

Although social practices that are coconstructed, mutual, collaborative, and inclusive are key components of empowerment work, an important challenge that remains is the preparation of practitioners who can develop working rela- tionships. Engagement is essential for all participants to contribute to meaning- making and for all perspectives to be validated and legitimized (Rose, 2000). As a theory that highlights the relational aspects of practice and advocacy as a means to open new options for individuals, empowerment provides a framework for the identifi cation of services for immigrants, engagement, implementation of service delivery, and macro advocacy eff orts that aff ect their communities.

EMPOWERMENT PERSPECTIVE: IMPLICATIONS FOR PRACTICE

Empowerment practice requires development of the following skills on personal, interpersonal, and political levels:

• Engagement skills: Without making assumptions about the immigrant’s social identity and level of acculturation, what engagement skills are needed to attune to the individual and to connect for the purpose of empowerment work?

• Personal: What needs to be known about the individual’s worldview and his or her hopes in order to join him or her and move toward greater empowerment?

• Interpersonal: In relation to the individual’s cultural worldview, who or what are important “others,” whose participation would facilitate empowerment?

• Political: What is the individual’s understanding and meaning-making of the emigration and resettlement in America? What type of activities or discussions would be useful to facilitate the individual’s framing (if not done already) of the sociopolitical factors that have a role in his or her life experiences? How can his or her eff orts for advocacy be supported?

■ CULTURAL COMPETENCE

Practice with immigrant populations by defi nition occurs in diverse settings with diverse populations and requires skill in providing eff ective services in a context

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of diff erence. Th e factors noted in the preceding text on the context of the immi- grant experience and immigrant life course events illuminate the importance of practitioner competence in working with diff erent ethnic cultures. Th is com- petence must include a wide range of skills that span from direct, face-to-face practice to organizational, programmatic policies that embody appreciation of diversity and demonstrate leadership in service delivery with diverse populations.

Cross-culturally relevant direct-service skills must draw from several concep- tual frameworks and display a capacity for bringing knowledge of diff erent cul- tures to one’s practice. However, all this must be balanced with ethics, awareness of one’s personal biases, and critical thinking about limitations in professional knowledge (Dean, 2001; Laird, 1998; Walker & Staton, 2000). Foremost, prac- titioners must manage ambiguity in the initial stages of contact with diverse indi- viduals, focus on engagement skills, and bring some knowledge of the immigrant’s lived experience, and historical and cultural context to bear. Factors such as the criminalization of nondocumented status (Cleaveland, 2010), traumatic experi- ences in desert border crossing (Androff & Tavassli, 2012), and the deportation eff ects on mixed-status families (Zayas & Bradlee, 2014), touch many immigrant lives and families and bear exploration in assessment. Sue (1998) points out that “knowledge” of the immigrant’s world and experience must be treated as hypo- thetical until the individual (immigrant) informs us of his or her uniqueness.

Th ere are specifi c models and approaches that are valuable for their distinc- tive conceptual contributions. Cross, Bazron, Dennis, and Issacs (1989) provide a continuum-based model that includes doing harm at one end, various points of competence achievement in the middle, and, most important, serves as an anchor at the competence end of the continuum, emphasizing the vitally signifi cant role of organizational profi ciency and competency. A major contribution of the Cross et al. (1989) model is the reminder that individuals alone cannot maintain cul- turally competent practice in organizational settings; commitment to diff erence must be demonstrated at the organizational level.

Th e NASW (2007) Indicators for the Achievement of the Standards for Cultural Competence in Social Work Practice, produced by the NASW National Committee on Racism and Ethnic Diversity (NCORED) assists in advancing practice in many ways. Th e development of the indicators strengthens the NASW cultural competence standards by operationalizing the standards and expanding awareness of domains of the standards. Th ese domains address practitioner aware- ness and skills, service delivery, advocacy, workforce concerns, professional educa- tion, language diversity, and leadership. Also, the National Center for Cultural Competence at Georgetown University off ers materials and tools to assist in self- assessment of professionals and organizations and strategies for improving com- petency. Both of these sources are cited in the Additional Resources at the end of this chapter.

For more information on cultural competence, see Chapter 3.

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CULTURAL COMPETENCE AND PROFICIENCY: IMPLICATIONS FOR PRACTICE

Culturally profi cient practice with immigrants occurs on individual and organi- zational levels that include the following skills:

• Engagement: Practitioners need to ask themselves: ■ What do I need to do to have credibility as a helping professional in the eyes of the immigrant and his or her family?

■ In relation to an immigrant’s culture, what would be useful to know in order to start a conversation with him or her or the family? How do I say hello in a way that communicates presence?

• Culturally competent self-awareness ■ What cultural baggage do I bring to my encounters with immigrants from cultures that are unfamiliar to me (e.g., negative stereotypes)?

■ What messages did I grow up with, in my family and my neighbor- hood, about diff erence?

■ How clear am I about my social and cultural identity in relation to values, beliefs, and practices, which I share with groups that I identify with (e.g., how did I get my name)?

• Sustaining culturally competent interventions with immigrants, their families, and communities:

■ What do I need to take initiative in exploring diversity considerations in supervision (e.g., structure, probes, responsive supervisor)?

■ How do I use supervision to balance the knowledge I bring to my practice with the process skills that promote learning about the immi- grants themselves?

• Organizational profi ciency ■ What message does my organization (at all levels) convey regarding cultural competence? Is it something that the staff is encouraged to explore; is it something that the organization states in its mission and purpose?

■ What supports do I need to pursue culturally competent practice in my organizational setting?

■ STRENGTH-BASED PRACTICE

Th e strengths perspective (Saleebey, 2012) promotes attention to the assets and resources embodied by all individuals, particularly in expression and manifestation of resilience, wisdom, and knowledge. As an empowerment-based perspective, a strengths approach intends to “discover and expand resources” (p. 9). It is distin- guished by a focus on the signifi cance of relational skills and partnership, is inclusive,

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and supports experiences that facilitate regeneration and wholeness (Rose, 2000; Saleebey, 2012). Practice from a strengths perspective demonstrates validation and recognition of individual uniqueness, capacity of individuals to overcome hurtful life events, and signifi cance of belonging to a community as a measure of individual wholeness (Saleebey, 2012). Outcomes will show a noticeable expansion of resources to meet the needs of individuals and their families and a greater sense of well-being and life satisfaction, based on the possession of hope for the present and the future.

STRENGTHS PERSPECTIVE: IMPLICATIONS FOR PRACTICE

Exploratory questions to guide the recognition of strengths identifi ed by Saleebey (2012) focus on survival, support, high points in individuals’ lives, hoped-for possibilities, and esteem. Such areas of inquiry would potentially open up the following with immigrants:

• What decisions and adaptations were made in response to stressors regarding the departure from the country of origin, during the immigra- tion transition, and in the resettlement process?

• What inner strength and supports were used by the immigrants and their families as a means to persevere in their decisions and to protect themselves?

• Who has been there to support the individual (family, friends, com- munity groups, religious communities, and other organizations) in the transition, immigration, and resettlement? How were these resources found (e.g., the person found them, or were they given)? What requests have been made for support that were not responded to?

• What have been some exceptionally positive parts of the individual’s and the family’s lives in the past that perhaps represent something they would like to re-establish in their lives in their new home? What individuals or organizations have helped them achieve their hopes?

• What kinds of events and activities in the immigrant’s life signify con- tentment and well-being?

Information about an immigrant’s successes in overcoming challenges is informa- tive in identifying long-term goals related to “fl ourishing and growth” and diff erent from short-term survival goals regarding resettlement priorities, such as housing, food, employment, and/or legal issues. Finding out about what the immigrant had to cope with will also reveal a measure of what and how much strength and support the individual and family has. Th e individual’s image of “a good life” will convey meaningful values that may be cultural or spiritual in nature or may iden- tify the very purpose of the immigration. Most signifi cant is the view of cultural identifi cations and practices as strengths and resources, rather than defi cits.

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■ ECOSYSTEMS THEORY

Th e systems theory (Von Bertalanff y, 1968) and ecological theory combine in a theoretical formulation the ecosystems theory (Germain & Gitterman, 1996) that highlights the interdependent and adaptive aspects of behavior. Payne’s (2005) summary of systems theory points out the importance of understanding behav- ior in the context of systems (e.g., family, peer support, culture, Immigration and Customs Enforcement [ICE]) with which individuals interact. Moreover, Payne discusses various features of systems functioning, such as boundaries and open and closed interactions and entropy, that assist us in comprehending indi- vidual and family behavior. Ecological theory illuminates the signifi cant role of goodness of fi t among system needs (e.g., food, housing, validation, social sup- port, safety, integration into one’s community) and environmental resources and adaptive coping that is required for optimal functioning by all-size systems such as immigrants and their families and communities.

SYSTEMS AND ECOLOGICAL THEORY: IMPLICATIONS FOR PRACTICE

A systems and ecological approach to practice promotes a holistic view of the immigrant and his or her family that explores the following areas:

• What systems are the immigrant and his or her family part of (e.g., social network, extended family, spiritual, religious, civic, cultural) that are essential to know about in order to view their behavior in context?

• What adaptive, coping responses have the immigrant and his or her family demonstrated, to what situations, under what conditions? How can the worker assist in applying these adaptive responses to other chal- lenges or settings (e.g., reframe, invoke internalized or external cultural resources to enhance coping with stressful or overwhelming situations)?

• How can the worker collaboratively support the immigrant and family in utilizing and applying creative and imaginative alternatives to problem solving (e.g., promoting equifi nality, i.e., identifying many alternative ways to achieve a proposed goal)?

■ FAMILY SYSTEMS THEORY

As a theory of family systems, Bowen family theory focuses our attention on multi- generational issues, diff erentiation of family members, family emotional fi eld, trian- gulation, emotional cutoff , and societal emotional process (Kerr & Bowen, 1988). Bowenian theory is invaluable for its focus on multigenerational issues, patterns,

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and themes and the use of the genogram as a vehicle for the exploration of mul- tigenerational family experiences and responses to those experiences. As such, it directs our attention to the powerful role of family history, self-image, coping, and interaction in infl uencing an individual immigrant’s development of complexity.

From a larger systems perspective, the concept of triangulation suggests evaluation of the potentially powerful role of organizations. For example, the system could be seen as consisting of the government (e.g., USICE as one point of the triangle, advocacy groups as another part of the triangle, and of course, immigrant families themselves as the third part). Also, “Bowen recognized . . . class and ethnic prejudice as examples of toxic social emotional processes” and the importance of high levels of diff erentiation to cope with these “destructive social infl uences” (Nichols & Schwartz, 2007, p. 85).

A culturally competent application of family systems theory recognizes the uniqueness of traditional cultures and the intersections between acculturation and traditional values. Th is suggests it would be extremely important to explore and understand the meaning of family behaviors in the cultural context of each family and to utilize family systems theory to develop hypotheses to be matched with the family’s realities.

FAMILY SYSTEMS THEORY: IMPLICATIONS FOR PRACTICE

A culturally profi cient practice approach will explore the viewpoints of immi- grants, from their lived experience, and will include the following questions:

• Who is defi ned as family (relatives, neighbors, friends, religious commu- nity members)?

• What is the family experience in the emigration and resettlement? Were family members left behind? If so, what adjustments did this require for the family?

• What theoretical biases might the practitioner bring regarding boundary issues? What kinds of questions should be raised before making assump- tions regarding parentifi cation of minors (e.g., the eff ect on the minor) that could interfere with seeing the family function in its wholeness?

• What life cycle and life course events has the family experienced in the immigration process and how has the family coped with these experiences?

■ OPPRESSION CONCEPTS

Oppression concepts enhance practice knowledge and skills in that they represent frameworks that explore the role of social power in the lives of immigrants, their

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families, and their communities. Social power is essential to understand because it endows unearned privilege and can cast social groups as targets of negative stereotypes. Critical-thinking concepts complement analysis of social power and its eff ects in personal life (e.g., the public is personal) in their emphasis on ana- lyzing underlying value assumptions of propositions and also by bringing clarity to situations through an examination of diverse perspectives (Gambrill, 2012). Oppression concepts thus contribute an understanding of how low social power and lack of societal validation for certain individuals illuminates ways that popu- lations can be marginalized, invalidated, and deemed invisible. Rose (2000) pro- poses that oppression is foremost a relational dynamic that is perpetrated at the societal institutional level. However, it is carried out and maintained via the inter- actional, day-to-day activities between individuals. Th ere is increased attention to the potentially devastating eff ects of incessant, daily interactions described as microaggressions (Sue, 2010) that convey devaluation and marginalization. Prac- titioner awareness of the signifi cance of daily events is essential; lack of awareness can promote practitioners carrying out institutionally ascribed roles that convey prejudice and/or dismiss the immigrant’s “voice.”

Bulhan (1987) developed indicators that are insightful in understanding the impact of oppression in the lives of individuals.2 Th is formulation of oppression focused on the role of liberty as the freedom to make choices and oppression as the absence of liberty introduces stressors relative to captivity. Th e liberty-based choices compromised by oppression are

• Space: Physical and economic—the freedom and resources to go where one wants and the quality of those choices (e.g., it is legend that many children in low income families in coastal cities never experience going to the shore). Th is has implications for understanding the eff ects of colonization, slavery, and segregation.

• Time: Although we assume all individuals have choices regarding how they use their 24 hours per day, we must ask, “How much time is yours?” and factor in time demands introduced by responsibilities and roles (e.g., single parent, worker, slave).

• Energy: Are individuals’ lives characterized by living to work or working to live? How is an individual’s energy expended, on what tasks, and determined by whom? Who is benefi ting from the use of one’s time?

• Access to information: Th e digital divide has become legend in the 21st century as a measure of marginalization and underclass status. To what degree is there equal distribution of access to information via press, technology, and social sources? Inquiry is directed thus: “Who defi nes the rules of information access, societal norms, and values promulgated via media?” and “What is the basis of regulation governing information access?”

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• Mobility: Th is regards one’s freedom to go where, when, and with whom one chooses and is directly related to the factors identifi ed earlier. Th e experience of documented and undocumented immigrants alike with ICE workplace raids seeking undocumented immigrants with criminal histories and intensifi ed surveillance (e.g., review of documentation if there is due cause to suspect nondocumentation) has prompted a dimin- ished sense of safety among immigrant and traditional communities resulting in fear of public visibility.

Bulhan (1987) proposed a constrained–strained theory of oppression that identi- fi ed three key dynamics:

1. Constraint: Th e objective social conditions that impose limits on privi- leges and rights; these include barriers, social and institutional in origin, that create, maintain, and justify inequities of the rights and privileges of individuals, such as immigrants.

2. Strain: Th e subjective world of perceptions, feelings, and meanings; strain refers to the experience of undermined and/or depleted psycho- logical resources and results in distortion or diminishment of perceptual and attitudinal capacities. Individual and familial variations in abilities to adapt to the strain can result in various types of vulnerabilities.

3. Th reshold of tolerance: Th e presence of cultural norms and laws, extrale- gal and legal sanctions that regulate and control diversity and diff erence.

OPPRESSION CONCEPTS: IMPLICATIONS FOR PRACTICE

Social marginalization and lack of social power associated with oppression in the lives of immigrants suggest that the following are important questions to explore to help practitioners comprehend the unique experiences of the immigrants to whom they provide services:

• In what ways have the immigrant and his or her family experienced constraints? Under what conditions, and in what context? Who were the participants? What were the outcomes? How have the individual and family coped and adapted to constraints related to their documented or undocumented status?

• How does the immigrant manage and interpret his or her life experi- ence arising from negative stereotypes and/or constraints? Who does the immigrant blame (himself or herself, the family, their culture)? Does he or she hold perspectives that may contribute to his or her challenges (e.g., possibly behavioral, legal, societal, or religious beliefs)?

• How can the worker explore the implications of power diff erentials in interactions with the immigrant and as a focus of supervisory feedback?

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■ PRACTITIONER SELF-AWARENESS

Concepts that aid professional self-awareness represent a cornerstone of prac- tice knowledge with immigrant populations. Th e loaded and potentially highly charged context of practice with immigrants requires heightened awareness of countertransferential issues that can arise in both relation to the individual experi- ence (Borden, 2009) and intergroup experience—issues on which Bowen’s (1978) societal projection concepts shed light. Interpersonal countertransference concepts remind practitioners to be mindful of how vulnerabilities and needs may be exacer- bated due to the timing of the contact or how working with a particular person may arouse feelings from the practitioner’s own past. Bowen’s concept highlighted how social groups can impose unwanted qualities onto other social groups, thus suggest- ing a role that the professional’s social identity (i.e., group identifi cations) can have in response to immigrant qualities, real or imagined.

PRACTITIONER SELF-AWARENESS: IMPLICATIONS FOR PRACTICE

Eff ective use of self by practitioners must be based on self-awareness related to the following:

• What awareness does the worker bring in relation to culturally based coun- tertransference and societal projection? What motivation and commitment does the worker have to explore these issues (e.g., same- ethnicity workers of diff erent class backgrounds and/or acculturation levels)?

• How will the worker manage his or her comfort and discomfort levels in practice (i.e., explore the triggers), particularly in relation to diff erences in aff ect conveyed in communication (i.e., diff erences in communication styles)?

■ CONCLUSIONS

National and regional responses to the presence of immigrants is characterized by several themes. Signifi cant consideration has been given to the creation of a guest worker program, various strategies for providing options to secure citizen- ship status, shoring up a border patrol, and building of a border fence. At times when national legislation has not clarifi ed policy toward immigrants, regional alternatives have gushed forth. Th ese regional alternatives and national debates are the context of social work practice and have an impact on social workers’ perspectives. Th eory and concepts guide practice, in principle, to enhance and promote eff ective interventions.

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America has seemingly lost perspective on its origins as a land of immi- grants; instead, federal, state, and local policies (both proposed and enacted) are attempting to manage the presence of immigrants in increasingly hostile and punitive ways. Th ese conditions challenge social workers to creatively and critically utilize theories and concepts in line with the ethical and professional mandate that promotes social justice and recognizes the self-determination and dignity of all individuals, families, and communities. Th eories that promote an understanding of the sociopolitical context of immigrant populations, as well as linguistic and cultural competencies, are essential for eff ective social work practice.

■ CASE STUDIES

Th e following case studies illustrate life experiences commonly encountered by immigrants. You are invited to discuss the following questions about each case:

• What social work issues are raised by this vignette? • What legal issues are raised by this vignette? • What additional key information would help you understand the

identifi ed concerns? • What is the role and function of the social worker working with the

client and/or family in this vignette? • What short-term interventions and resources do you think would be

helpful in this situation? Long-term interventions and resources? • Which theory (or theories) of social work practice discussed in this

chapter provides the best framework for analyzing or responding to the situation described in the vignette?

• What, if anything, could be done on an organizational (mezzo) level to help in this case? What could or should be done on the policy (macro) level?

CASE STUDY 1: STRIPPED STATUS

A 25-year-old woman from South America travels to the United States alone on a student visa for graduate study in biology at a college in the Northeast. While in college, she starts dating a young man, 27, from Southern California. She is absorbed in her studies and has little social contact except for her relationship with her boyfriend.

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At the end of their studies, they marry and move to Southern California, a location that is far from his family and where she does not have any estab- lished friendships or social contacts. Upon arrival in Southern California, she immediately applies for permanent residency. However, before her application is approved, her husband dies in a swimming accident. Th e U.S. immigration “widow penalty” policy requires that her application be denied, because she is no longer married to a U.S. citizen.

CASE STUDY 2: PICKUP FOR DETENTION

Gabriela, 8, and Roberto, 10, the youngest of four siblings with immigrant par- ents, ride the bus every morning for an 8-mile drive to school. Th eir parents are farm workers who live in a California Central Valley neighborhood and work in diff erent fi elds depending on the season. One morning, the bus is stopped by the California Highway Patrol. Offi cials board the bus and take Gabriela and Roberto into custody. Th e children are driven to a detention center administered by USICE. At the detention facility, they are informed that their parents were apprehended and are being detained for deportation. Gabriela and Roberto will be held in detention until deportation along with their parents.

CASE STUDY 3: CITIZENSHIP APPLICATION

After a year in detention, the Ramos family (Rosalie, 37; Ricardo, 39; and two daughters, ages 7 and 11) are released after one of Ricardo’s sisters, a U.S. citizen, fi les for their permanent residency due to the failing health of Ricardo’s brother. Ricardo’s brother is a U.S. citizen, whose health is deteriorating due to diabetes and commencement of dialysis. Ricardo’s health status in general is good, except for the loss of his foot, which occurred during his immigration 3 years ago. Although relieved to be out of detention, the family must now deal with family health issues and adjustment issues as they reintegrate into their community life.

CASE STUDY 4: RAIDS IN THE NEIGHBORHOOD

Alicia is a single parent who lives with her 16-year-old daughter and 17-year-old son in a small rural community on the East Coast. Both her children are well on

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their way to completing high school and hope to enter college. Alicia’s parents were immigrant farm workers, as was she until the age of 12. Born in the United States, a high school graduate, and employed as a store clerk, she is strongly infl u- enced by the traditional Latino culture practiced by her parents.

Recent raids by the ICE agency in her community have sought out undoc- umented immigrants with criminal backgrounds. In the past month, a large farming employer was raided by ICE agents, who arrested approximately 1,350 individuals and, from that group, identifi ed 234 who were undocumented and had criminal histories. Th is raid was one of several that have terrifi ed the com- munity because of the risk of arrest for residents who appear to be undocu- mented, even though they are documented or legal citizens. Alicia, like many of her neighbors, only leaves the house when she has to (e.g., for work) and has arranged for food delivery at her home by an individual who provides that ser- vice at an exorbitant cost.

■ NOTES

1. Assessment content modifi ed from Melendez (2006). 2. I understand that Dr. Bulhan developed these concepts in conjunction with Chet Pierce,

MD.

■ REFERENCES

Androff , D. K., & Tavassoli, K. Y. (2012). Deaths in the desert: Th e human rights crisis on the U.S.–Mexico border. Social Work, 57(2), 165–173.

Borden, W. (2009). Contemporary psychodynamic theory and practice. Chicago, IL: Lyceum. Bowen, M. (1978). Family therapy in clinical practice. New York, NY: Jason Aronson. Bulhan, H. (1987). Th e constrained-strained theory: A general theory of deviance (BHM

Review 1). Boston, MA: Basic Health Management, Inc. Cleaveland, C. (2010). “We are not criminals”: Social work advocacy and unauthorized

migrants. Social Work 55(1), 74–81. Cross, T., Bazron, B., Dennis, K., & Issacs, M. (1989). Towards a culturally competent sys-

tem of care (Vol. 1). Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Dean, R. (2001). Th e myth of cross-cultural competency. Families in Society, 82(6), 623–630. Frey, A., & Dupper, D. (2005). A broader conceptual approach to clinical practice for the

21st century. Children & Schools, 27(1), 33–44. Gambrill, E. (2012). Critical thinking in clinical practice (3rd ed.). New York, NY: John Wiley. Germain, C., & Gitterman, A. (1996). Th e life model of social work practice: Advanced theory

and practice. New York, NY: Columbia University Press. Gutierrez, L., & Lewis, E. (1999). Empowering women of color. New York, NY: Columbia

University Press.

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Gutierrez, L., Parsons, R., & Cox, E. (1998). Empowerment in social work practice. Pacifi c Grove, CA: Brooks/Cole.

Kaplan, A. (1964). Th e conduct of inquiry. New York, NY: Chandler Publishing Company. Kerr, M., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New

York, NY: W.W. Norton. Kondrat, M. D. (1992). Reclaiming the practical: Formal and substantive rationality in social

work. Social Service Review, 66(2), 237–255. Laird, J. (1998). Th eorizing culture: Narrative ideas and practice principles. In M.

Mc-Goldrick (Ed.), Revisioning family therapy: Race, culture and gender in clinical practice (pp. 20–36). New York. NY: Guilford Press.

Lee, J. (2001). Th e empowerment approach to social work practice: Building the beloved com- munity (2nd ed.). New York, NY: Columbia University Press.

Lee, T. (2006, April 17). A new domestic and global strategy. Nation, 20–22. Melendez, M. (2006). Assessing psychosocial stressors and supports of immigrant families. Course

handout. Boston, MA: Simmons College, School of Social Work. Montgomery, D. (2007, August 19). Immigration anger seems to usher in era of xenophobia.

Fresno Bee (Fresno, CA), pp. A1, A22. National Association of Social Workers. (2006). Immigration policy toolkit. President’s Initia-

tive, weaving the fabrics of diversity, 2006–2008. Washington, DC: NASW Press. National Association of Social Workers. (2007). Indicators for the achievement of the NASW

standards for cultural competence in social work practice. Washington, DC: NASW Press. Nichols, M., & Schwartz, R. (2007). Th e essentials of family therapy. Boston, MA: Pearson/

Allyn & Bacon. Payne, M. (2005). Modern social work theory (3rd ed.). Chicago, IL: Lyceum Books. Pozzuto, R. (2007). Understanding theory, practicing social work. In S. Witkin & D. Salee-

bey (Eds.), Social work dialogues. Alexandria, VA: Council on Social Work Education. Rose, S. (1990). Advocacy/empowerment: An approach to clinical practice for social work.

Journal of Sociology & Social Welfare, 17(2), 41–51. Rose, S. (2000). Refl ections on empowerment-based practice. Social Work, 45(5), 403–412. Rumbaut, R. (2005). Th e melting pot and the pot: Assimilation and variety in American life.

In P. Kivisto (Ed.), Incorporating diversity: Rethinking assimilation in a multicultural era (pp. 154–173). Boulder, CO: Paradigm.

Saleebey, D. (2012). Th e strengths perspective in social work practice (6th ed.). Boston, MA: Pearson/Allyn & Bacon.

Sue, D. W. (Ed.). (2010). Microaggressions and marginality: Manifestation, dynamics and impact. Hoboken, NJ: John Wiley.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448.

UNESCO. (2003, July). International migration programme. United Nations International Convention on the Protection of the Rights of all Migrants Workers and Members of Th eir Families. Paris, France.

Von Bertalanff y, L. (1968). General systems theory: Foundations, development, applications. New York, NY: George Braziller.

Walker, R., & Staton, M. (2000). Multiculturalism in social work ethics. Journal of Social Work Education, 36(3), 449–462.

Zayas, L. H., & Bradlee, M. H. (2014). Exiling children, creating orphans: When immigra- tion policies hurt citizens. Social Work, 59(2), 167–173.

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■ ADDITIONAL RESOURCES

National Association of Social Workers, Indicators for the Achievement of the Standards for Cultural Competence in Social Work Practice: http://www.socialworkers.org/practice /standards/NASWCulturalStandardsIndicators2006.pdf

National Center for Cultural Competence at Georgetown University: http://nccc.george- town.edu/

Social Work Today (off ers numerous articles about practice with immigrants): www.social worktoday.com

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c h a p t e r FIVE

Th is chapter deals with major health care issues that social workers need to be familiar with in working with immigrants. It provides an introduction to the many complex, interconnected issues that social workers and their immigrant clients face as they navigate the U.S. health care system in an attempt to obtain quality health care.

In 2012, 4.2% of the population (13.3 million people) were legal perma- nent residents (LPRs; Rytina, 2013) and 3.6% (11.4 million people) were esti- mated to be undocumented (Baker & Rytina, 2013). In other words, over 24.7 million people living in this country are immigrants who, depending on when they arrived and their socioeconomic status, may have limited or no access to health insurance and limited access to health care. Furthermore, one fi fth of low-wage workers in the United States are immigrants and nearly half of all working immigrants, both documented and undocumented, earn less than twice the minimum wage. Immigrants often face medical conditions due to the inter- connected issues of their employment, low socioeconomic status, lack of funds to buy health insurance or pay for health care, and lack of government and private sector policies that would protect the immigrant worker (American Fed- eration of Labor and Congress of Industrial Organizations [AFL-CIO], 2005; Broder & Blazer, 2011; Goldman, Smith, & Sood, 2006; Montoya, 2005).

As discussed later in Chapter 8, immigrants are disproportionately repre- sented in low-wage jobs in farming, fi shing, forestry, maintenance, meatpack- ing and poultry industries, manufacturing, construction, landscaping, the service industries, and garment industry sweatshops. Within these sectors, undocu- mented immigrants are more likely to work in the less skilled and more hazard- ous jobs. Th ey face long days of hard physical labor that can cause or contribute to health problems such as musculoskeletal or repetitive motion injuries. Unsafe work conditions can lead to exposure to chemicals (in pesticides and chemi- cal-based cleaning supplies), organic dust, allergens, and toxic gases, which can result in skin rashes, respiratory disease, and, sometimes in the long run, cancer

Social Work and Physical Health Issues of Immigrants Sarah Blair Smith

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(AFL-CIO, 2014; Lashuay et al., 2002; Pransky et al., 2002; Ruttenberg & Lazo, 2004; Schenker, 2007; Villarejo, 2003). Th e following two examples provide a glimpse of the myriad problems faced by immigrants as they try to support them- selves and their families in this country. It is hoped that these examples will raise awareness about the role of the social worker in these situations.

In 2002, the Asian Immigrant Women Workers Clinic in Oakland, California, examined the health of women who attended their clinic and worked in Califor- nia sewing factories, and the clinic found that 99% had diagnosed work-related injuries, including back, neck, or shoulder strains or sprains causing pain severe enough to interfere with their daily activities. About one third had not seen a doc- tor for their injuries. Almost all of the women (97%) were eligible to fi le for work- man’s compensation but were either not aware of the program or afraid to fi le for fear of what their employer would do to them if they did (Lashuay et al., 2002).

Th e AFL-CIO (2005) conducted a study of Hispanics working in the con- struction industry and found that in 2000, although they made up less than 16% of the construction work force, they suff ered 23.5% of the fatal injuries. Th ey also found that one of the major contributing factors to the fatalities was the lack of safety training in the workers’ language. After trainings were conducted in Span- ish, the workers reported using safe work practices, such as wearing harnesses when working above the ground and using protective equipment such as goggles. Th ese trainings reduced the number of injuries and deaths (AFL-CIO, 2005; Ruttenberg & Lazo, 2004). A new report issued by the AFL-CIO in May 2014 confi rms that the death rate has fallen, but also notes that “Latino workers con- tinue to be at increased risk of job fatalities with a fatality rate of 3.7 per 100,000” (AFL-CIO, 2014, p. 2). Th is is 9% higher than the overall fatality rate. In 2012, there were 748 Latino deaths in the workplace, with the construction industry responsible for the greatest number of deaths. In that same year, there were totally 848 workplace deaths among all immigrant workers. Th is rate has been reduced by 35% since 2001, when 6 deaths per 100,000 were reported (AFL-CIO, 2014).

Against this backdrop of low wages, dangerous employment, lack of insur- ance, and lack of status, this chapter examines policies that support health care services for documented, undocumented, and mixed-status families; barriers to health care; public health issues; and health issues faced by specifi c immigrant groups, including seniors, women, and children. Finally, the chapter looks at some of the implications for social work practice that arise from these issues and provides discussion questions and several case studies.

■ FEDERAL LEGISLATION AFFECTING IMMIGRANT HEALTH CARE

A number of federal laws provide protection to all persons and help to make ser- vices accessible. For example, Title VI of the Civil Rights Act of 1964 prohibits

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organizations that receive federal funds from discriminating against individuals on the basis of race, creed, color, or national origin. Th e federal Offi ce of Civil Rights and the courts have determined that discrimination on the basis of national origin includes failing to provide accommodation for individuals who do not speak or read English. Organizations receiving federal funds must provide oral and written language assistance to individuals with limited English profi cient (LEP) in a timely manner and at no cost to the individual if the language diff erence will adversely aff ect medical care or the provision of social services (Frates & Saint-Germain, 2004). Translator and interpreter services make it possible for patients who do not speak English to communicate with their health care providers.

In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act of 1986, which included the Emergency Medical Treatment and Labor Act (EMTALA). Th is law ensures emergency medical care for all people who enter the emergency department of a hospital, including undocumented immigrants, regardless of their ability to pay. Hospital emergency departments must screen and stabilize all patients and cannot reject uninsured patients or transfer them to char- ity or county hospitals without fi rst stabilizing them. Th is law makes it possible for immigrants to receive emergency treatment even if they do not have insurance or the fi nancial resources to pay for their health care (Staiti, Hurley, & Katz, 2006).

Th e Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) bars immigrants other than refugees and asylees from enrolling in Medicaid and State Children’s Health Insurance Programs (SCHIPs) for the fi rst 5 years of residency if they entered the United States on or after August 22, 1996. However, after 5 years, qualifi ed immigrants can apply for Medicaid and SCHIP if they meet eligibility requirements (Broder, 2007). Unfortunately, not all immigrants are qualifi ed. Section 1011 of the Medicare Modernization Act of 2003 authorized the disbursement of $250 million per year for fi scal years 2005 to 2008 to hospi- tals and other facilities that provide emergency health care to undocumented immi- grants. Th e funds were allocated to the 50 states and the District of Columbia based on the number of undocumented immigrants estimated to be in each state. Th is program will not receive any additional funds, but the program will continue until all the funds have been exhausted. Many states have exhausted their allotment of funds, but other states still have funds available (Medicare Learning Network, 2014). Originally, the facilities were required to ask immigrants their status at the time of treatment and give that information to the government in order to be reimbursed. A revision allows the data to be obtained indirectly. Unfortunately, there is still confu- sion about the law, and immigrants fear that if they seek care they will be discovered and deported. Th e fear of this law has acted as a barrier to undocumented immi- grants who need emergency health care (Staiti et al., 2006). Entitlement to public benefi ts based on legal status is explored in more detail in Chapter 13.

Th e most recent law that has an impact on immigrant health insurance options is the Patient Protection and Aff ordable Care Act of 2010 (also known as

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the Aff ordable Care Act or ACA). Th e object of this Act is to increase the number of insured adults in this country by requiring that all U.S citizens and legal residents have qualifying health coverage or pay a tax penalty. Th e Act is implemented through a combination of requiring all employers with 50 or more full-time employees to off er health insurance or pay a yearly fi nancial penalty; creating state and federal health insurance exchanges through which individuals and families can purchase health insurance (subsidized if their incomes are between 138% and 400% of the federal poverty level); and expanding Medicaid to 138% of the federal poverty level and opening it to individuals under age 65 who meet the income guidelines (Th e Henry J. Kaiser Family Foundation [KFF], 2012, 2013). Th e expansion of Medic- aid is a state option, and not all states have chosen to expand their Medicaid cov- erage (Artiga, 2013). Th e ACA makes it easier for some immigrants to get health insurance but continues the eligibility restrictions for others.

Over the years, many immigrants have entered this country with their chil- dren or sent for their children later, and often both adult and child entered with- out documents or inspection and are considered undocumented. In June 2012, President Obama issued a memorandum entitled Deferred Action for Childhood Arrivals (DACA). Th is memorandum addresses the status of those children who are now either adults or approaching adulthood but are still undocumented. Th e order allows individuals who meet certain guidelines to request that any action regarding deportation be deferred for a period of 2 years, with options to apply for a renewal. Individuals must have been under age 31 as of June 15, 2012; have come to the United States before age 16; have continuously lived in the United States since June 15, 2007; have entered without documents prior to June 15, 2012, or have had lawful immigration status expire on or prior to June 15, 2012; either currently be in school or have graduated or been honorably discharged from the Armed Forces or the Coast Guard; and have not been convicted of a felony or pose a threat to national security or public safety. If all these guidelines are met, then the individual can apply for deferred action. Approval for deferred action will prevent the individual from being placed in removal proceedings or being deported and will also allow individuals to get a Social Security card and employment authorization so they can work. It is important to note that defer- ral of action does not provide lawful status or a pathway to permanent residence for citizenship (United States Department of Homeland Security, 2015; Th e National Immigration Law Center, 2014).

■ HEALTH CARE AVAILABLE FOR IMMIGRANTS

In addition to broad legislation discussed previously, a patchwork of federal laws enacted over the past two decades has made it very confusing to understand the type of health services available to immigrants of diff ering legal status. It is

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imperative that social workers have a good understanding of eligibility so that they can eff ectively assist their clients, especially those who do not understand English, the U.S health care system, or U.S. laws.

PRWORA includes exceptions for certain types of services that are not aff ected by immigrant status. All immigrants, regardless of status, have “access to public health programs providing immunizations and/or treatment of commu- nicable disease symptoms (whether or not those symptoms are caused by such a disease)” (Broder, 2007, p. 3). EMTALA provides emergency medical treatment for all immigrants, regardless of status or ability to pay; and PRWORA continues to allow all immigrants, regardless of status, to be eligible for emergency Medicaid if they would be eligible for their own state’s Medicaid program (Broder, 2007). Emergency Medicaid provides time-limited coverage for a medical emergency that is defi ned as “any severe medical condition (including labor and delivery) for which the absence of immediate medical attention could place an individual’s health in serious jeopardy, seriously impair bodily functions, or result in serious dysfunction of any bodily organ or part” (Fremstad & Cox, 2004, p. 14). Once the coverage expires, it is up to the treating physician, health clinic, or hospital to reapply if the situation is still life-threatening.

DOCUMENTED IMMIGRANTS

As discussed in Chapter 2, documented immigrants are those who hold proper documentation (passport and visa). Th is category includes refugees, asylees, and LPRs. Refugees and asylees are exempt from the 5-year ban and are eligible for Medicaid and SCHIP benefi ts for the fi rst 18 months they are in the United States as long as they meet income requirements. After that, they must reapply in order to continue their coverage. Other qualifi ed immigrants are eligible for Medicaid and SCHIP benefi ts 5 years after entry into the United States as long as they meet eligibility requirements (Broder, 2007).

In the past, during the fi rst 5 years that documented immigrants are in this country, it was often a challenge for them to access health care and purchase health insurance. Since the enactment of the ACA, legal permanent residents who have been here for 5 years or more will continue to be eligible for Medicaid as long as they meet income guidelines. If they have not been here for 5 years, they will be eligible to purchase health coverage in the exchange and receive tax credits. Th is group includes those who would otherwise be eligible for Medicaid (Artiga, 2013). It is important to remember that some states have chosen to expand their Medic- aid and SCHIP health insurance coverage, whereas others have not. Depending on the state, the expansion might include normally excluded immigrants, such as pregnant women and children. Other options are safety net providers such as public and private hospitals, community health clinics, and nonprofi t clinics

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(Broder, 2007; Staiti et al., 2006). In some states, documented immigrants may be eligible for breast and gynecologic cancer screenings and treatment. Because the access varies by the city, county, and state in which the individual resides, social workers must be aware of the laws governing access to health care and the health resources available in their geographic region.

UNDOCUMENTED IMMIGRANTS AND DACA GRANTEES

As noted in the preceding text, undocumented immigrants, including DACA grantees, are ineligible for almost all federal programs except emergency Medic- aid, hospital emergency department care, immunizations, and testing and treat- ment of symptoms of communicable diseases. In addition, they may be eligible for care at city, county, and state public health clinics depending on local laws as well as nonprofi t neighborhood clinics staff ed by volunteers (Broder, 2007; Staiti et al., 2006). With the enactment of the ACA, undocumented immigrants will still not be eligible for Medicaid and are prohibited from purchasing health cover- age on the exchanges (Artiga, 2013). Th ey can, however, purchase private health insurance in the open market, without subsidy options, if they can aff ord it. Th ey are also not subject for fi nes if they do not have health insurance (Healthcare.gov; Rejeske, 2013). Th ey also can enroll in health insurance off ered by an employer.

MIXED-STATUS FAMILIES

Th e defi nition of a mixed-status family is a family in which a least one parent is a noncitizen and at least one child is a citizen (Capps, Kenney, & Fix, 2003). In 2008, 73% of the children who had noncitizen parents were citizens. Th e citizen children in mixed-status families are entitled to the same public insurance or health exchange options as all citizen children who are eligible based on income, yet 17% remained uninsured in 2011. Th is rate is signifi cantly higher than chil- dren of citizen parents (Passel & Cohn, 2009; Ku & Jewers, 2013). Th e lack of insurance is often due to language barriers or lack of awareness of the child’s eligibility for Medicaid or SCHIP. Sometimes, though, it is due to fear of the application process if a parent is undocumented (Capps, Kenney, & Fix, 2003).

WAIVER OF EXCLUDABILITY

A key legal immigration issue aff ecting newcomers is the provision in the Immigration Act that excludes persons from entering the country if they have

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“ communicable diseases of public health signifi cance” (U.S. Citizenship and Immigration Services [USCIS], 2015a). Such diseases now include chancroid, gonorrhea, granuloma inguinale, HIV, infectious leprosy, lymphogranuloma, venereum, infectious syphilis, and active tuberculosis (USCIS, 1991). Th ese med- ical conditions, which can serve to exclude persons from entering the country, however, can be waived by applying for a waiver of excludability.

Having established reasons to exclude persons from entering the United States, the immigration law, however, does provide for a process to request a waiver so as to allow the person admission to the United States. Applicants use Immigration Form I-601, Application for Waiver of Ground of Inadmissibility (USCIS, 2015b). Filing this application is an instance in which social workers and providers can have an important impact on keeping families together. In order to gain admission, the form requires the applicant to prove that his or her entry will cause

• Minimal danger to the public health • Minimal possibility of the spread of HIV • No cost to a government agency without that agency’s prior consent

In fi ling this waiver with the government, a social worker’s affi davit, attesting as to how he or she will provide counseling to the individual, should the individual be admitted, may help in persuading the government to allow the person to enter the country.

■ BARRIERS TO HEALTH CARE FOR IMMIGRANTS

Despite the existence of laws that provide health care protection to immigrants, regardless of legal status, immigrants nevertheless face barriers that limit their access to health care. In addition to immigration status (if the immigrant is undocumented or has not lived in this country for 5 years), other barriers also exist that prevent or deter immigrants from receiving health care. Th ese chal- lenges include fear, lack of money or health insurance, language barriers, cultural issues, lack of knowledge of the U.S. health care system, and lack of facilities and transportation.

FEAR

Fear can play a major role in the decision not to seek health care. Immigrants unfa- miliar with health care providers might be fearful of the experience or might fear the news of a serious diagnosis (Garcés, Scarinci, & Harrison, 2006). Many undoc- umented immigrants fear they will be discovered, reported to the Department of

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Homeland Security (DHS), and deported if they apply for public health insurance for a citizen child. Although public assistance offi ces may only require documenta- tion of citizenship of the person who will be covered, not the parent applying for the child or others living in the same household, the fear still exists (Broder, 2007; Derose, Escarce, & Lurie, 2007). Immigrants fearing discovery might provide inaccurate, incomplete, or no contact information or no medical history when seeing a health care provider. Lack of complete or accurate medical information can result in a delay or mistake in diagnosis and treatment (Staiti et al., 2006).

Documented immigrants, though eligible for Medicaid and other public benefi ts after the fi rst 5 years of residence, may be fearful that use of these ben- efi ts will cause them to be classifi ed as a public charge, which may be grounds for deportation. According to the U.S. Citizenship and Immigration Services, the use of Medicaid, SCHIP, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), food stamps, immunizations, prenatal care, testing and treatment of communicable diseases, emergency medical assistance, and other noncash benefi ts does not constitute a public charge, but the fear still exists and may impact access to care (Derose et al., 2007; USCIS, 2009). Social workers who are aware of local, state, and federal regulations regarding immigrant eligibility for specifi c programs can alleviate some of these fears and encourage use of the benefi ts.

LACK OF MONEY AND HEALTH INSURANCE

Studies have shown that almost half of all working immigrants, particularly the undocumented, earn less than twice the minimum wage and live in poverty. In addition, only 26% of documented workers have access to health insurance through their employer (AFL-CIO, 2005; Broder, 2007; Camarota, 2012; Goldman et al., 2006; Montoya, 2005). PRWORA bans most immigrant access to public health insurance for the fi rst 5 years of residence in the United States. A Center for Immi- gration report (Camarota, 2012) indicates that in 2010, although only 13.8% of native citizens did not have health insurance, 34% of noncitizens did not. Without health insurance, many families will be less likely to receive preventive care and will not seek necessary medical care until it becomes an emergency. In addition, when they do seek care, they will have diffi culty paying because of their low income (Aiker & Urrutia, 2004). Lack of insurance and low socioeconomic status are eff ective barriers to access to health care for the immigrant population.

LANGUAGE BARRIERS

Th e inability of patient and provider to communicate in the same language can be an almost insurmountable barrier to access to and quality of patient health

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care. According to Nwosu, Batalova, and Auclair (2014), more than 25 million individuals age 5 and up living in the United States either do not speak English at all or speak it poorly. Immigrants who do not speak English or do not have a health care provider who speaks their language are less likely to seek health care. Th ey are also less likely to receive good-quality care when they do seek it (Brach, Fraser, & Paez, 2005). Th e provision of nondiscrimination based on national origin, by agencies that receive federal funds, may result in the provision of oral and written language assistance ( interpreters and translators) to those who do not speak, understand, or read English well, as is mandated by Title VI of the Civil Rights Act of 1964; and this does reduce the barrier somewhat. However, neither the law nor its regulations specifi cally details exactly what the services must be (Frates & Saint-Germaine, 2004). Th e four -pronged test as laid out in the law is broad enough to possibly still result in barriers to service.

Social workers and health care providers must consider a number of issues when attempting to address the language barrier. Th e best option for the immi- grant needing health care is that the provider, that is, the nurse, the doctor, or the social worker be himself or herself bilingual or bicultural. If the provider agency has not hired such culturally competent direct service workers, a second option is for the agency to use certifi ed medical interpreters who are present onsite and have been trained in medical terminology, ethics, and the impor- tance of confi dentiality. Often these interpreters are also capable of understand- ing and explaining cultural aspects of the interaction that might impact care (International Medical Interpreters Association [IMIA], 2007). Unfortunately, just as there may not be suffi cient nurses, doctors, and/or social workers who can communicate directly with the non-English-speaking patient, similarly, there is a dearth of trained and certifi ed medical interpreters. In addition, many health care workers (including nurses, social workers, and physicians) have not received training in how to use interpreters. If on-site interpreters are not avail- able, another option might be trained telephonic interpreters who are accessed using telephones with two receivers. Th is type of 24-hour service is particu- larly helpful if one needs an interpreter who speaks a less common language or dialect.

Still other options are trained bilingual staff and ad hoc interpreters, includ- ing family members and friends. Confi dentiality becomes an issue with family and friends, since the Health Insurance Portability and Accountability Act (HIPAA) regulations prohibit health care workers from discussing a patient’s care with any- one else without the patient’s consent. It is important not to use anyone under age 18 to interpret in a medical setting unless the patient refuses a trained interpreter or there are no other options. Using a child as an interpreter may result in the child being exposed to parental medical issues that should be kept confi dential. Another problem may occur when children are kept out of school to interpret for parents who must see health care providers.

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Communication barriers often result in poor-quality communication between the patient and the health care provider that can lead to misdiagnosis or a threat to the patient’s life if, for example, the directions for patient care or medi- cine dosages are misunderstood. In addition, patients might not seek care until they are critically ill because they are afraid of being misunderstood (Staiti et al., 2006). Social workers can and should be vigilant in advocating for increased trans- lator and interpreter services at their agency or medical setting, not just for the convenience of the patient, but for his or her safety and improved health. Many large metropolitan hospitals have arranged for electronic or staff interpretation, but with the multiplicity of languages and limited resources, skilled interpretation is not always available.

CULTURAL ISSUES

Gregg and Saha (2006) defi ne culture as a “set of behaviors and guidelines that individuals use to understand the world and how to live in it” (p. 543). As dis- cussed in Chapter 1, today’s immigrants come to the United States from all over the world and they bring with them their own cultures, including religion, lan- guage, behaviors, and family, community, and societal structures. Th is cultural component is a benefi t to the immigrants because it provides a familiar structure to their lives and also a connection to their past. It can also be a barrier, though, when it confl icts with U.S. culture. Th is is particularly true in the area of health care, when cultural barriers create a “cultural distance” between an immigrant’s culture and the health care provider’s Western culture (Gregg & Saha, 2006, p. 542). Cultural competency and cultural sensitivity by the health care provider can bridge the distance. Cultural competency and sensitivity refer to one’s ability to be aware of the fact that there are cultural diff erences and to be sensitive to and respectful of those diff erences. When working with an immigrant patient, it is important to ask about that person’s culture and try to understand how it will impact the care that the immigrant wants, needs, and ultimately receives. It is also important not to generalize or develop stereotypes based on one immigrant’s cultural beliefs (Congress, 2004).

Although Chapter 3 explores the issue of cultural competency in more depth, it is important to note that most native-born residents of Western countries believe that most illnesses are caused by something physical (e.g., bacteria, viruses, poor nutrition, old age) that can be treated with such things as antibiotics or surgi- cal procedures. Some immigrants, however, depending on the country of origin, might attribute the cause to spiritual or religious factors or to being out of balance with nature (Congress & Lyons, 1992; Ma, 1999; Murguía, Peterson, & Zea, 2003). Prior to immigrating to the United States, many immigrants have had little or no exposure to Western medicine, so they might hesitate to seek treatment

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for a physical ailment from a Western health care provider. Instead, they might use herbal remedies, acupuncture, spiritual folk healers, folk remedies, refl exol- ogy, massage, chiropractic, or homeopathy (Congress & Lyons, 1992; Dhooper, 2003; Ma, 1999; Murguía et al., 2003; Shpilko, 2006). If an immigrant does go to a Western physician, he or she might not disclose that he or she is also using a traditional remedy due to the belief (real or perceived) that the physician will not understand. If a physician has an understanding of some of the culture-bound syn- dromes of Central Americans, for example, and respectfully asks the patient about the use of traditional treatments, the patient might be willing to share the informa- tion that he or she is using a folk remedy. Th is knowledge will allow the physician to discuss the traditional treatment and its potential side eff ects or complications if used with Western medicine (Murguía et al., 2003).

In addition, some Asian cultures believe in the interconnectedness of the mind, body, and spirit; and they treat all three systems if a patient is ailing. If an Asian patient seeks care from a Western physician and is given a prescription for some pills but nothing for the mind or spirit, he or she might disregard the prescription. If, however, the Western physician takes the time to ask the patient about traditional beliefs about the interconnectedness of the mind, body, and spirit, he or she might prescribe medicine for the body and also recommend acu- puncture and meditation to heal the mind and spirit (Dhooper, 2003).

Culturally competent health care providers (and in their absence, inter- preters) who understand and respect the value of traditional and alternative health care treatments should be an essential component of Western facilities that treat immigrants. Social workers who can advocate for their patients and be part of an organization’s development and implementation of ongoing pro- grams to address cultural competency should also be an integral part of these organizations. Social workers should advocate not only on behalf of their cli- ents (micro advocacy) but also within the workplace to ensure that systems are in place to make services available (mezzo advocacy). Th is book ends with an exploration of systemic or macro advocacy aimed at changing city, state, or federal policies—another important function, particularly in the context of examining health care policies.

Cultural competence also extends to the physician’s bedside manner when providing a diagnosis. For example, Shpilko (2006) points out that in Russia, a cancer diagnosis is not discussed with the patient in the hospital. Rather, the diagnosis is discussed with family members who then choose a time and place to inform the patient when he can be surrounded by supportive family and friends. In such a situation, if the physician tells the patient, it could be seen as a sign of disrespect for the family’s traditional values, but if the physician tells the family and not the patient, he is violating the patient’s right to privacy, which is guar- anteed in HIPAA. In other cultures, the challenge is to fi nd the locus of power, sometimes the husband and sometimes the elderly grandfather or grandmother,

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as the target of the communication. Th ere is no easy solution to this dilemma, but it is one that health care providers might face, should be aware of, and will need to navigate when they care for immigrants.

Th e cultural issue also involves the idea of self-care. Immigrants uncomfort- able with Western medicines sometimes choose to diagnose and medicate them- selves and their families using medicines from their country of origin. Shpilko (2006) describes elderly Russian immigrants, and Dyck (2006) describes Sikh women who used medications brought from their countries of origin because they were familiar with the drugs and their use. Unfortunately, sometimes these drugs can be dangerous to the user’s health because they are past expiration or because they might interact with drugs prescribed by U.S. physicians who are unaware the immigrant is taking another drug. Western physicians must know enough to ask about other medications being used, but they must also develop a good rapport with their patients so the patients will answer honestly.

CONFUSING U.S. HEALTH CARE SYSTEM

Navigating the U.S. health care system is confusing and intimidating even if one speaks English and has a basic understanding of preventive health care, that is, how to schedule and keep appointments, the reasons for diagnostic tests, and the meaning of all the terminology and restrictions that are part of U.S. health insur- ance. Imagine what it would be like to be a newly arrived immigrant who does not speak or understand English, has had little exposure to Western medicine or health care facilities, and has limited resources to pay for medical care. It is no wonder that so few immigrants seek care unless they are desperately ill. Th e com- plexity of the U.S. health care system is a very formidable barrier to immigrant health care.

Research also shows that immigrants often do not have a primary care provider, do not visit doctors, and do not get preventive care (Fremstad & Cox, 2004). Th ose with limited resources rarely spend money on a doctor’s visit when they do not feel sick. Unfortunately, all people need periodic physicals to make sure they are healthy and, if not, to identify a medical condition, such as diabetes, in the early stages while it can be controlled with diet, not when it has advanced to the stage that it requires insulin injections. Infants and children also need well-child visits to monitor their growth and development and to receive all their immunizations on time.

Another barrier to immigrant health care is the confusion about who is and is not eligible for various federal programs, a confusion that was compounded by PRWORA (Derose et al., 2007). Eligibility requirements for immigrant health care get even more confusing when one considers state-funded and state-run Medicaid and SCHIP programs that are open to documented immigrants and

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sometimes even to undocumented immigrants. Th e available services, however, vary by state and year. Th e language barrier makes the situation even more con- fusing (Derose et al., 2007; Fremstad & Cox, 2004). In addition, even many immigrants who are eligible for federal or state programs do not enroll in state Medicaid and SCHIP programs based on the unfounded fear of being declared a public charge (Aiker & Urrutia, 2004; Fremstad & Cox, 2004).

Immigrants are not the only ones who are confused about these health care programs. Program employees are also confused about what questions they can ask regarding immigrant status and Social Security numbers (SSNs). Applicants (but only applicants) for Medicaid, SCHIP, or insurance through the new insur- ance exchanges are required to provide their SSNs; state employees who are work- ing with the immigrant may ask nonapplicant family members to give their SSNs but federal rules allow immigrants not to specify the immigrant status or the SSN. Immigrants are not required to list the country of birth or country of origin, even if those questions are on an application. In addition, no one is required to provide his SSN if he is seeking emergency Medicaid (Tumlin, 2007).

LACK OF FACILITIES AND TRANSPORTATION

Lack of nearby facilities, too few primary care providers and specialists willing to take uninsured immigrants, and lack of transportation are also barriers that hinder immigrant access to health care (Fremstad & Cox, 2004). Over the years, communities with large numbers of immigrants have developed safety net health care providers for the immigrant population. Communities that are just start- ing to experience an infl ux of immigrants are struggling to develop health care options for them and may not have adequate resources to address immigrant health care needs (Staiti et al., 2006). Transportation can be a barrier to health care both in urban and rural settings. Sometimes public transportation is avail- able but the immigrant lacks the money to pay for it, whereas other times there is no transportation or it can take several buses to get there. Zuroweste (2007) states that only 44% of migrant farmworkers own a car. In rural settings, lack of a car can make it as diffi cult to access health care as lack of a token in the city.

■ IMMIGRATION AND PUBLIC HEALTH ISSUES

Th e Centers for Disease Control (CDC) Foundation defi nes public health as “the science of protecting and improving the health of families and communi- ties through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases. Overall, public

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health is concerned with protecting the health of entire populations” (CDC Foundation, n.d.). Th e issues and populations that public health offi cials are concerned with can be as small as a local community or as large as the world, because diseases are not necessarily stopped by the borders of countries (CDC Foundation; World Health Organization, 2012). One focus of public health offi cials is the immigrant population, starting when immigrants are screened for seven contagious diseases and proof of vaccination for nine vaccine-preventable diseases when entering this country (Wasem, 2014) and continuing over time as they settle into communities, join the workforce, become acculturated to the United States, and sometimes, either get deported or voluntarily return to their country of origin.

One diffi culty with addressing the health care of immigrants, both docu- mented and undocumented, is illustrated by the data reported by Goldman and colleagues (2006) from the 2000 Los Angeles Family and Neighborhood Survey (LAFANS), Los Angeles County, California, which show that approximately one quarter of the foreign-born population in Los Angeles County had never had a medical checkup and one in nine had never visited a doctor. Th e numbers are even worse for the undocumented: Forty-two percent had not visited a doctor within the past year (Goldman et al., 2006).

It is diffi cult to provide health care for a population that does not see health care providers. As the providers try to reach out to this underserved population, it is important for them to remember not to lump all immigrants together and con- sider them as a homogeneous group with a common culture. It is always necessary to look at the subpopulations and individuals that comprise the group (Congress, 2004; Mui, Kangel, Kang, & Domanski, 2007; Pang, Jordan-Marsh, Silverstein, & Cody, 2003). Cultural diff erences and responses to the changed dynamics of family relationships and life in the United States will vary not just because of the culture of the country of origin but also because of individual diff erences. In addi- tion, the role of and the expectations for men, women, children, and seniors will vary by and within their culture and their family structure.

IMMIGRANTS AND INFECTIOUS DISEASES

Immigrants who enter the United States illegally are not screened for infec- tious diseases or proof of vaccination and can spread disease unknowingly to those they come in contact with in their communities, in the workplace, and when traveling. One example of this is tuberculosis, which has been shown to be spread by undocumented immigrants crossing into border communities in the southwestern United States (Deiss et al., 2009). Remember that undocumented immigrants have very limited access to health care. As a result, these diseases frequently go undiagnosed unless an individual seeks medical care. Once that

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person seeks care, however, PRWORA guarantees all immigrants, regardless of status, access to programs providing immunization and/or treatment of commu- nicable disease symptoms.

From time to time, diseases, such as severe acute respiratory syndrome (SARS), Ebola and other hemorrhagic fevers, avian infl uenza (H5N1), polio, cholera, plague, smallpox, yellow fever, diphtheria, and infectious tuberculosis, may be identifi ed as having the potential to cause a pandemic that could aff ect the health of Americans (Wasem, 2014). Immigrants coming from areas where the disease has been identifi ed as active might be screened at their point of depar- ture rather than on arrival in the United States and banned from entry if they are experiencing symptoms of the disease in an eff ort to curtail the spread of the disease into the United States. During periods of global or regional epidemics, it will be important for U.S. social workers and health care providers who work with newly or recently arrived immigrants to provide further screening and assist with obtaining medical care if they suspect that the immigrant might have one of these diseases. Th ere may be instances in which denying entry to an immigrant with one of these diseases will cause extreme hardship to the family and relatives already in the United States, and in these instances, social workers can provide invaluable assistance in helping that individual obtain a waiver of excludability to come to the United States despite being ill and arranging for medical care on arrival (Wasem, 2014). In addition, social workers can be instrumental in delay- ing or halting deportation of an immigrant with one of these diseases because the deportation would cause extreme hardship to the family members remaining.

COMMUNITY HEALTH

As concerned as public health offi cials are with limiting the spread of infectious diseases both into the country and within the community through screening, treatment, and vaccination, they are equally concerned with other health issues that occur locally. Th ese issues include promoting healthy behaviors, safety in the workplace, safe and healthy environments (food, water, air), and reducing deaths from chronic diseases and are addressed by public health offi cials who include emergency responders, health educators, physicians, nurses, social work- ers, occupational health and safety professionals, nutritionists, community plan- ners, sanitarians, public policy makers, and scientists and researchers. On the macro level, public health workers are doing research and developing policies to deal with identifi ed issues. On the micro level, public health workers provide a range of services from basic health care and health education to monitoring air and water quality and safety of the workplace (American Public Health Associa- tion, n.d.; CDC Foundation, n.d.; World Health Organization, 2012). Many cities, counties, and states now have comprehensive websites listing resources

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for immigrants ranging from physical and mental health clinics to organizations providing housing or legal assistance, senior services, crisis intervention, sexual abuse counseling, and substance abuse assistance. Many of these organizations off er culturally sensitive and language-appropriate health care and health educa- tion. Th e websites contain a wealth of information both for immigrants who are computer literate and for social workers and other community workers who are able to access these resources to provide assistance to the immigrants in their communities.

Public health eff orts are largely reliant on free and reduced-cost community clinics to provide safety net health care for the undocumented immigrants and the many documented immigrants who do not qualify for any insurance cover- age. Although these clinics provide basic health care, including care for chronic illnesses, as well as prescriptions and medical equipment, they are often unable to provide diagnostic and specialty care that many of the patients need. Th is need remains largely unmet. Th ese clinics may be staff ed by volunteers, run by non- profi ts, or funded by grants or government programs. Often volunteers are physi- cians and students from local medical schools. All provide low- or no-cost care in clinic settings with staff who are bilingual and culturally sensitive to the needs of the specifi c immigrant populations they serve.

One important resource for public health workers serving the migrant farmworker communities is the Migrant Clinicians Network (MCN), which was founded in 1984. “MCN’s goal is to improve health care for migrants by providing support, technical assistance, and professional development to cli- nicians in Federally Qualifi ed Health Centers (FQHCs) and other healthcare delivery sites” (Migrant Clinician Network, n.d., Paragraph 2, Goal). According to the Farmworker Justice organization, there are now 165 centers nationwide providing primary and preventive care to migrant farmworkers on a sliding fee scale (Farmworker Justice, n.d.). Th e clinics provide basic health care; screen- ings for tuberculosis, mammograms, and Pap smears; follow-up care for chronic conditions such as diabetes and hypertension; and prenatal care. Th ey also pro- vide screening, diagnosis, and treatment for breast, cervical, and colon cancer. Participating clinicians provide education about the importance of preventive care, screenings, and prenatal care. When a migrant worker patient is getting ready to move, his clinician makes sure the patient knows the location of the next clinic, and, with patient approval, transfers his medical records to the new clinic. Continuity of care is particularly important in the management of chronic conditions and communicable diseases such as tuberculosis. In addi- tion, the MCN has developed specifi c networks to track and provide continuity of care for diabetes, specifi c cancers, and tuberculosis (Kugel, 2007). Approxi- mately 863,000 migrant farmworkers and their families received care at one or more of these centers in 2010 (Farmworker Justice, n.d.).

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HEALTHY MIGRANT PHENOMENON AND ACCULTURATION

Th e “healthy migrant phenomenon” has been described by Fennelly (2006) as the idea that, when individuals migrate from their country of origin to the United States, they arrive in a healthier state than native-born residents. Although they have higher rates of some infectious diseases, Fennelly (2006) reports that they generally receive better ratings in the areas of health risk factors, chronic con- ditions, and mortality. Schenker (2007) describes a similar concept, which he calls the “healthy immigrant hypothesis,” when he talks about immigrant Latina women who have better-than-expected birth outcomes when they fi rst arrive in the United States.

Acculturation refers to how an immigrant adapts over time to the culture of his receiving country. Schwartz, Unger, Zamboanga, and Szapocznik (2010) argue that the degree of similarity between the culture of origin and the culture of emigration is an important factor to consider when thinking about accultura- tion. If the two cultures are similar, it is usually very easy for the immigrant to adapt to the new culture. If, however, the immigrant is coming from a country or region where collectivism is emphasized, with its focus on family, clan, nation, or religion, to a country like the United States, where individualism is prized, that immigrant will have a more diffi cult time adjusting to and adopting the new cul- ture (Schwartz, Unger, Zamboanga, & Szapocznik, 2010). Acculturation occurs at diff erent rates for diff erent immigrant groups, sometimes based on age at the time of immigration. It is also dependent on where the immigrant settles. If he settles in an established community with others from his home region, accultura- tion may not take place until the second or third generation, but if the immigrant settles in an area where there are few other immigrants, then acculturation usually occurs fairly rapidly (Schwartz, Unger, Zamboanga, & Szapocznik, 2010).

Public health offi cials are concerned with ways to help immigrants adapt to their receiving country without adopting the negative behaviors exhibited by the citizens of that country. One of the results of acculturation, or the “para- dox of assimilation,” is that immigrant health care often declines the longer the immigrant lives in the United States because, over time, immigrants will gradu- ally adopt the culture of the United States, including the language, norms, and values. Along with the norms and values, the immigrants often adopt less health- ful eating habits and lifestyle choices such as high-risk sexual behavior, cigarette smoking, and substance abuse (Derose et al., 2007; Fennelly, 2006; Schenker, 2007). Th e loss of supportive family and social networks in their home coun- try also contributes to the deterioration in health. In addition, settling in a new country and culture is stressful and can contribute to health problems (Fennelly, 2006). Acculturation has been linked to increases in preterm, low-birth-weight babies, adolescent risk behaviors, anxiety and depression, and general mortality.

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Th e longer immigrants are in this country, the more closely their rates of health risks, chronic conditions (such as obesity, diabetes, and cancer), and mortality approach that of native-born citizens and the more health care they need but are often unable to get (Fennelly, 2006; Schenker, 2007).

MEDICAL ISSUES OF IMMIGRATION DETAINEES

In fi nancial year 2010, approximately 363,000 immigrant detainees were held in federal penitentiaries, prisons, local jails, and service-processing centers that are overseen by DHS’s bureau of Immigration and Customs Enforcement (ICE; Sis- kin, 2012). Because they are not considered to be prisoners, they are not entitled to legal channels of appeal (Dow, 2007). Th ey do, however, have the right to med- ically appropriate treatment, according to a 2012 Congressional Research Search Report (Siskin, 2012). In 2008, in response to numerous reports documenting failure to provide adequate medical care, ICE issued new National Detention Standards that include provisions for the delivery of medical care. ICE also has the responsibility of ensuring that all facilities housing detainees maintain those standards. Unfortunately, because the standards have not been enacted into law, they are not legally enforceable (Siskin, 2012; Th errien & Mattie, 2011).

Numerous reports document delays in initial medical screening at the time of intake, delays in initial medical examinations, critical medical staffi ng short- ages (both physicians and nurses), staffi ng shortages to handle requests for off -site medical care for detainees, inadequate or nonexistent treatment of chronic or pre- existing medical conditions, denials of medical care, and lack of accurate mortal- ity and morbidity data (National Immigration Forum, 2011; Th errien & Mattie, 2011). In addition, there is a discrepancy between the ICE standards that call for providing medical care, which includes treatment of chronic and preexisting care, and the covered service health care package provided by the Division of Immi- gration Health Services (DIHS), which is responsible for health care for ICE detainees. Th is package stresses that medical care for detainees should only cover emergency care, not pre-existing conditions (Human Rights Watch, 2009; Th er- rien & Mattie, 2011). One concern when these facilities do not complete initial medical screenings and complete physical exams in a timely manner is that they sometimes do not diagnose a communicable disease that requires treatment (e.g., tuberculosis) quickly, or they fail to provide continuous, ongoing treatment for a previously diagnosed communicable disease (e.g., tuberculosis or HIV/AIDS; Venters, McNeely, and Keller, 2013). In addition, when detainees are deported before completion of their course of treatment, follow-up care is supposed to be arranged but sometimes is not. Both these situations can and do result in drug- resistant strains of these diseases (Deiss et al., 2009; Venters et al., 2013).

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Th errien and Mattie (2011) also report that there were 104 detainee deaths from January 2004 through March 2009 that occurred in ICE or ICE-supervised facilities and that “approximately one-third of reported deaths may have been avoid- able according to medical experts” and were attributable to inadequate medical care in ICE facilities (p. 437). On the macro level, social workers can advocate for improved, consistent health care for all detainees and laws to enable enforcement of good-quality medical care.

WORK-RELATED MEDICAL ISSUES

Approximately 84% of immigrant families have at least one full-time worker, but that worker is much more likely to be employed in a low-wage job than is a native citizen (Camarota, 2012). Agriculture, fi shing, forestry maintenance, meat packing, man- ufacturing, construction, service and hospitality industries, day labor, and garment industry sweatshops are the industries that hire the largest numbers of immigrants and they are also some of the industries with high rates of injury (AFL-CIO, 2005; Kugel, 2007; Lashuay et al., 2002; Montoya, 2005; Pransky et al., 2002; Schenker, 2007; Villarejo, 2003).

Immigrant workers in these industries suff er musculoskeletal injuries that can be isolated or cumulative over time. Th ese injuries occur from improperly lift- ing or carrying heavy objects or from performing too much stoop labor. Workers can develop carpal tunnel syndrome from repetitive hand and arm motions used in their jobs (AFL-CIO, 2014; Zuroweste, 2007).

Th ey can also develop environmental injuries from exposure to chemicals. Th e arms and hands of farmworkers who pick produce can develop skin irritation due to exposure to pesticides sprayed on the plants. With continued exposure over a long period of time, the irritation can turn into dermatologic disease or chronic occupational disease that has the potential to eventually kill the worker (AFL-CIO, 2014).

Farmworkers and maintenance workers can develop respiratory prob- lems from breathing in the airborne pesticides or cleaning chemicals that, with long-term exposure, can turn into chronic respiratory disease. Long-term expo- sure to some chemicals can even cause cancer or neurologic disease (AFL-CIO, 2014; Schenker, 2007; Villarejo, 2003).

Th e AFL-CIO (2014) reports that immigrants are not as likely as native citi- zens to complain about hazardous job conditions or to stay home from work after an injury for fear of losing their jobs. Unfortunately, if workers return to work before the injury has healed suffi ciently, it can become more severe and inhibit the worker’s ability to do the same job any more (AFL-CIO, 2014). Many workers do not stay home after being injured because they lack health insurance and cannot

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aff ord to miss work and pay for a doctor visit. Without insurance or money, the injured immigrant worker has little hope of receiving care. In addition, over 50% of foreign-born workers surveyed in one study did not know about workman’s com- pensation (AFL-CIO, 2014; Zuroweste, 2007).

It is estimated that there are over 25 million migrant workers employed in agriculture, construction, meat packing/poultry industries, and the seasonal service industry and that over 53% of these workers are undocumented. Migrant worker health is adversely aff ected by the migratory lifestyle, because it is more diffi cult to access care when workers are unfamiliar with local resources in their temporary homes (Kugel, 2007; Zuroweste, 2007). Zuroweste (2007) reports that migrant workers have a higher rate of diabetes than nonmigrant workers and that babies born to migrant working women have a high rate of congenital abnor- malities. In addition, tuberculosis rates are 30% to 50% higher in the migrant population than in the general population.

■ SPECIAL POPULATIONS

Elderly, female, and child immigrants face special health challenges. Th is section examines in more detail some of the challenges facing these vulnerable immigrant populations.

HEALTH CARE FOR SENIOR IMMIGRANTS

Elderly immigrants are the most underserved seniors in the health care system because of language and cultural barriers (Mui et al., 2007). Many elderly immi- grants do not speak English well, if at all, making it diffi cult to describe symptoms and understand physician recommendations. It becomes even more diffi cult if the provider does not understand the patient’s culture. In addition, Mui and colleagues (2007) report that elderly Asians who do not speak English often choose not to get health care in order to save face by not having to admit that they do not speak English or understand what is being said. Social workers need to factor in the idea of saving face when working with LEP individuals, particularly seniors.

Cultural diff erences may also aff ect the way immigrant seniors adjust to the aging process and cope with chronic illness. As noted previously, many immigrants prefer traditional medicines and health care and this preference is particularly true of seniors. Unfortunately, seniors also tend to have more chronic illnesses that require regular monitoring and care. Avoidance of the U.S. health care system may also cause these elderly immigrants to become seriously ill (Mui et al., 2007; Pang et al., 2003).

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Often seniors immigrate to the United States to join adult children who are already settled here. In their country of origin, these seniors were the caregivers and the children sought their advice. Here, however, the role is reversed, and seniors who may not speak English or understand how to navigate U.S. society and the health care system are dependent on their children for their care. Th is dependence may cause stress that can aggravate existing health conditions and/ or cause immigrant seniors to neglect health care so they do not have to ask for help (Fitzpatrick & Freed, 2000). Th e relationship becomes particularly diffi cult if the children have further redefi ned the traditional role because of acculturation to the United States (Pang et al., 2003). Chapter 12 examines issues of elderly immigrants in more detail.

HEALTH CARE FOR IMMIGRANT WOMEN

Th e LAFANS data from 2000 show that 20% of undocumented women had never received a checkup (four times the rate for native-born women) and 7% had never seen a physician. Th e numbers would be even more distressing if preg- nancies (with their hospital deliveries) were not factored in. Although these num- bers are for Los Angeles County, California, and not the entire United States, it is still possible to deduce that some of the barriers discussed earlier play a role in the low numbers of immigrant women who get checkups just as they do for most immigrants. With women’s health issues, however, the literature indicates that culture, language, lack of a normal source of care, and access to health insurance are four of the most formidable barriers.

In Western medicine, one focus of women’s health care is on breast and gynecologic cancer screenings. Studies have shown that female immigrants are much less likely than female citizens to have Pap smears and mammograms (De Alba, Hubbell, McMullin, Sweningson, & Saitz, 2005). According to Matin and LeBaron (2004), often the reason is due to religious and cultural beliefs. Muslims place a high value on modesty, bodily privacy, and premarital virginity, which confl icts with Western standards of health care, with its focus on gyneco- logic exams and Pap smears by the age of 21. Th e confl ict creates tension between the patient and the physician, who is seen as being insensitive to Muslim cultural and religious beliefs. Results of another study indicate that Latinas also tend to be modest and, as a result, often avoid breast and gynecologic cancer screenings (Garcés et al., 2006). It is crucial for the health and well-being of all immigrant women for health care professionals to develop a sensitivity to and respect for the cultures and religious beliefs of their immigrant patients while still fi nding a way to provide quality medical care and screenings.

Immigrant women also face barriers accessing health care when they are preg- nant. All immigrants, regardless of status, are eligible for Emergency Medicaid for

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labor and delivery. Th ey are not necessarily eligible, however, for prenatal care, even though studies have shown that lack of prenatal care can increase poor preg- nancy outcomes, such as prematurity, and possible resulting long-term disabilities ( American Academy of Pediatrics, 1997). Eventually, the Centers for Medicare & Medicaid Services amended the SCHIP regulations to allow states to use SCHIP funds to provide prenatal care to pregnant women, regardless of immigrant status. As of April 2006, seven states allowed enrollment for prenatal care and another 18 states provided state-funded coverage (KFF, 2006). Even in the Western culture, women’s health issues are still sensitive topics because they concern private parts of the body. Addressing women’s health issues becomes even more diffi cult for immigrant women whose cultural and religious beliefs stress modesty and virgin- ity. Th is is yet another reason why culturally competent health care and social service practitioners are sorely needed, particularly when dealing with immigrant communities.

HEALTH CARE FOR IMMIGRANT CHILDREN

In 1997, the American Academy of Pediatrics stated, “Every child within the geo- graphic boundaries of the United States, regardless of that child’s ‘status,’ should have full access to all social, educational, and health services that exist at the local, state, and federal levels for the care and benefi t of children” (American Acad- emy of Pediatrics, 1997, p. 153). Th e United States still has a long way to go to implement these recommendations. According to a report on young immigrant children issued by the Urban Institute (Fortuny, Hernandez, & Chaudry, 2010), immigrant children under 8 make up 24% (8.7 million) of the 8-and-under pop- ulation of the United States; 93% of those children are citizens, with 53% of the children living in mixed-status families; over 50% live in low-income families; and immigrant children are more than twice as likely to be uninsured as children of native citizens (Fortuny, et al., 2010).

Because many immigrant children do not have regular health care providers or receive regular well-baby/child visits, they may not have received appropriate immunizations and may have undiagnosed health problems, including parasitic and infectious diseases and vaccine-preventable diseases (American Academy of Pediatrics, 1997). Th e aforementioned barriers to access to health care (fear, lan- guage, culture, income, and insurance) also apply to children, many of whom are eligible for Medicaid or SCHIP coverage based on family income and child citi- zenship status. Unfortunately, it will take signifi cant culturally appropriate out- reach eff orts in the community to increase enrollment in these programs. Once the children have insurance, it will take more outreach to get them, and their families, into the habit of accessing preventive health care and seeking treatment for easy-to-treat conditions before they become critical (Lessard & Ku, 2003).

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■ IMPLICATIONS FOR SOCIAL WORK PRACTICE

Social workers who work with immigrants must be particularly cognizant of the National Association of Social Workers (NASW) Code of Ethics (2008) section on values (service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence) and the ethi- cal principles that derive from them. Social workers must use those values as a foundation and guide in their practice with this population. Many individuals in this population are vulnerable because of the barriers they face living in the United States and some are particularly vulnerable because of their undocu- mented status. Th e barriers of immigrant status, language, income and health insurance status, and culture impact every aspect of an immigrant’s life. When those barriers adversely aff ect access to health care, the negative impact is even greater, for the status of one’s health aff ects every other facet of one’s life, including school, work, family relationships, and community relationships. Social workers in the fi eld of health care must actively address the issues of language, culture, and income/health insurance status as well as legal status when working with immigrants.

Social workers, by their training, have the unique ability to assist the immi- grant in all aspects of his or her life, from helping him or her connect with commu- nity resources to attempting to fi nd insurance coverage, to acting as an advocate for him or her within the health care system. One of the fi rst goals a health care social worker should work toward is establishing trust with the immigrant client. Trust can lead to a working relationship between the immigrant and the social worker where the immigrant feels safe telling his or her story and describing the cultural and religious beliefs so that the worker will be able to help the client identify needs and clarify how those needs interconnect with the health care sys- tem. Th e social worker can then act as a bridge or cultural mediator between the immigrant and the health care provider in an eff ort to ensure that both the immigrant’s health care and cultural needs are met (Carr, 2006; Congress, 2004). If the immigrant establishes a degree of comfort with the health care provider, it is more likely that he or she will continue to participate in and be compliant with a plan of care.

Social workers must develop a broad knowledge base of the resources in their clients’ geographic region as well as federal and state laws regarding access to those resources and immigrant status. Although it is impossible for one person to be an expert in everything, it is important to develop relationships with experts in topics such as immigrant or employment law, so there is someone to ask when questions arise. It is crucial to know what services the local public and nonprofi t welfare and social service agencies off er as well as the barriers to those services. Th is knowledge will make it easier to help the immigrant client. It is also crucial to develop a working list of physicians, pharmacists, clinics, and hospitals that are

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willing to see immigrants with limited fi nancial resources, whose staff is culturally competent and sensitive to the needs of immigrants and who have trained bilin- gual staff , interpreters, and translators to communicate eff ectively.

Social workers must make an ongoing commitment to education, both their own and that of others in the health care fi eld. Th ey need to address the question of their own cultural competence and, as they work with individual patients, strive to learn more of that person’s cultural and religious beliefs. In addition, they need to educate those with whom they work about the cultural and religious beliefs of the patients they are seeing and the social issues faced by the patient and the population, which might impact patients’ ability to be compliant with and to actively participate in their care (Congress, 2004; Fennelly, 2006). Social workers can and do play a major role in helping immigrants access and use appropriate medical care. Th ey can also advocate for a health care system that would be avail- able to all based on medical need rather than immigration status.

■ CASE STUDIES

Th e following case studies illustrate the types of health issues that social workers may encounter in working with immigrant clients and their families. You are invited to discuss the questions following each case.

CASE STUDY #1: PEDRO

Pedro is an undocumented migrant farmworker from Mexico. He has a wife, Jovita, and three children, ages 3, 5, and 7. Th e 3-year-old and 5-year-old were born in the United States, but the 7-year-old and Jovita were born in Mexico. Spanish is their native language and none speaks English except the 7-year-old. Th ey are currently working in Florida, picking blueberries, but the crop is almost done, so they are getting ready to move to South Carolina where the blueber- ries are almost ready for picking. Th ey share a house with one other family and three single men. All have been working together—the men in the fi elds and the women packing the blueberries. Two of the single men have cars and provide rides for the rest as needed. Th ey plan on moving to the next picking location together.

Pedro has been coughing a lot lately, has been tired, and for the past 2 weeks has been waking up with night sweats. Jovita fi nally has convinced him to go to the local health center and has found a friend willing to drive him there. Th e local health center clinicians belong to the MCN. After examining him, the clinician does a skin test and gets the friend to bring him back in 2 days to read it. At the second visit, the clinician diagnoses Pedro with an active case of tuberculosis.

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Pedro will need to be hospitalized for a short time and then will need to continue taking a combination of daily medicines for months. After a few weeks, he will be able to return to work as long as he continues taking his medicines. Th e clinician convinces the friend to bring Jovita and the three children in for testing as well. Th e youngest child is diagnosed with an active case and the older two children and Jovita have the latent form of tuberculosis. Th e youngest child will be hospi- talized for a few weeks, whereas the two older children and Jovita can be treated with daily medicine at home. Th ey will need to take the medicines for between 9 months and a year. Jovita can continue working, but Pedro will not be able to return to work for about a month.

Pedro and Jovita are depending on the friend for a ride to the next job in South Carolina. Th e job in Florida is over and they can no longer stay in their temporary housing there. By the time the child is diagnosed, all the workers except the friend have moved on to South Carolina. Th e friend needs to leave as well in order to keep working. Th e clinician refers the family to the social worker at the clinic and to the hospital social worker. A referral is also made to the MCN near the South Carolina farms where the migrants are moving.

• What social work issues are raised by this vignette? • What legal issues are involved because the workers are undocumented? • What can the social worker do to help this family in the short run and

long term? • What can the social worker and the clinician do about the other work-

ers and family members who were exposed to tuberculosis and have moved on?

CASE STUDY #2: MARIA

A young woman named Maria has recently emigrated from Cuba and was able to bring her medical records with her. She moved to Columbus, Ohio, because she had a cousin there. Neither she nor her cousin speaks English. Maria has had gynecologic issues for several years and needs to continue being followed for the condition. Her cousin takes her to the local health clinic, where some of the staff are bilingual and she can communicate easily with them. Unfortunately, the clinician must refer Maria to a specialist. Maria is uncomfortable with the idea but knows she needs to go to the appointment. Workers at the clinic assure her that, on the day of the appointment, they will have a trained interpreter from the clinic available to go with her. Unfortunately, on the day of the appointment, Maria arrives at the clinic and fi nds out that the interpreter is sick and cannot go. It took months to get this appointment and, if it is canceled, Maria will need to wait several more months for a new appointment. Both she and the clinician

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agree that she cannot wait for a new appointment, so the clinic off ers to have the bilingual social worker take her.

Maria and the social worker meet with the specialist and Maria gives him all her medical records. Th e specialist, who does not speak or read Spanish, looks at the records and says he cannot do anything with them. First, they are in Spanish and he does not read Spanish. Second, he has no way of verifying if they are real medical records because he cannot speak with the physician in Cuba whose offi ce they came from. He tells the patient that he must ignore the fact that the records exist and start diagnosing her from the beginning. She has been on a particular medication for this condition, but he refuses to continue prescribing it until he has done a complete workup.

• What social work issues are raised by this case? • What legal issues are raised by this case? • What can the social worker do to help Maria? • What, if anything, could be done on an organizational (mezzo) level to

help in this case? What could or should be done on the policy (macro) level?

CASE STUDY #3: PHUONG

Phuong is a documented immigrant from Vietnam who arrived in the United States in March 2005. She is slowly learning English, but is not comfortable speaking it and still has diffi culty understanding it. Phuong has a full-time job working in a factory. She assembles tiny parts, so she needs good eyesight. Her employer does not provide health insurance. Her income is less than twice the federal poverty level and she has a 10-year-old son who lives with her. She and her son live in Philadelphia and have been able to live on what she earns. She reports that she has always been in good health so she has not visited a doctor since she arrived in this country.

Lately Phuong has been feeling very tired and has started losing weight. She always seems to be thirsty now and has to urinate often. In addition, her vision is now blurry, which makes it hard to do her job. She talks to a friend at the factory who tells her about a local health clinic where some of the staff speak Vietnamese. She takes a day off from work and gets to the clinic early to wait in line to see a clinician. Phuong brings her son with her, because she is scared to go alone and afraid that there will be no one there that day who speaks Vietnamese. After wait- ing 3 hours, Phuong sees the doctor, who does not speak Vietnamese but who brings in one of the desk clerks to interpret. Phuong knows the desk clerk, who lives in the neighborhood, and she does not want the clerk to know her personal business. Phuong has her son tell the doctor and the clerk she wants her son, not

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the clerk, to be her interpreter. Th e doctor tells Phuong, with her son translating, that he thinks she has diabetes but that will she need to have some lab work done to verify that. She will need a fasting 4-hour glucose tolerance test that must be started when the lab opens in the morning and she will need to stay at the lab for the entire time. Phuong will need to miss another day of work, and her son will need to miss another day of school in order for her to take the test. Th e doc- tor stresses how important it is that Phuong take the test as soon as possible for confi rmation of the doctor’s diagnosis. While waiting for the test, the doctor gives Phuong a special diet to follow, but the diet does not list any Vietnamese foods. Phuong is not used to eating American food, so she says she cannot eat the foods on the diet. Th e doctor refers her to the clinic social worker.

• What social work issues are raised by this case? • What legal issues are raised by this case? • What would you, as Phuong’s social worker, do to help Phuong and her son? • What, if anything, could be done on an organizational (mezzo) level to help

in this case? What could or should be done on the policy (macro) level?

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Pransky, G., Moshenberg, D., Benjamin, K., Portillo, S., Th ackrey, J. L., & Hill-Fotouhi, C. (2002). Occupational risks and injuries in non-agricultural immigrant Latino workers [Electronic version]. American Journal of Industrial Medicine, 42(2), 117–123.

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Schenker, M. (2007). Healthcare challenges of global migrants: Farmworker health. PowerPoint presentation presented at the 16th Annual Global Health Education Consortium. Santo Domingo, Dominican Republic.

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Shpilko, I. (2006). Russian-American health care: Bridging the communication gap between physicians and patients [Electronic version]. Patient Education and Counseling, 64(1–3), 331–341.

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U.S. Citizenship and Immigration Services. (2015b). Form I-601: Instructions for appli- cation of waiver of grounds for inadmissibility. Retrieved from http://www.uscis.gov /i-601

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U.S. Department of Homeland Security. (2015). Deferred action for childhood arrivals. Washington, DC: Author. Retrieved September 14, 2014 from http://www.dhs.gov /deferred-action-childhood-arrivals

Venters, H. D., McNeely, J., & Keller, A.S. (2013, August 29). HIV screening and care for immigrant detainees. Health and Human Rights Journal. Retrieved September 10, 2014, from http://www.hhrjournal.org/2013/08/29/hiv-screening-and-care-for-immigration -detainees/

Villarejo, D. (2003). Th e health of U.S. hired farm workers [Electronic version]. Annual Review of Public Health, 24, 175–193.

Wasem, R. E. (2014). Immigration policies and issues on health-related grounds for exclusion. Washington, DC: Library of Congress, Congressional Research Service Report for Con- gress. Retrieved on September 7, 2014, from http://fas.org/sgp/crs/homesec/R40570.pdf

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Zuroweste, E. (2007). Health care challenges of global migrants: US migrant farmworkers and other mobile populations. PowerPoint presentation presented at the 16th Annual Global Health Education Consortium Conference, Santo Domingo, Dominican Republic.

■ ADDITIONAL RESOURCES

GENERAL WEB SITES

Center on Budget and Policy Priorities: www.cbpp.org Th e Henry J. Kaiser Family Foundation: http://www.kff .org/ Kaiser Commission on Medicaid and the Uninsured (information on immigrant access to

and utilization of health insurance and health care): http://www.kff /org/kcmu National Council of La Raza: www.nclr.org National Immigration Law Center: http://www.nilc.org/ Th e Pew Hispanic Center (fact sheets and reports on immigration issues concerning

Hispanics): http://pewhispanic.org/ Urban Institute (sections on health and health care, immigrants, families, children, and race):

http://www.urbaninstitute.org/ Th e Urban Institute, Th e Health and Well-being of Young Children of Immigrants (a very

comprehensive look at the lives of young immigrant children): http://www.urban.org /uploadedPDF/311139_ChildrenImmigrants.pdf

U.S. Citizenship and Immigration Services (especially sections on laws and regulations and humanitarian benefi ts): http://www.uscis.gov/portal/site/uscis

WEB SITES CONCERNING MEDICAL INTERPRETING

AMA Offi ce Guide to Communicating with Limited English Profi cient Patients: http:// www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf

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http://www.hhrjournal.org/2013/08/29/hiv-screening-and-care-for-immigration-detainees/

http://fas.org/sgp/crs/homesec/R40570.pdf

http://www.who.int/trade/glossary/story076/en/

http://www.cbpp.org

http://www.kff.org/

http://www.kff.org/kcmu

http://www.nclr.org

http://www.nilc.org

http://pewhispanic.org

http://www.urbaninstitute.org

http://www.urban.org/uploadedPDF/311139_ChildrenImmigrants.pdf

http://www.uscis.gov/portal/site/uscis

http://www.dhs.gov/deferred-action-childhood-arrivals

http://www.hhrjournal.org/2013/08/29/hiv-screening-and-care-for-immigration-detainees/

http://www.who.int/trade/glossary/story076/en/

http://www.urban.org/uploadedPDF/311139_ChildrenImmigrants.pdf

5: SOCIAL WORK AND PHYSICAL HEALTH ISSUES OF IMMIGRANTS ■ 141

International Medical Interpreters Association (home page): http://www.mmia.org/ Medical Interpreting Standards of Practice: http://www.mmia.org/standards/standards.asp

FURTHER READING

Aroian, K. J. (2005). Equity, eff ectiveness, and effi ciency in health care for immigrants and minorities: the essential triad for improving health outcomes. Journal of Cultural Diversity, 12(3), 99–106.

Choi, H. (2001). Cultural marginality: A concept analysis with implications for immigrant adolescents. Issues in Comprehensive Pediatric Nursing, 24(3), 193–206.

Congress, E. P. (2004). Cultural and ethical issues in working with culturally diverse patients and their families: Th e use of the Culturagram to promote cultural competent practice in health care settings [Electronic version]. Social Work in Health Care, 39(3/4), 249–262. [Provides a good tool for the social worker who will be working with culturally diverse populations—helps give a visual picture of the patient/client.]

Cosman, M. P. (2005). Illegal aliens and American medicine. Journal of American Physicians & Surgeons, 10(1), 6–10.

de Alba, I., Hubbell, F. A., McMullin, J. M., Sweningson, J. M., & Saitz, R. (2005). Impact of U.S. citizenship status on cancer screening among immigrant women. Journal of General Internal Medicine, 20(3), 290–296.

Dibble, S. L., & Lipson, J. G. (Eds.). (2005). Culture and clinical care. San Francisco, CA: UCSF Nursing Press.

Dyck, I. (2006). Travelling tales and migratory meanings: South Asian migrant women talk of place, health and healing. Social and Cultural Geography, 7(1), 1–18.

Ghazal Read, J., & Emerson, M. O. (2005). Racial context, black immigration and the U.S. black/white health disparity. Social Forces, 84(1), 181–199.

Goldman, D. P., Smith, J. P., & Sood, N. (2006). Immigrants and the cost of medical care. Health Aff airs, 25(6), 1700–1711.

Kemp, C., & Rasbridge, L. A. (2004). Refugee and immigrant health: A handbook for health professionals. New York, NY: Cambridge University Press.

Kullgren, J. T. (2003). Restrictions on undocumented immigrants’ access to health services: Th e public health implications of welfare reform. American Journal of Public Health, 93(10), 1630–1633.

Lai, K. (2005). Managing the drug regimens of immigrants from other cultures. American Journal of Health—System Pharmacy, 62(2), 205–210.

Lasser, K. E., Himmelstein, D. U., & Woolhandler, S. (2006). Access to care, health status, and health disparities in the United States and Canada: Results of a cross-national population-based survey. American Journal of Public Health, 96(7), 1300–1307.

Marks, L., & Warboys, M. (Eds.). (1997). Migrants, minorities, and health: Historical and contemporary studies. London, UK: Routledge.

Migration and health: A complex relation. (2006). Lancet, 368(9541), 1039. Perreira, K. M., DeRosset, L., Arandia, G., & Oberlander, J. B. (2014). Implementing health

care reform in North Carolina: reaching and enrolling immigrants and refugees. Chapel Hill, NC: University of North Carolina at Chapel Hill. Retrieved September 21, 2014, from http://perreira.web.unc.edu/implementing-health-care-reform-in-north-carolina/

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http://www.mmia.org/standards/standards.asp

http://perreira.web.unc.edu/implementing-health-care-reform-in-north-carolina

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Pransky, G., Moshenberg, D., Benjamin, K., Portillo, S., Th ackrey, J. L., & Hill-Fotouhi, C. (2002). Occupational risks and injuries in non-agricultural immigrant Latino workers. American Journal of Industrial Medicine, 42(2), 117–123.

Rashidi, A., & Rajaram, S. S. (2001). Culture care confl icts among Asian-Islamic immigrant women in U.S. hospitals. Holistic Nursing Practice, 16(1), 55–64.

Villarejo, D. (2003). Th e health of U.S. hired farm workers. Annual Review of Public Health, 24(1), 175.

Weitzman, M., & DuPleiss, H. M. (1997). Health care for children of immigrant families. Pediatrics, 100(1), 153–156.

White, K. (1998). Cultural sensitivity needed to protect girls at risk of mutilation. Journal of Women’s Health, 7(7), 793–795.

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c h a p t e r SIX

Immigrant and refugee populations in the United States are an ever-changing dynamic force representing a vast diversity of language, culture, geopolitical real- ity, and experiences that aff ect their understanding of mental health and their role as consumers of social behavioral health services in the United States. In the United States, from 1980 to 2010, the Asian community has increased 319%, the Latin American community 246%, and the African community 47%, and the number of Caucasian-born U.S. citizens 9% (Annie E. Casey Foundation, 2011).

As the numbers and complexities of these newcomer populations increase, so does the necessity for social work and mental health professionals to explore and create appropriate methodology for addressing the myriad mental health concerns and service needs that these individuals may experience. Sadly, there is little information and insuffi cient resources allocated for research in this area, leaving individuals and entities in a position of “reinventing the wheel” for each new population and treatment need. Outreach and prevention services that are specifi c to a particular cultural or high-risk group, including community-based interventions, are essential.

Culturally and linguistically appropriate therapeutic services and models will increase the eff ectiveness and effi caciousness of mental health treatment. Fur- thermore, opportunities to explore multiculturalism in an applied area, such as immigrant mental health, can lead to deeper understanding and exploration of general issues in psychology and social work, including resilience, trauma, and cultural diversity.

Th is chapter explores the defi nition of mental health as a culturally pre- scribed concept with special emphasis on the topic of strength-based and resil- iency-focused assessment. Furthermore, attention is given to the aspects of immigrant experiences that are unique, such as the triple trauma paradigm and other trauma-based pathologies. Next, the chapter covers the complexities of psy- chological assessment with new immigrants as well as the determination of appro- priate levels of intervention, including specialized treatment options. Th e chapter addresses current issues in culturally competent treatment as well as changes

Mental Health Issues in Immigrant Communities Denise Ziya Berte

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in the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), including specialized consideration for service provision with newcomers, with a focus on working with immigrant children and families.

■ CULTURAL DEFINITIONS OF MENTAL HEALTH

Th ere is no way to extrapolate mental health from culture. All cultures defi ne, prioritize, measure, and treat mental health in diverse ways that are appropriate and utilizable in their context, for their communities, based on specifi c value- laden structures.

Some propose that the goal of individual development is to endure great hardship without complaint, signifying submission to God’s will; others believe that a balance between opposing biological and spiritual dichotomies epitomizes a comprehensive health system, which includes body, mind, and soul.

Internationally, there are a myriad of culturally prescribed indicators of men- tal health that are internally entrenched and are not erased when an individual or community crosses a border or learns a new language. In any case, most new immigrants will have a diff erent and potentially confl icting view of their mental health diagnosis, prognosis, and desired treatment than their host culture mental health practitioner. Th ese diff erences, if unexplored, ignored, or confronted in a cultural win/lose showdown, will certainly render any treatment off ered less eff ec- tive, if not completely inutile or dangerous (if it interacts negatively with confl ict- ing traditional methods of healing).

In addressing symptoms, the practitioner must understand the individual’s personal belief about the etiology and prognosis of the experience and symptoms. People who believe that their symptoms are the consequence of an external force (a social characteristic, their birth order, or animal guide) will be unmotivated to participate in a mental health intervention based solely on “talking” about their feelings. A client who believes in predetermination may question a therapy that looks at changing how he or she makes life decisions. A client who follows the edict that personality is decided by signs, spiritual guides, or birth order will fi nd an intervention focused on “changing” the personality type confusing at best and laughable at worst.

Furthermore, cultures hold unique beliefs to explain the body–brain or somatic–emotional relationship. Some traditions stress the primacy of the physical and explain and treat emotional symptoms as secondary to a bio- logical imbalance or neglect of correct diet, herbs, and so forth. Others focus on the eff ects of external factors (fear, bad winds, evil eye) on the biological system and ignore emotionality completely. Some explanations (including the U.S.-based behavioral medicine) target emotions and explore how emotional

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states aff ect biological systems in both negative and positive ways. Clearly, the client’s belief about the body/brain/emotion triad is critical in fi nding an inter- vention that will meet the personal criterion for eff ectiveness.

Th ere may be spiritual, meaning-based explanations for symptoms that must be uncovered and addressed for the mental health treatment to be eff ec- tive. For example, child soldiers who were forced to violate and kill their elders may explain their symptoms as a punishment from their ancestors for breaking a societal taboo. In a case such as this, treatment may have to include a ceremonial cleansing or forgiveness from elders in the community to be complete.

PRACTITIONER’S DEFINITIONS OF MENTAL HEALTH

In exploring the client’s beliefs, it is also imperative for the mental health practi- tioner to question, and in some cases, decide to put aside his or her own beliefs, assumptions, and “expertise” in a Westernized concept of mental health to join with the client in a therapeutic manner (Sachs, 1987). A culturally competent mental health provider, in a nonjudgmental, skilled manner, balances his or her own defi nitions, beliefs, and methodologies while respecting and working within the system adhered to by the client.

Th e inability to establish collaboration, mutual respect, and understand- ing will leave a new immigrant client and mental health practitioner at odds and make positive intervention impossible. Psychotherapists in particular need to understand and validate their immigrant client’s individual/cultural concep- tualization of the symptom or the problem. Th ey must also recognize their own value-laden judgments as to the functioning and lifestyles of their diverse clients (Kleinman & Good, 1985).

Western-trained mental health providers are frequently criticized by immi- grant communities for their focus on feeling “good” and equating happiness with mental health. Th e isolation of individual well-being to the possible detriment of the family or cultural unit may also be a source of confl ict between immigrant clients and mental health providers. In collective cultures, guidance based on the idea that personal growth or achievement is the fi nal goal will be unintelligible.

One of the most common sources of tension between immigrant clients and their mental health practitioners is the structure and parameters of the thera- peutic relationship itself. In most developing nations, educated people, such as mental health professionals, are sought out because of their perceived wisdom, knowledge, and resources. Th e expectation is that a learned person will listen to your concern and then utilize expertise and infl uence to assist you to resolve the issue. Th e refl ective (ask, not guide) nonstructured methodologies of counsel- ing as practiced in Western countries may be confusing and frustrating to a new immigrant client who may feel pressured to “fi x” or cure his or her symptoms

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immediately. Th e client may perceive the professional’s neutral refl ective feed- back as an insult. Even the service environment (large metal desk, bright lights, and closed doors) may mimic an interrogation session rather than a consultation about healing. Clients with past trauma may experience triggers in that setting that increase anxiety and distress, making the therapeutic intervention null.

■ RESILIENCY IN IMMIGRANT POPULATIONS

Th e idea of resiliency as a general concept describes the ability of a person or a people to withstand a physical, emotional, or social crisis and respond to such cir- cumstances with a return to a sense of self-effi cacy and a feeling of personal con- trol as well as the ability to create supportive and mutually benefi cial relationships and the desire to accept new challenges with the ability to gain mastery over new skills within a reasonable amount of time. It may be that the behavioral factors (what the outside world sees as “adjustment”) are based on the ability to process the events of the trauma in a meaningful, rule-guided manner. Th e individual or group integrates the experience into a working schema (e.g., it was God’s will and must be accepted) that creates a level of comfort rather than distress.

Th e inability to fi nd understanding results in feelings of confusion, incom- petency, fear, lack of confi dence in one’s self and the world, and a loss of motiva- tion to complete the tasks required to move forward.

Resiliency (or the lack thereof ) is based on a multilevel response that can- not be easily predicted for any individual. Clearly, vulnerabilities and strengths are found in both the internal and external resources and environments of those involved. A mix of genetics; temperament; development; and cognitive, spiritual, and physical characteristics as infl uenced by a political, economic, social, or religious reality all determine postcrisis functioning in the case of new immigrants.

For example, a highly intelligent, middle-class attorney, with rigid expecta- tions of himself may have a more diffi cult challenge in second-language acquisi- tion after migration than a worker with less academic preparation, less concern about embarrassment, lower expectations, and a higher level of exposure to the host community. Even the age and developmental stage of the individual on immigration may determine adjustment (Guarnaccia & Lopez, 1998), with younger, less-established individuals demonstrating higher levels of resiliency after a culture transition than their older, more professional peers.

Resiliency may also be infl uenced by family and community factors. Closely attached, unifi ed, low-confl ict groups with a collective goal and understanding about immigration as a process may share resources, off er emotional buff ers, and provide a feeling of meaning to the diffi culties of immigration that enhance both the individual’s and group’s ability to adjust. Th e role of an individual within the

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family or community group or the role of the immigrant community within the larger society may also bolster a sense of belonging, obligation/responsibility, and structure that lessens the disruption of immigration.

Th e voluntary or forced nature of immigration may also be a defi ning fac- tor in resilience. Sadly, few immigrants select to leave their home, family, status, profession, and security for mere adventure. War, oppression, severe economic hardship, and natural disaster are more often the impetus for immigration. Th ese factors aff ect not only the immigrant’s feelings of personal control but the very nature of the immigration experience itself (which may include an inability to plan or prepare for the process, family separation, vulnerability in travel, history of trauma, lack of economic resources, etc.).

In the face of crisis or symptom presentation, many new immigrants utilize traditional methods of creating health and positive adjustment. Th e “interven- tions” may be individual or collective. Th ey may include festivals, ceremonies, or creating associations/institutions that off er material support in familiar ways. Practices may address physiological (massage, traditional medicine, etc.), emo- tional (ceremonies, storytelling), or social (festivals, ethnic-based money-lending practices, etc.) needs.

What is critical for a social service provider is to recognize and affi rm healthy and positive functioning in new immigrants and to credit and encourage methods, ideas, instruction, and people in the client’s life that support natural resilience.

■ PHASES OF IMMIGRANT ADJUSTMENT

A cultural transition involves a multitude of challenging tasks, including securing legal status, language acquisition, stable employment, safe housing, social inte- gration, and family reunifi cation. A new immigrant and a new immigrant com- munity will move forward in the tasks on a chronological schedule unique to themselves and their experiences. However, there are stages of adjustment (not unlike the stages of processing grief ) that one can anticipate in integration. Each phase has opportunities for support from social service and mental health provid- ers (Table 6.1).

■ IMMIGRANTS AND TRAUMA

A major mental health vulnerability in new immigrant populations is often the variety of traumatic experiences that has forced these individuals into the role of immigrants. It has been demonstrated that voluntary economic immigrants have diff erent levels of psychological symptoms than do those with forced immigra- tion scenarios (Escobar, Hoyos, Nervi, & Gara, 2000). Higher levels of mortality

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TABLE 6.1 Stages of Newcomer Integration

Physical Events Psychological/Social Service Implications

Arrival

Reunited with family Relief Need to provide orientation Residence established High expectations Concentrate on basic needs Education for children Gratefulness Explain role of service Medical services Confusion Be ready for emergencies Employment search Disorientation Assess strengths and risks

Reality

Negative experiences Culture shock Noncompliance Intergenerational confl icts Disappointment Manage complaints Recognize obstacles Disillusion Maintain hope Note cultural diff erences Frustration Acknowledge grief Realize loss of home Grief Educate about culture

Negotiation

Higher exposure to host Healing Move to consultant role Increase language skills Increased self-confi dence Refer to interest areas Rebuild support systems Increased fl exibility Less “charity” Defi ne new roles Increased creativity Diversifi ed services Explore new opportunities Increased self-determination Less frequent intervention

Integration

Basic needs met Sense of control Service terminated Basic language competence Bicultural identity Future focused Social relationships adequate Pride Expert for new-er comers Community ties established Recognition of journey Gestures of gratitude

Alienation/Marginalization

Inability to meet basic needs Anger Address psychological needs Inadequate communication

skills Despair Assess for specialized concerns

Isolation from host culture Longing for past Identify natural supports

within fi rst-generation immigrants have also been documented in those with refugee status as opposed to those selecting immigration (Jablensky et al., 1994).

Discrimination, oppression, war, and torture are unique predecessors to immigration because they are a result of targeted, intentional human action that aff ects not only the individual but an entire community.

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Diff erences among immigrants, refugees, and asylees are found in Table 6.2.

TABLE 6.2 Types of Newcomer Groups

Immigrants

Personally decide to leave country Enter with varied legal status Ineligible for most public benefi ts Varied language/employment skills and challenges

Refugees

Experience a natural disaster or political disturbance Flee to second country (usually in a group), which is unwilling/unable to serve as a permanent

host country Must be certifi ed by the United Nations or other governmental body as a “refugee” May reside in temporary housing provided by the international community for long periods

of time (generations); if born into the refugee experience, the child is not recognized as a citizen of the host country

Have no rights or have rights only at the discretion of the host country for work authorization, and education, housing, and medical services

Temporary housing units are generally unsafe and only have limited protection from both criminals and aggression from outside communities/countries

Wait to be relocated to a permanent host country with legal status and organizational support Refugee resettlement agencies off er housing, economic support, and employment services for

approximately 3 months in the United States; medical benefi ts may last up to 18 months periodically, limited specialized loans and scholarships are available

After resettlement period (generally 3 months in the United States/longer in other countries), refugees are expected to be self-dependent

Asylees

Individuals or groups targeted for oppression or abuse in country of origin based on race, ethnicity, religion, political opinion, or social group

Must demonstrate in court of law or administrative procedure a “well-founded fear” of persecution or torture if returned to country of origin

Application for asylum disallowed while in country of origin, therefore, almost all asylees enter under a false pretext

Asylees may be detained (jailed) by the Department of Homeland Security (DHS) indefi nitely and without legal counsel; there is no governmentally provided legal representation for any immigration concern, even for minors

Asylees, if living in the community, receive no benefi ts initially, including no work authorization, housing, and medical, economic, or social services

Asylees receive benefi ts (including the right to work) over an unspecifi ed timeline and at the discretion of DHS (under the Bureau of Immigration and Customs Enforcement)

Th e process for hearing and granting asylum cases has no timeline requirements and case can linger for years without a fi nal determination

After asylum is granted, the individuals may be eligible for limited benefi ts such as those off ered to refugees

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THE TRIPLE TRAUMA PARADIGM

Orley (1994) proposed that new immigrants are often in the midst of a chron- ological intersection of three distinct traumatic periods. Th e individual is fi rst aff ected by the trauma in his or her country of origin, which precipitated his or her fl ight from the country. Th ese experiences may include, but are not limited to, oppression, discrimination (denial of employment, housing, medical care, or basic human rights based on a perceived identifi cation with an undesired group), increased targeting (threats, vigilance, interrogation, detention, forced relocation, etc.), and torture (severe physical emotional distress, including beatings, mock assassinations, isolation, sexual violation, injury and death of family members, starvation, exposure to extreme conditions, etc.).

Because of the vulnerability of the victims of such actions, the escape/journey of immigration itself is also fraught with traumatic events. Individuals are forced to leave family, friends, and all possessions (including legitimate travel documents) as they escape. Th ey are often exposed to severe travel conditions (walking for days at a time, locked in enclosed spaces, suff er lack of food and water, etc.). Many immi- grants become victims of crime, robbery, sexual violation, and extortion as part of their experience. Because of the lack of accessible and legal means for migration, most individuals are forced to use illegal systems fi lled with risk and insecurity to make their journey. Expediential costs, high levels of personal danger, illegality, and terror are faced by individuals as they travel through countries with limited or no permission. Sadly, many people do not even identify themselves as victims, instead blaming themselves for incompetence or immorality in the survival decisions they were obligated to make under severe duress.

Finally, the relocation process is also the stage for a plethora of traumatic events. Indefi nite detention, retraumatization by a hostile legal system, poverty, social isolation, forced family separation, the lack of legal status, and loss of social role are all ongoing traumas common in the lives of new immigrants. Fur- thermore, the experience of trauma-related symptoms may cause the individual to doubt his or her own sanity and competence, adding to stress and disrupting any sense of well-being.

Th e loss of family, identity, community, culture, and position is profound for people whose sense of well-being, pride, and safety are based on these mark- ers. Diffi culties with adjustment to unfamiliar employment, a new language, changes in familial and gender roles, as well as unknown and often isolating social structures in the new country add to the ongoing trauma experienced by the individual (Brody, 1994). Furthermore, there is a real fear of retribution and continuation of country-of-origin confl icts in the host country for some com- munities (Pope & Garcia-Peltniemi, 1991), where members of warring groups are living in small isolated homogeneous pockets. Th ese factors, combined with

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the ever-present fear of immigration policy and deportation, increasing confl icts between immigrant groups and local authorities (police, child protective services, etc.), as well as general anti-immigrant attitudes create a continual parade of trau- matic events for new immigrants.

PSYCHOLOGICAL CONSEQUENCES OF TRAUMA

Th ere are a variety of ways in which the human psyche adjusts to severe trauma that allows the individual to survive. Some of these mechanisms may be labeled “maladaptive” or described as a psychiatric syndrome by the host culture. Still others may be deemed evidence of strength and positive adaptation. Th e diff erence may be determined by the functionality of the individual in the host culture and not an objective criterion of distress or mental health. Imagine a victim of war who has witnessed the murder of countless family members. Th at victim, in a healthy process of grief, would need months of crying and anguish to fully move on; however, if the individual represses those feelings, gets a job, and then takes years to heal, he or she may be considered better “adjusted” by the host culture.

In the DSM-5 (APA, 2013), trauma-based syndromes are grouped together and follow the life span from age 6 to death. Symptoms include the re-experiencing of the traumatic events in memories, thoughts, and dreams, avoidance of those memories and thoughts, and physiological sensitivity (hypervigilance).

Disassociation, a common traumatic symptom, describes the individual’s removal of conscious attention from reality to another distracting or numbing cognition. Th is is often involuntary and frequently occurs in response to a trigger from the traumatic event (if the event has ceased). It is often described as the feel- ing of being “outside” of or “hovering” over one’s own body. During a crisis (such as a rape), to detach from physical reality may be a necessary tactic for survival. However, after the immediate danger is over, disassociation may cloud or inhibit the individual’s healing process. At best, disassociation may be interpreted as a coping skill that needs to be controlled and monitored after a traumatic incident.

Th ese very symptoms may create obstacles for individuals for achieving success in the very areas critical to their establishing a more stable life in the country of origin. Disassociated witnesses, for example, when at their own hear- ing for asylum, may present the facts of their case in such a detached manner that offi cials may fi nd them not to be credible witnesses. New employees who work as if in a daze may look unmotivated or be accused of being in a drugged state. Building new relationships while suppressing emotional reactions will lead to superfi cial and dysfunctional attachments. At the same time, stability and safety are needed to provide a therapeutic environment to open and process the traumatic events.

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PHYSICAL AND PHYSIOLOGICAL CONSEQUENCES OF TRAUMA IN NEW IMMIGRANTS

As discussed earlier, new immigrants may have been exposed to extreme vio- lence, malnutrition, severe travel conditions, lack of medical care, and lack of safety, all of which may lead to serious physical problems as well as psychological symptomology. In addition, many of the psychological concerns of new immi- grants (posttraumatic stress disorder [PTSD], depression, anxiety, etc.) may have component physical symptoms (fatigue, loss of appetite, headache, etc.). Further- more, cultural factors may make it more likely that a symptom will be perceived or described as somatic and not “emotional” or related to the environmental stressors.

It is of critical importance to attend to and explore the etiology of both the psychological and physiological factors when addressing symptoms of unknown origin, to ensure that the treatment selected is appropriate and eff ective. Th is goal is complicated by the limited access that new immigrants have (being the one group untouched by the regulations under the Aff ordable Care Act) to appro- priate medical care and best practice technology in diagnosis. Many available complex diagnostic procedures (MRIs, CAT scans, etc.) are not off ered or are cost prohibitive to new immigrants.

MEDIATING FACTORS IN TRAUMA-BASED PSYCHOPATHOLOGY

Not all survivors of war trauma, oppression, or torture respond to their expe- riences with diagnostic levels of psychological symptoms. Th ere are protective factors within each experience, each individual, and each posttrauma environ- ment that may add support and reduce the impact of the trauma mitigating an individual’s reaction.

Frequency, intensity, duration, and repeated exposure to traumatic events are known to diff erentially eff ect the creation of traumatic symptoms. Preparedness describes the degree to which the victim made a predetermined and conscious decision to defy an unjust authority and become part of a net- work of peers that have been tortured previously, giving them information and somewhat more control over the traumatic exposure. Th is may be compared with someone who has no political history or interest, who happens into a gov- ernmental raid and is arrested and tortured. In the latter case, the person has no control over or preparation for the traumatic events that ensue. Individuals who defi ne themselves by a religious, cultural, or political belief that off ers an explanation, justifi cation, and compensation for their traumatic experiences may perceive the events diff erently (fi ghting for their cause, standing up for justice, etc.) and actively engage in returning to their pretrauma functioning.

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Th is, along with actual peer support (material, emotional, and social) may mitigate the psychological eff ects of the trauma for these individuals.

Th ose for whom the trauma is more random and “unselected” may interpret the experience as a verifi cation that the world is chaotic, unjust, and bad. Such individuals are more likely to feel hopeless, depressed, and have little motivation to recover, believing that there is no right or wrong worth living for.

Finally, it is important to recognize chronological factors in healing. On arrival, many immigrants are still experiencing traumatic events and function- ing in a “survival mode.” Th e immediate need for basic shelter, safety, and life necessities overrides the processing of the preceding traumatic events. For a true therapeutic intervention to be successful, it should not be undertaken until the individual has the stability, attention level, and safety to begin to think about the experiences and revisit the trauma to put it to rest. Before that window of oppor- tunity, psychotherapy serves best as a supportive measure to manage the stress of immigration but not to address severe traumatic experiences.

TREATING VICARIOUS TRAUMA

A primary challenge in relationships with service providers may be the intensity of secondary or vicarious trauma experienced by the professionals working with new immigrant communities. In the face of the horror of the story, a provider may try, even unconsciously, to minimize or deny the veracity of the client’s expe- riences that are overwhelming or unfamiliar to them. At times, a professional may be so shocked by the reality of the client’s life that he or she is unable to off er normalization or controlled empathy to the client. Alternately, some practitioners become so attracted to the dramatic and “exotic” nature of the story that they focus on the trauma to the detriment of the treatment process.

Mental health professionals may experience depression, anger, anxiety, and spiritual questioning in response to a client’s experience. Th e practitioner may become politicized and focus on advocacy in order to balance the feelings of help- lessness that working with an individual victim may invoke. Secondary trauma experiences are expected and demonstrate a healthy, committed, and compassion- ate understanding of the new immigrant’s experience.

In order to best address this experience, there are steps that mental health professionals can take to ensure their own effi cacy. Adequate rest, exercise, and good health habits are essential for all caregivers. A reasonable balance between work and recreation, supportive social networks, and discovering a level of mean- ing in existence or work will enhance the provider’s energy and passion for such intense work. Personal crisis, including any psychological/addictive symptoms experienced, should be addressed immediately by the mental health professional, apart from known colleagues.

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■ PSYCHOSOCIAL ASSESSMENT OF NEW IMMIGRANT INDIVIDUALS

Assessment of any immigrant community must be undertaken with extreme caution, appropriate resources, and with a clear and benefi cial goal preemp- tively designated. Th ere are few scientifi cally validated measures of mental illness for immigrant communities living in the United States. Immigrant communities have unique stressors and characteristics from either the popula- tions in their countries of origin or the host country, and measures validated and utilized with those groups may not be appropriate for use in the new immigrant population. Th e assessment of mental functioning is a particularly culture-based activity that utilizes societal norms, methods of inquiry, and cul- tural defi nitions that exclude even marginalized groups within the society and that may be virtually useless when considering immigrant mental health. Th is is true for the most part with regard to measures of intelligence, personality, or specifi c host culture concepts (such as self-esteem).

When attempting to assess immigrants for mental illness, practitioners must take into consideration the medical/psychological service climate of the country of origin. Historically, many individuals have faced an inability to access appro- priate medical and mental health services in their country of origin and may never have been diagnosed previously or treated despite severe symptomology.

Assessments should be heavily weighted on clinical interviews with a cul- turally competent mental health professional. Generalization should be limited to unique circumstances mimicking the testing situation. Whenever possible, a variety of information sources, diversifi ed methods, and multiple sessions must be used.

Th e goal or purpose of the assessment should be concise and predetermined. Measures should be selected for their utility in answering a specifi c question (e.g., “What symptoms of depression is the individual experiencing daily?”).

Assessments with immigrants will require more time due to the need to move at a slower pace. All measures used should be explained to the client and infor- mation regarding the reliability and validity openly discussed when interpreting any fi ndings. Disclosure about the evaluation (including purpose, method, and potential outcomes) is not only ethical but may enhance the client’s feeling of power, control, and active participation in the process.

Diff erential diagnosis across cultures, races, and ethnicities needs to be care- fully explored within both an individual case and in community-wide interven- tions. Th e experiences of mental health, as defi ned by general life satisfaction, perception of symptomology, and expectation of a positive outlook on life are almost entirely culturally defi ned (Marsella, 1993). How a person defi nes an expe- rience is determined both by expectations from the culture and the person’s own interpretation of symptomology. At the same time, disclosure of the symptom

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to another may rest on the level of trust, motivation, and expectation of symp- tom alleviation. It is interesting, but not surprising, that the most organic and chronic mental illnesses appear most similar in description and prognosis across cultures. Schizophrenia and intellectual disabilities, for example, have strikingly homogeneous presentations across continents, although explanations of etiology and treatment options may vary widely. Disorders with more “emotional” pre- sentations (e.g., mood and anxiety disorders) are more varied and at times have culturally specifi c variations.

DSM-V AND CULTURAL CONSIDERATIONS FOR NEW IMMIGRANTS

In late 2013, the DSM-5 was widely introduced as the most recent update of the Diagnostic and Statistical Manual of Mental Disorders. Th e revised DSM-5 system is generally more medically focused and in fact includes simultaneously the codes for mental health disorders of the DSM-5 and the International Classifi cation of Disease and Related Health Problems, 10th Revision (ICD-10; World Health Organization, 1992). It discontinued the multiaxial structure of diagnosis and instead introduced a coding system with narrative notes more in line with medi- cal diagnosis. Mental health professionals are slated to utilize the ICD system for diagnosis to increase the globalization, both internationally and interprofession- ally, of their work.

Being tied diagnostically to an international and more medically based cod- ing system may enhance the ease with which individuals coming from other coun- tries with a previous diagnosis are transitioned into medical and mental health services in the United States. Th e ICD and DSM-5 (APA, 2013) have addition- ally included a cultural index (called the Cultural Formulation Interview [CFI]) to the diagnostic system to be used when “cultural issues” are felt to be relevant to the diagnosis or response to treatment. Th e guided interview format includes 16 prompts to explore areas such as the cultural defi nition of the problem, cultural perceptions of the cause, context and support of the symptoms, stressors and supports, role of cultural identity, cultural factors aff ecting self-coping and past help seeking, and cultural factors aff ecting current help seeking. Th e interview provides a good base for initiating conversation and exploration of cultural issues in diagnosis and treatment. Th e CFI, however, is not required for diagnosis, and it is unclear how frequently and to what extent it will be utilized in general prac- tice. Th ere is also no clear set of indicators to assist practitioners in determining if the CFI should be completed or not. Generally, it is left to the discretion of the individual professional or institution.

Th e DSM-5 (APA, 2013) has included a few “culturally specifi c” manifesta- tions of disorders, such as the concept of nervios in Latin American countries under

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anxiety disorders and the “cultural concepts of disease,” including shubo-kyofu, koro, and jikashu-kyofu under obsessive-compulsive disorders, which are examples of disorders common within a particular population. In addition, various gender- specifi c presentations and disorders have been added in the DSM-5, including premenstrual dysphoric disorder.

Distinctions among disorders presenting fi rst in childhood and those in adulthood have been eliminated in DSM-5 (APA, 2013), and diagnostic codes for children and adults are generally the same, with diff erential presentation and course of disease being discussed in the narrative.

Th e area that most aff ects traumatized immigrant diagnosis may possibly be the changes introduced in the area of what are now categorized as “trauma-based disor- ders.” Th ese disorders were previously scattered throughout the manual and include reactive attachment disorder, disinhibited social engagement disorder, and a revised diagnosis for PTSD. Th e diagnosis for PTSD was changed in signifi cant ways, includ- ing the requirements and symptom presentation. Th e classifi cation for PTSD is now separated into two sections: children younger than age 6 and individuals 6 and older.

Exposure to trauma is no longer limited by the individual’s experience of fear but instead includes either exposure to the trauma directly, witnessing the trauma, being made aware of close family members or friends being victims of the traumatic event or repeated exposure to the consequences of the traumatic events (bodies, injuries, etc.). Th e diagnosis specifi cally disallows media exposure and/or presentations of violence as the major trauma experience.

Th e major symptom categories under PTSD now include intrusion (memo- ries, dreams, and thoughts), avoidance (of both thoughts and triggers), and altera- tions in moods and cognition and requires that the individual experience clinical levels of distress about the symptom. Symptoms should be present longer than 2 months (they are otherwise diagnosed as acute stress disorder within the fi rst 2 months). Th e PTSD diagnosis is specifi ed as either with or without disassociation.

For children younger than 6 years of age, the diagnosis is parallel to that of adults but includes playing out or enacting the traumatic incident as an intrusive event and combines the symptom categories of alterations of mood and cognition and avoidance.

Th e changes in the diagnostic categories are still new, and no comprehensive research has yet been completed, which would address their validation in new immigrant communities. Time will tell whether the changes have enhanced their functionality with specialized populations.

ASSESSMENT OF ASYLUM SEEKERS

One practical use of assessment of asylum seekers is to verify the extent of their physical and psychological distress due to targeted oppression, violence, and

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torture. In such cases, forensic medical and psychological evaluations may be the only “evidence” the individual is able to produce that supports his or her claims for asylum.

In this area, credibility as well as psychological damage is given consideration in identifying “true victims.” Th e determination of authenticity must be handled delicately in these cases as actual survivors of torture and trauma may respond in atypical ways to inquiries and environments reminiscent of interrogation. Utiliz- ing multiple sources for information about both individual and country con- ditions, extending evaluations over time to ensure consistency, and monitoring internal integrity are all methods for increasing the confi dence and psychological integrity of the diagnosis.

ASSESSMENT OF CHILDREN

Evaluation of immigrant children may also be recommended to ensure appro- priate academic placement, to identify the need for special education services, and to provide indicated therapeutic services. Assessing trauma based on behav- ioral and emotional patterns in children is particularly diffi cult. Due to natural resiliency, children may appear to adjust well in most areas but retain symp- toms in areas seemingly unrelated to their traumatic experiences (such as anger or oppositional behavior). Children’s experience with a particular academic or mental health service environment may be limited, which aff ects their perfor- mance. Furthermore, pervasive but periodic symptoms of anxiety or depression may mask the child’s true ability if placement is determined by a one-session assessment.

■ INDIVIDUAL INTERVENTION STRATEGIES WITH NEW IMMIGRANTS

Actual social work treatment within new immigrant populations is almost always multimodal in methodology. Services must take into consideration life circum- stances, cultural competency, mental health complexities, and medical factors as well as social and spiritual aspects of the individual’s life. Woodcock (1997) describes treatment with new immigrants as such a new fi eld that eclecticism and the use of varied methodologies are the only ethical and logical options for practitioners. Kleinman and Kleinman (1991) suggest that the major tasks for the therapeutic alliance between professionals and new immigrants are build- ing a long-term trusting and supportive relationship; recognizing recent stressors; reducing psychiatrically related symptoms; strengthening social ties; and increas- ing the client’s sense of competence, autonomy, and power.

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Although a variety of specialized methods, such as prolonged exposure ther- apies, biofeedback, and other trauma-specifi c therapies, have been utilized on a small scale and suggested for use with immigrant clients, no studies have been conducted to verify their diff erential eff ectiveness in newcomer populations. Logi- cally, as in the nonimmigrant population, treatment eff ectiveness is dependent on the interaction between the treatment method and the individual’s belief about his or her own mental health, education, and relationship with the therapist.

A mental health intervention cannot be introduced in isolation of the actu- ality of the current life situation of the new immigrant client. Concerns about immigration status, safe housing, adequate employment, and appropriate medi- cal care as well as suffi cient food, clothing, and transportation must be addressed as a basis of treatment (Pederson, 2000). Although concurrent case management and therapy may be ideal, it is not often available to new immigrant clients with limited access to public benefi ts and tight work schedules.

Th e most practical solution for practitioners wanting to focus on mental health issues with immigrants is to foster relationships with them and be well informed about social service, legal, medical, and other charitable agencies in their geographic area that can assist clients with their global needs. Utilizing ori- entation sessions or some part of ongoing sessions for the monitoring of basic needs, providing information and referral concerning community resources, and following up on encountered obstacles or achievements in obtaining needed ser- vices will create a feeling of increased collaboration, trust, and understanding with new immigrant clients. Furthermore, an individual with stable housing, employment, childcare, and basic life needs maintained will be better able and motivated to address his or her mental health symptoms.

Despite best intentions and adequate referrals, it may be that the systems encountered by the new immigrant clients (including legal concerns related to immigration or criminal issues, school districts, child protective services, county or federal relief organizations, employee benefi ts, and charitable medical services), with their concurrent regulations, bureaucratic requirements, and multiplicity of complications may leave them feeling confused, overwhelmed, and frustrated. Although it is necessary to create appropriate professional boundaries, in lieu of a case coordinator, a mental health professional may need to dedicate some time and energy to service coordination and advocacy to ensure that the immigrant client has a base of services that will allow him or her to peaceably participate in the mental health treatment.

ESTABLISHING THE THERAPEUTIC RELATIONSHIP

As in any client population, the best indicator of treatment success will be the ther- apeutic relationship between the mental health provider and the client (Kinzie &

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Fleck, 1987). Th is is especially true for immigrants who may be socially isolated and marginalized, separated from family and friends, and for whom the therapist may be the only representative conduit of the host culture.

For new immigrant communities, trust is a major theme in all interactions. Immigrants, especially those who have experienced intentional human violence or oppression, have seen a side of human nature that to which most people are never exposed. Th ey are aware of the human capacity to harm, violate civil rights, and disregard individual dignity. Th ese experiences may certainly leave these individu- als with high levels of suspicion about the integrity of both people and institutions.

Furthermore, for all immigrants, having to address mental health issues with service providers who may be of a diff erent religion, culture, race, or gender than themselves may cause signifi cant barriers to trust.

Trust will be a sensitive issue for new immigrants who are exposed to regula- tions, which appear nonsensical in the host culture (e.g., you can live here but you may not have permission to seek employment, yet your children are required to receive a free public education). In these cases, trust is diffi cult to establish in the face of fear of violating unknown rules or social norms.

In order to create a trusting therapeutic bond, it may be necessary for the practitioner to be more forthcoming and disclose more personal information than he or she is accustomed to when dealing with individuals from the host culture. For many new immigrants, distinctions among religions, ethnicities, and classes are assumed to be confl ictual and potentially dangerous. Th e power diff erential between most new immigrants and their service providers is so great that the dis- closure of any personal information may feel risky to the client. A client anxious to know where you worship, how you vote, or your ethnic background may be attempting to manage his or her own feelings of safety and ability to confi de in you. Simply answering questions directly (“Yes, I am of this ethnicity. Do you think that will aff ect our ability to work together?”) or explaining the parameters of the therapeutic relationship (“I don’t believe my political affi liation will aff ect our ability to work together. Is there something specifi cally you are concerned about?”) may suffi ce. In many instances, the therapist will serve as a cultural con- sultant for the new immigrant, who is learning the complexities of the host culture through observation and individual experience. Although disclosure and positive aff ect may be the basis of the therapeutic relationship, the upkeep of professional boundaries is also educative and critical. Th e role of the mental health practitioner is unknown in many cultures. A stranger to whom you tell your most intimate concerns and who responds by asking you how you feel about it, instead of off er- ing material assistance or advice, is a bizarre proposition in many communities. New immigrant clients (in particular, those who are receiving charitable services) may want to off er payment or gifts to demonstrate their appreciation and respect of your expertise. Small cultural mementos, food, and handcrafts are appropriate and can be accepted. Expensive gifts, trips, or invitations to visit clients in their

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homes should be discouraged (explaining about professional boundaries, agency policies, and licensure regulations will help to depersonalize any perceived rejec- tion). Gracious thanks should always be off ered in response to an off ered gift.

“Adoption” of the mental health professional as an honored family or com- munity member with correspondent title (sister, mother, etc.) is also common and not harmful as long as real boundaries are respected. Perfunctory attendance at signifi cant family or cultural events may be acceptable, dependent on practi- tioner comfort, public nature of the event, and signifi cance to treatment (gradu- ation, asylum hearing, and naturalization ceremony). Any attendance should be initiated by the client and never proposed by the professional.

OVERCOMING SHAME AND GUILT

Immigrants, generally speaking, lose status, power, resources, role, and other sig- nifi cant indicators of respect in their move from one culture to another. Further- more, those who have experienced violence and trauma may perceive that they have in some way created or deserved such an experience. Th is belief is enhanced by the fact that in the desperation of war and forced migration, individuals may have been obligated to act in ways they themselves fi nd distasteful or shameful. Finally, new immigrants are often aware that they are not appreciated or respected in the host culture, thereby increasing their feelings of shame and embarrassment. Due to these multiple levels of shame, immigrants may wish to avoid discussing or disclosing their mental health symptoms or sensitive aspects of their histories at all costs, leading service providers in the dark without adequate information to off er effi cient, eff ective treatment.

In addition, feelings of guilt create an obstacle to the identifi cation and treatment of mental illness in new immigrant populations. Many individuals feel undeserving when comparing their fates to the family and community members left behind. It is common for people to sacrifi ce personal well-being in a variety of areas in order to economically sustain those left behind or assist newly arrived community mem- bers, including helping others to immigrate. Th erefore, the idea of “complaining” or utilizing valuable resources (money, time, etc.) on identifying nebulous feelings or treating “emotions” of a non-life-threatening mental illness may be discouraged and ridiculed as an “American” luxury not appropriate for a new immigrant.

ADDRESSING CULTURAL ISSUES

In order to sustain therapeutic legitimacy, it is often incumbent upon the men- tal health professional to address cultural issues and inconsistencies within his

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or her own country or people. Unjust immigration policies, racial and linguistic discrimination, forced poverty, diff erential access to needed services, social iso- lation, and cultural egocentrism are all potential aspects of a new immigrant’s experience that may be addressed in the mental health intervention. For social service practitioners, their own reactions may range from disbelief, guilt, and embarrassment toward their country or culture to anger at the new immigrant for being critical or “ungrateful” for the host country’s generosity. In most cir- cumstances, work with new immigrants will expose the professionals to a previ- ously unexplored side of their own culture.

It takes professional training, supervision, self-exploration, and a true desire to understand the new immigrant’s experience to confront these realities in a therapeutic manner that is of assistance to the client. However, denial or avoid- ance of these issues may lead to a deterioration of the therapeutic alliance.

As in all areas, practitioners themselves should not probe into or focus too exclusively on these themes. Th e new immigrant clients will address them if they feel themselves to be in a supportive and safe environment and when they are relevant. Some new immigrants will be ardent supports of the host country and will be in denial about any negative aspect of the host country. Th ese indi- viduals should also not be challenged about their current beliefs. A dynamic ebb and fl ow of idealism and cynicism about the host culture is expected and is a sign of normal adjustment.

Th e concept of “acculturation” as a goal of treatment or indicator of mental health must also be explored as to its appropriateness, given the individual’s cir- cumstances. Acculturation was historically defi ned as the “adaptation” of the new immigrant to the values, lifestyle, and economic, educational, and legal systems of the host culture. Th e belief was that by joyfully and gratefully embracing the host culture in its entirety, the new immigrant would be accepted and successful and exhibit little to no grief about leaving the homeland—a psychological version of the American dream.

More recently, alternative models of immigrant adjustment have been pro- posed that are based on integration, preserving cultural identity, and strength- ening global ties. Th ese methods strive to bolster and enhance the immigrant’s primary identities (cultural, religious, etc.) while opening opportunities for eco- nomic development, education, and contribution to the tolerant host society and also maintaining social and cultural ties with the country of origin.

However, a practitioner’s multiculturalism may be challenged when faced with the actual deep-rooted cultural diff erences that divide nations and cul- tures represented in the behaviors, opinions, and values of a new immigrant client. For example, a female client who discontinues her own academic or pro- fessional advancement to support her family, a family with chronic economic struggles that continues to send a signifi cant portion of their salaries abroad,

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and parents who utilize their children as emergency interpreters or childcare providers in lieu of making school attendance a priority may experience nega- tive feedback from a mental health provider who has an unexplored cultural value placed on individual rights over collective survival (a classic and profound cultural diff erence).

Th ese issues may be further unearthed as the immigrant client begins to negotiate with the host culture and determine which values, lifestyles, and cus- toms to accept and which he or she will ultimately reject. New immigrants may decide to commit to preserving the primacy of their family, dedicate themselves to strict religious or cultural customs, prioritize family peace over economics, and maintain strict rules of conduct between genders or ages. Th ey may openly criticize the perceived materialism and permissiveness of the host culture’s dress, religiosity, and family relations. Th ey may reject the host society’s treatment of the elderly and specialized treatment of animals. New immigrant clients may even question the signifi cance of mental health treatment itself.

An unprepared mental health practitioner may feel defensive and irritated and may, so to speak, “symptomize” the cultural diversity from which these opin- ions and observations arise.

■ CULTURALLY COMPETENT MENTAL HEALTH SERVICES

Mental health professionals in the United States frequently pride themselves on being “color-blind” and laud themselves for believing that their cultural view can accommodate any level of diversity (Ivey, 1995). Most immigrant clients, however, are hyperaware of diff erences between themselves and the professionals they are exposed to and are frequently uncomfortable about them. Diff erences in gender, race, age, education, and class may create barriers within their cultural context that need to be overcome in working with a mental health professional (Freire, 1973). In such cases, the opinion, will, and belief of the professional about his or her own cultural competence is irrelevant. Th e immigrant must also be able to access benefi t from a service provider who meets personal needs and preferences.

Th ere are many ways for a practitioner and an agency to expand or enhance prevention, psychoeducation, and ultimately treatment services to include new immigrant populations. Th e fi rst and most obvious is to ensure representation from the community, including ethnic–insider mental health professionals at all levels of the program design, implementation, and evaluation. Within cultural groups, there will always be diversity. However, utilizing ethnically based provid- ers will reduce the gap of understanding and increase the appropriateness of the services.

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CLARIFYING TREATMENT GOALS

Clarifi cation of treatment goals is also critical in cross-cultural therapies. Th e alle- viation of distress (no matter how defi ned), the increase in positive life experi- ences, and the ability to complete expected life roles, coupled with the increase of resources (personal coping skills, informational, psychoeducational, social, etc.) are all generalized goals that most new immigrant clients will fi nd some resonance with. Th erapeutic relationships need to be based on mutual respect and dignity with a priority on witnessing, comforting, and creating collaboration, as well as having the client express relevant thoughts and feelings.

For many mental health practitioners confronted for the fi rst time with the stark realities of life in developing nations during times of war, and the host of challenges induced by immigration, the most diffi cult task may be the ability to serve as a mere witness to the individual’s story. Immigrants feel (and may even been told) that no one will understand, believe, or care about their suff ering, losses, or struggles. Th e immigrant client may perceive questioning, confusion, or curiosity on the part of the professional as disbelief or the inability to fully comprehend the reality.

Th emes, such as individualism versus collectivism, belief in predetermina- tion (God’s will), as well as age, class, and gender diff erences, may lead to discom- fort between a practitioner and the client. Positive respectful interactions with members of the host culture are essential for adjustment for immigrants who may have lost the feeling of self-effi cacy in all other aspects of their lives (Silove, Tarn, Bowles, & Reid, 1991). Using formal titles (Mr., Mrs., and Dr.), respecting time limits, and consistently reminding clients of their rights and decision points will assist in this endeavor.

When working with couples or families, demonstrating an understanding of or deference to the culturally defi ned family or gender role will generally inspire confi dence and reduce concern that the practitioner will question or challenge the client’s cultural or religious beliefs and lifestyle choices. Immigrant clients may feign acquiescence and respect when in reality they have completely dismissed the service or service provider as incompetent or unable to assist in treatment due to cultural norms and social behavior. Noncompliance and premature termination of services by immigrant clients may in fact be an expression of their frustration over culturally inappropriate services.

LINGUISTIC CONSIDERATIONS

Linguistic appropriateness is a minimum requirement of culturally informed mental health services. Clearly, the client must have a common language with

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which to communicate with the service provider. But this is not suffi cient. Indi- viduals who speak English as a second language may be able to communicate in a variety of situations but may not progress adequately in mental health treatment without interpretation. Memories and emotionally laden events are encoded in the language in which they occurred. Examining traumatic memo- ries or confl ict will be more challenging and less eff ective using an individual’s second language, which is more cumbersome and is not the language of the experience itself.

Th e use of interpreters is indicated always when completing a detailed evalu- ation and in situations in which the understanding of the emotional content and context of the information is a focus. Interpreters not only serve as language facilitators but also, in the best of circumstances, work as cultural brokers who may add historical context, cultural understanding, and normalization of the cli- ent’s presentation in the community.

Concurrently, interpreters can be a source of confusion and mistrust in a therapeutic relationship. Within many new immigrant communities that are small and insular, the likelihood that the interpreter and client are already acquainted is high. Confi dentiality, which may be a new concept for both the client and the interpreter, must be stressed at every opportunity and clear professional boundar- ies modeled and upheld.

An individual speaking the same language but with signifi cant diff erences in geographic locale, gender, religion, class, education, or social group may not be an appropriate or eff ectual interpreter. It is important preemptively to discuss with the client (through a telephonic or neutral interpreter) the comfort level with a particular or general interpreter characteristic (gender, country of origin, etc.). It is equally important for the mental health practitioner to remain aware and alert for these issues as treatment proceeds. An astute observer (even with no linguistic skill) can recognize a relational or linguistic diffi culty in a session and address the issue utilizing an alternative interpreter or interpretation method.

Th e primary relationship between immigrant clients and mental health practitioners should be created and maintained. England-Dimitrova (1991) sug- gests the following eight rules for positive interpretation:

1. Use short sentences. 2. Isolate complicated or multifaceted concepts. 3. Always look directly at the clients when addressing them. 4. Ask for verifi cation that the client understands by asking the client to

restate instructions or concepts. 5. Explain openly and verbally your own appraisals and reactions. 6. Use summary statements and check for feedback. 7. Do not interrupt the client or interpreter. 8. Wait for the complete message to be interpreted before speaking.

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Training and ethical guidelines as well as specialized trainings and certifi cations are available and should be recommended and, as possible, required for interpret- ers’ use in mental health treatment.

TRADITIONAL HEALING METHODS

Within the realm of cross-cultural therapies and cultural competence, there has been a movement to include traditional healers and ceremonies in the therapeutic setting for both immigrant and nonimmigrant clients. Although this may, on occasion, be requested and appreciated by the client, there is much to be inves- tigated, negotiated, and understood before any such intervention is introduced.

One important caveat is that the impetus for the involvement of traditional healing methods must originate from the individual clients themselves. People within a culture may have vastly diff erent opinions about and acceptance of the practice of traditional healing. Ceremonies are not just cultural practices used in isolation but are integrated as part of a deeper understanding about the world and cannot be used in isolation of the implications of whatever that belief system may be. For some new immigrants, such practices are secret, unique, and not to be shared with individuals outside the community. For others, such methods are considered sinful, backward, or dangerous. A mental health practitioner may open the discussion by questioning a client about his or her beliefs and the utili- zation of alternative healing methods in relation to the situation or symptoms at hand. No further probing should be initiated unless the client pursues the topic.

If it is determined that the client believes in and desires to integrate traditional or alternative healing methods, it is incumbent upon the practitioner to understand what methods are being utilized, for what expected results, and with what poten- tial interactional eff ects on the treatments already in place (therapy or medication). It is essential to seek information and assistance from community members who are trustworthy and culturally competent (and without strong personal beliefs that might infl uence the information provided) to become aware of the procedures, expectations, side eff ects, and reputation of the traditional method being considered.

EXPLORING ALTERNATIVE THERAPIES

It is important to meet the diverse clinical needs of new immigrants who may also perceive and experience mental health symptoms in unique ways by utilizing creative and holistic treatment plans. For those who have been victims of violence or sexual violation and those experiencing chronic pain, therapies incorporating physicality may be of great use. Th is may include massage, dance/movement

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therapies, and forms of progressive muscle relaxation and biofeedback as well as traditional medical treatment, including physical therapy.

In order to increase opportunities for expression, particularly in populations where verbalization and written language are a challenge, alternative forms of communication of experiences and emotional states such as art, drama, music, or play therapy may work well. Simple recreational activities and participating in cultural festivals and dances may also be eff ective (Kalcik & Jordan, 1985).

UTILIZING GROUP THERAPY

Group therapies have been applied with varying measure of success to new immi- grant communities over time. Group therapy, on the surface, has much to off er a new immigrant clientele. It may increase feelings of inclusion for this particu- larly marginalized population and enhance actual social support and socialization when members form friendships and bonds that develop beyond the therapeu- tic environment. Group therapies may focus on the multiple losses experienced by new immigrants, address cultural adjustments and education, and introduce relevant symptoms and coping skills associated with PTSD (Woodcock, 1997).

At the same time, however, there are obstacles to creating a positive group therapy experience for new immigrants as well. On a pragmatic note, many new immigrants are employed in base-level jobs with little fl exibility. Th ey generally fi ll the most undesired shifts and have frequent and unexpected schedule changes. In addition, many new immigrants, due to desperate economic conditions, work at several positions concurrently, which makes attendance at a predetermined and infl exible group meeting time an impossibility.

Th e balance of homogeneity and diversity in a new immigrant therapy group becomes an issue of great importance. Obviously, a group without a common language using multiple interpreters will become unwieldy and will create bar- riers to building group cohesiveness as well as interrupting the dynamic fl ow of group process. On the other hand, country-specifi c groups may draw participants from diff ering sides of political, ethnic, or religious confl icts that will decrease comfort and confi dentiality. Very homogeneous groups may be so similar that the therapeutic intent becomes secondary to general social interaction and familiar patterns of in-group communication.

■ FAMILY OR COMMUNITY INTERVENTION

Despite the fact that mental health symptoms most frequently present in a par- ticular individual, in many cases, the best interventions may be targeted at the level of the family, community, or society as a whole.

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FAMILY-LEVEL INTERVENTIONS

In most cultures, the family is the basic social unit of survival. People defi ne their success, well-being, and identity within a family. It may even be a family unit that fi rst identifi es or designates an individual as having diffi culty and needing treatment. Th is becomes complex as family members may be diff erentially accul- turated (diff ering levels of language competence, diff erential embracing of host culture values, etc.), may utilize distinct and even confl icting coping skills for addressing family trauma (one member who completely represses the memories, while another grieves openly), and may serve as each other’s buff er, strength, or trigger in dealing with the mental health diagnosis. Furthermore, there may even be multigenerational trauma that aff ects the entire system. In these cases, utilizing structured family discussions to address trauma, mental health symptoms, and coping skills to create a place for healing within the family unit may help.

COMMUNITY-LEVEL INTERVENTIONS

Although immigrant clients may well benefi t from individual treatment methods (e.g., therapy, medication), community interventions may also be appropriate. Furthermore, for many survivors of oppression, war trauma, and torture who have decided to confront violence and injustice, being treated as individual vic- tims will be unacceptable. In these situations, personal testimonies, class action suits against perpetrators of human rights, and participation in truth and recon- ciliation commissions are appropriate and can be powerful methods of healing.

Th e process of documentation, picture taking, writing a testimonial, recog- nizing and honoring the stories of others, as well as openly naming perpetrators generally will increase the feelings of meaning and self-effi cacy in a “survivor” population that has decided to use activism as part of the recuperation.

Participation in such interventions may be preferred by immigrant clients as one does not need to self-identify as symptomatic or defi ne one’s self as trauma- tized to receive the benefi t. Rather, a positive role as an activist or “expert witness” is often propagated by these eff orts. Th is process may bind an exiled community together (or increase intergroup confl ict); it may strengthen an individual’s stand- ing or role in the community; and it may also increase memories, fears, and other negative symptoms. Results are varied, and all individuals should receive orienta- tion and information about all possible outcomes before deciding to participate.

Of course, it is critical to be aware of a particular client’s or community’s expectation for the intervention and prepare the client for mixed feedback from the host community, which may be either apathetic or openly critical. On the positive side, community-level programs may result in an increase in

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actual resources (legal, medical, mental health, etc.) for the specifi ed com- munity. Media attention may bring the particular group and their story to the larger society’s eye. However, the reaction may be varied and clients need to be prepared for diff erential consequences. Even in the face of overwhelming evi- dence, little may be done to punish or seek true justice against powerful insti- tutions or governments that engage in torture or oppression. Furthermore, inadequate attention in the host culture media may result in the designated community feeling further marginalized and unappreciated.

A philosophical and possibly religious debate has risen around the goal of such community interventions. For some, the historical documentation in itself is a reasonable end to eff orts in the community. Th at a fair and objective history will endure creates a sense of justice and a deterrent for further generations. For others, documentation of atrocities is imperative in the struggle for reparation, punishment, and impunity. Th e feeling that only via consequences for perpetra- tors can community interventions be legitimized is the basis of this argument.

Another perspective is to utilize community action to increase tolerance and diversity in reconciliation eff orts, focusing on a future based on collaboration and joint coexistence. Finally, there are those striving for the goal of “forgiveness” between groups and individuals within the society aiming at a mutually benefi cial view of allowing “bygones to be bygones” to ensure peace for future generations.

Although individuals may have their own personal beliefs, agendas, or cre- ated meaning regarding their participation in community-based interventions, it is important for the mental health professional to remain neutral as to the desired goal and to play a supportive role for the immigrant client involved.

For many individuals, having their personal pain and symptomology addressed as a community issue may lessen their feelings of embarrassment or responsibility for their current negative stressors. Furthermore, direct comparison to peers with a similar history may result in an increase of feelings of self-effi cacy.

Finally, community interventions strengthen the ties among the new immi- grant populations, their families, peers, and community in the country of origin. Frequently, there is a parallel process occurring in the country of origin that allows both the immigrants and their communities at home to join together in a united experience of healing and restoration. Th is process may decrease the immigrant client’s feeling of isolation and distance from the homeland and people.

■ IMMIGRANT CHILDREN AND MENTAL HEALTH

Th e process of immigration of children interrupts normal and natural structures of development, physiology (change in diet, disease process, medical care, etc.), social/community interaction, and cognition. Children left in transitional and resource-depleted environments for long periods of time (such as those who

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have been separated from their parents and families or who have lived in refugee camps, etc.), may experience a loss of playfulness, creativity, and imagination and have disrupted attachment patterns that follow them into adulthood.

Even on arrival in the host country, an immigrant child may experience signifi cant distress. As with all children, the adjustment of immigrant children depends greatly on the adjustment of their caretaking adults. Th e ability of the adults to protect or buff er them from the harsher realities of the immigration experience, as well as the ability to recognize and assist in modulating excessive emotional distress for the child is critical.

Th e quality of the caretaking relationship is extremely variable. Although many immigrant cultures revere childhood as a symbol of the family’s future, in the face of war, trauma, and exile, many protective structures fall away and leave children in particularly vulnerable positions. Furthermore, new immigrant caretakers may be overwhelmed by the need to learn a new language, fi nd safe housing, steady employment, and navigate unfamiliar cultural systems. Parents experiencing mental health issues and/or cultural adjustment challenges may themselves have little energy to dedicate to a child experiencing diffi culties.

Children who have been separated from their parents or immediate fami- lies for extended periods of time may face special diffi culties. Many children are not given the opportunity to immigrate together with their base family unit and instead fi nd themselves in a loosely structured conglomeration of extended family members who are minimally obligated to provide care for the child. When under stress, these relationships are often severed, and the child may be left to forge his or her own way alone in the host country at a premature age.

Adolescents, who during the period of familial separation were forced to exist as independent adults, possibly engaged in violent or antisocial behaviors, and may have formed strong bonds with a delinquent peer group, have particular challenges when reunited with caretaking adults. Th ese youth consider them- selves adults and engage in oppositional behaviors, skeptical of all adult attempts to form disciplinary control in their lives.

For their part, immigrant parents who rightfully feel as if they have done everything possible to prioritize and protect their children in the country of origin by arranging care, sending economic resources, and maintaining regular contact with their children during the separation, often at high emotional and economic cost, are often hurt and confused by the maladaptive behaviors and “rejection” from their children. Parents may deny or minimize the suff ering of their children, whom they were forced by circumstances to leave behind (an “abandonment” in the eyes of the child). Th is dynamic may increase the child’s feelings of being unloved and misunderstood by the formerly idealized parent with whom he or she expected to be reunited. Concordantly, parents are confused and frustrated by children who appear angry, demanding, disrespectful, and demonstrate no attachment or aff ection after waiting so long to be rejoined with their families.

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Obviously, the child’s personal history of development, attachment, intellectual abilities, and socialization will interact with the current environment. Sadly, the chil- dren who have the fewest personal resources, due to multiple losses, environmental neglect, and histories of abuse, may be in situations that call for the highest level of personal strength, intellectual fl exibility, and self-protection (Kopola, Esquivel, & Baptiste, 1994).

Furthermore, the dissonance between the culture of the host community and the family culture may be most profoundly expressed in the lives of the chil- dren. School-age children spend the majority of their day interacting and learn- ing from the host culture, immersed in the values and expectations of the host country. Th ese children may experience the more child-“indulgent” system and adults who make the child the recipient of excess resources (toys, clothes, leisure activities, etc.) as preferable to those in their own family and community. Chil- dren quickly become aware of the tension between the host culture and their family’s values, rules, and priorities. In school, children may be exposed to explicit information about the expectations of parenthood in the new culture, even being given information on the educational rights, child abuse laws, and emergency interventions available to them. In a situation where the host culture may already have a predisposition against the culture of the family, children may be encour- aged to “break away” from the traditions, beliefs, and restrictions of their parents.

Furthermore, in practicality, children become bilingual and familiar with the host culture more quickly than adults and are frequently placed in the precari- ous situation of having to advocate or interpret for their parents in adult, serious matters, which may signifi cantly interrupt traditional family roles.

Diff erences in values, lifestyle, and familial expectations may become a source of severe confl icts between immigrant children and their families, creating unresolvable distances over time.

Children respond to trauma and change in unique ways. Although on the surface appearing to adjust well, immigrant children may become withdrawn or depressed (behaviors that may go unnoticed in a stressed system) or aggressive and oppositional (which may be defi ned as disrespect or a behavioral issue instead of a reaction to trauma). Many mental health issues for immigrant children are left unaddressed until a behavioral, academic, or familial crisis is already at hand.

In initiating mental health interventions with immigrant children, it is ideal to engage the caretakers and complete family system in order to ensure treatment compliance and success. Trusting relationships and strong collaborations with caretakers will ensure the goal of preserving the integration and well-being of the family unit. Utilizing a therapist who can speak the language of the family, even if the child is fl uent in the host country language, is most helpful.

Work with immigrant children may stretch and challenge professional boundaries that must be maintained at all times. Frequently, host culture mental health providers feel at odds with the child’s parent or family around expectations

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of childhood, development, and parental obligations per the divergent cultural defi nitions of childhood. Children in most countries are considered vital partici- pants in a family system and there is a high expectation of loyalty, respect, social obligation, and morality. Children may be considered an “investment” of the fam- ily with few individual privileges. Such beliefs and practices may cause the prac- titioner to question the love and commitment of the family to the child and to inappropriately off er alternatives to children they defi ne as “victims” of uncaring or abusive family systems. Th is perspective serves to disassociate children from their natural primary support group and may increase the expectations of the child in an unrealistic manner and do serious harm to the familial system. Immigrant children are almost always best served when maintained in their families or communities of origin while being supported in symptom reduction and positive coping skills.

■ CASE STUDY

After reading the vignette, explore the questions in the following text: • What social work issues are raised in the case? • What legal issues are raised? • As a social work professional, what would you identify as the presenting

problem? How would you prioritize the needs of the client and the fam- ily?

• What strengths do you fi nd in the client and in the family structure? • What short-term interventions and resources do you believe would best

assist the client and family? • What alternative referrals would you provide to the client and family?

CASE STUDY: PAULINA

Paulina is a 15-year-old daughter of a Latin American family. She is the youngest child and the only member of the family to be born in the United States and to have legal status. Paulina, her four siblings, and her parents live in a rented home in a rural area of a southern city. Her parents and siblings all work in a produce- packing factory.

Paulina has presented in treatment at the request of her parents who are con- cerned about the consequences of her recent behavior. She has been suspended from school twice for fi ghting and has been arrested for shoplifting. Th e parents are terrifi ed about the legal implications for the family, given their lack of legal status in the country. Th ere is some speculation that Paulina is a fringe member of a local gang of Latino origin.

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Paulina is bilingual (Spanish and English), but her parents and older siblings communicate only in Spanish. Her parents are illiterate and did not attend school in their country of origin. Paulina is receiving special education services in her school and tests at the range of borderline intellectual functioning.

Paulina reports periodic use of alcohol and experimental drug use with barbi- turates and marijuana. Paulina has been consensually sexually active since age 14. Her current partner is a same-age peer. Paulina is not currently using any contra- ception methods and mentions being concerned that she has never been pregnant.

Paulina refuses to be in therapy sessions with her parents. Th e parents appear genuinely committed to Paulina’s well-being and distressed by her high-risk behaviors.

■ REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Annie E. Casey Foundation. (2011). Th e changing child population of the United States. Retrieved from http://www.aecf.org/resources/the-changing-child-population-of-the -united-states/

Brody, E. (1994). Th e mental health and wellbeing of refugees: Issues and directions. In A. J. Marsells, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: Th e mental health and well-being of the world’s refugees (pp. 57–68). Washington, DC: American Psychological Association.

England-Dimitrova, B. (1991). Flyktingar och invandrare I sjukvarden [Refugees and Immi- grants under medical care]. Stockholm, Sweden: Spri.

Escobar, J., Hoyos Nervi, C., & Gara, M. (2000). Immigration and mental health: Mexican Americans in the United States. Harvard Review of Psychology, 8(2), 64–72.

Freire, P. (1973). Pedagogy of the oppressed. New York, NY: Seabury Press. Guarnaccia, P., & Lopez, S. (1998). Th e mental health adjustment of immigrant and refugee

children. Child and Adolescent Psychiatric Clinic of North America, 7(3), 537–553. Ivey, A. E. (1995). Psychotherapy as liberation: Toward specifi c skills and strategies in mul-

ticultural counseling and therapy. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 53–73). Th ousand Oaks, CA: Sage.

Jablensky, A., Marsella, A. J., Ekblad, S., Jannson, B., Levi, L., & Bornemann, T. (1994). Refugee mental health and well-being: Conclusions and recommendations. In A. J. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.). Amidst peril and pain: Th e mental health and wellbeing of the world’s refugees (pp. 1–13). Washington, DC: American Psy- chological Association.

Kalick, S., & Jordan, R. (1985). Women’s folklore, women’s culture. Philadelphia, PA: University of Pennsylvania Press.

Kinzie, J. D., & Fleck, J. (1987). Psychotherapy with severely traumatized refugees. American Journal of Psychotherapy, 41, 82–94.

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http://www.aecf.org/resources/the-changing-child-population-of-the-united-states/

6: MENTAL HEALTH ISSUES IN IMMIGRANT COMMUNITIES ■ 173

Kleinman, A., & Goode, B. (1985). Culture and pressure: Studies in the anthropology and cross- cultural psychiatry of aff ect disorders. Berkeley, CA: University of CA Press.

Kleinman, A., & Kleinman, J. (1991). Suff ering and it’s professional transformation: Toward an ethnography of interpersonal experience. Culture, Medicine, and Psychiatry, 15(3), 275–301.

Kopola, M., Esquivel, G., & Baptiste, L. (1994). Counseling approaches for immigrant children: Facilitating the acculturation process. School Counselor, 41, 352–359.

Marsella, A. J. (1993). Counseling and psychotherapy with Japanese Americans: Cross cultural considerations. American Journal of Orthopsychiatry, 63, 200–208.

Orley, J. (1994). Psychological disorders among refugees: Some clinical and epidemiological Considerations. In A. J. Marsella, T. Boremann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: Th e mental health and wellbeing of the world’s refugees (pp. 193–206). Washington, DC: American Psychological Association.

Pederson, P. B. (2000). Handbook for developing multicultural awareness (3rd ed.). Alexandria, VA: American Counseling Association.

Pope, K. S., & Garcia-Peltoniemi, R. E. (1991). Responding to victims of torture: Clinical issues, professional responsibilities, and useful resources. Professional Psychology: Research and Practice, 22, 269–276.

Sachs, L. (1987). Medicinsk antropologica [Medical anthropology]. Stockholm, Sweden: Liber Press.

Silove, D., Tarn, R., Bowles, R., & Reid, J. (1991). Psychosocial needs of torture survivors. Austrian and New Zealand Journal of Psychiatry, 25, 481–490.

Woodcock, J. (1997). Group work with refugees and asylum seekers. In T. Mistry & A. Brown (Eds.), Race and group work (pp. 254–277). London, UK: Whiting & Birch Ltd.

World Health Organization. (1992). ICD-10 classifi cation of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author.

Yonkers, K. A., & Clark, D. E. (2011). Gender and gender related issues in DSM-5. In D. A. Regier, W. E. Narrow, E. A. Kuhl, & D. J. Kupfer (Eds.), Th e conceptual evolution of DSM-5 (pp. 278–304). Washington, DC: APA Publishing.

■ ADDITIONAL RESOURCES

American Psychological Association: www.apa.org Church World Service: www.cwsglobal.org

REFUGEE AND IMMIGRATION SERVICES

National Institute for Mental Health: www.nimhnih.gov Offi ce of Refugee Resettlement: www.acf.dhhs.gov UN Refugee Agency (UNHRC): www.unhrc.ch US Committee for Refugees (USCR1): www.refugees.org

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http://www.refugees.org

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■ FURTHER READING

Harvey, J., & Pauwels, B. E. (2002). Post-traumatic stress theory: A guide to coping. Iowa City, IA: University of Iowa Publishers

Lindy, J. D., & Lifton, R. J. (Eds.). (2001). Beyond invisible walls: the psychological legacy of Soviet trauma (East European patients and their therapists). New York, NY: Brunner- Routledge.

Nader, K., Dubrow, N., & Slamm, B. H. (1999). Honoring diff erences: Cultural issues in the treatment of trauma and loss. New York, NY. Brunner-Routledge.

Woodcock, J. (1997). Group work with refugees and asylum seekers. In T. Mistry & A. Brown (Eds.), Race and group work (pp. 254–277). London: Whiting & Birch.

Zinner, E. S., & Williams, M. B. (Eds.). (1998). When a community weeps: Case studies in group survivorship. Philadelphia, PA: Brunner/Mazel.

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c h a p t e r SEVEN

Each year, the U.S. Department of Homeland Security removes hundreds of thou- sands of people from the United States.1 Increasingly, the federal agency tasked with removing noncitizens has prioritized removal of those who have had contact with the criminal justice system. In fact, 85% of those removed from the interior of the United States in fi scal year 2014 were convicted of some criminal off ense.2 Immigration and Customs Enforcement purports to focus its resources on those who “pose the greatest threat to public safety.”3 It should be noted, however, that convictions for minor off enses or even arrests with no fi nding of guilt often lead to removal or inability to obtain lawful status. In light of this increased focus on the formerly convicted, it is more important than ever that civil practitioners have knowledge of the intersection of criminal and immigration law to ensure the rights of immigrants and refugees are protected in the criminal justice system and nonciti- zens are able to avoid removal from the United States.

For individuals charged with crimes, the potential consequences stemming from a criminal conviction are numerous, including diffi culty obtaining employ- ment, ineligibility for certain public benefi ts, and loss of voting rights. Th ose who are not citizens of the United States may face additional consequences related to their immigration status, such as ineligibility to adjust their status to that of lawful perma- nent residents (i.e., Green Card holders), inability to travel abroad, ineligibility for U.S. citizenship, mandatory detention in an immigration facility, or removal. Indeed, even noncitizens who have extended family in the United States and have lived and worked in the country lawfully for decades are not immune from deportation.

Th e consequences of a removal order resulting from contact with the crimi- nal justice system are often far reaching and permanent. For some immigrants, the law explicitly prohibits them from ever returning to the United States. For

Crimes and Immigration: Civil Advocacy for Noncitizens at the Intersection of Criminal and Immigration Law Abel Rodríguez

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others, their circumstances simply do not meet the high legal burden placed on them to warrant return to the country. Extensive consideration has been given to the consequences this long-term separation has on families, including profound psychological eff ects, poor performance in school for children, and fi nancial inse- curity (Brabeck, Lykes, & Hunter, 2014; Center for American Progress, 2012; Dreby, 2012). Although some risk returning to the country without authoriza- tion, others are deterred by the perilous journey and the risk of a federal prison sentence for reentry.4

Recognizing the particularly harsh consequences that result from deporta- tion, the Supreme Court of the United States has found that criminal defense attorneys must take an active role in determining the immigration consequences to their clients. Since 2010, the law has required defense lawyers to advise non- citizens charged with crimes of the possibility of deportation arising from a plea in criminal court.5 In eff ect, failing to advise a noncitizen client of the immigra- tion consequences of criminal charges may lead to a claim of ineff ective assistance against the attorney, a potential basis to vacate a plea entered in criminal court.

Determining whether criminal charges carry immigration consequences requires careful analysis. First, it is crucial to determine a noncitizen client’s immigration status and history. Th ere is a broad range of possible immigration statuses—from lawful permanent resident, to refugee or asylee, to temporary visa holder or undocumented immigrant—each impacted diff erently by statutes under federal immigration law. It must also be determined which section of the immigration code applies to the noncitizen. Th e following are three of the pri- mary sections of immigration law aff ecting noncitizens charged with crimes:

• Grounds of inadmissibility:6 Th is section of the law applies to nonciti- zens seeking admission to the United States, such as people entering the United States from abroad or individuals already in the country seeking to adjust their status to lawful permanent resident. It is also applicable to certain lawful permanent residents seeking to return to the country after travel abroad.

• Grounds of deportability:7 Th is section of the law applies to noncitizens who have already been admitted to the United States, such as lawful permanent residents or refugees.

• Good moral character:8 Th is section of the law applies to noncitizens seeking certain forms of relief from removal and lawful permanent resi- dents pursuing U.S. citizenship.

Even a cursory look at the sections mentioned in the preceding text reveals that U.S. immigration law contains contradictions and internal inconsistencies. For instance, certain off enses may not trigger deportation for someone who remains in the country as a lawful permanent resident, but it would trigger removal proceedings for the same person upon his or her return from travel

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abroad. Conversely, a conviction that may result in a lawful permanent resi- dent’s removal from the country may not prohibit an undocumented person from obtaining that very status.

It is important to note that advising as to the immigration consequences of criminal charges often requires knowledge of how federal immigration law may be applied to state criminal statutes. Immigration law classifi es off enses in broad terms that defy intuition and require interpretation by courts. Th ese categories include “crimes of moral turpitude,” “controlled substances,” and “aggravated felonies.” Even minor criminal off enses under state law that appear fairly innoc- uous, such as shoplifting or marijuana possession, may constitute an off ense within one of these categories, triggering signifi cant immigration consequences.

Further complicating matters for noncitizens, immigration consequences may be triggered absent a fi nal disposition of guilt in a criminal court. For exam- ple, certain programs off ered by criminal courts in which a plea is entered and later withdrawn after fulfi llment of some requirement, such as drug treatment or community service, are generally considered convictions under immigration law.9 In addition, in some circumstances, immigration consequences may be triggered simply by an arrest with no subsequent fi nding of guilt or by a conviction that has been overturned by a judge. Even an admission to immigration offi cials of criminal activity absent any arrest or contact with law enforcement may have the same consequences as a conviction in criminal court.

After considering potential immigration consequences, the strategy in a criminal case may change signifi cantly. A criminal defense attorney may need to be creative and suggest uncommon compromises when negotiating with a prosecutor. Frequently, the desired outcome of the prosecutor and judge may be achieved while minimizing or avoiding harsh immigration consequences. Avoiding adverse immigration consequences may require pleading to alternate off enses to those charged, including specifi c details on the court record dur- ing a plea, or restructuring a jail sentence in a particular fashion. If a mutually benefi cial agreement cannot be reached, the client may choose to take the case to trial to attempt to avoid the potential consequences.

To be sure, the intersection of crimes and immigration is a particularly com- plex and perpetually evolving area of the law. Civil practitioners are invaluable advocates to immigrants and refugees who encounter the criminal justice system.

Th e following are actions that can be taken to assist noncitizens:

1) Provide orientation to the law and the criminal justice system to noncitizens who have recently arrived in the United States. Orientation may include discussion of the following points: • Only U.S. citizens are protected from deportation. Lawful permanent

residents should consult with an immigration attorney to discuss when they will become eligible to naturalize.

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• Th roughout the country, information obtained by police is shared with Immigration and Customs Enforcement. Because of such communications, immigration offi cials are typically aware of a noncitizen’s arrest.

• Generally, Immigration and Customs Enforcement agents are given access to police stations and jails to interview people of interest to them. Noncitizens should ask to speak with an attorney before providing any information to an immigration offi cial.

• Cultural diff erences can lead to contact with the criminal justice system. Addressing diff erences that may result in contact with law enforcement for a particular community, such as alcohol consumption or corporal punishment, may help noncitizens avoid removal.

2) Ensure noncitizens with pending criminal charges are properly advised. Th e following are common issues that arise for immigrants and refugees charged with crimes: • As discussed earlier, criminal defense attorneys have a duty to

advise their noncitizen clients of the immigration consequences of the charges against them. Defense lawyers must either familiarize themselves with this area of the law or consult with someone with the appropriate expertise. Civil practitioners can ensure defense attorneys are aware of this duty and connect them with resources, including those found in the “Additional Resources” section.

• Information about a noncitizen’s immigration status is crucial to providing accurate immigration advice. Civil practitioners are often able to provide documentation or connect attorneys with family members to clarify a noncitizen’s status.

• Th e question of whether to pay bail in order to be released from a jail or prison can be complicated for a noncitizen. A growing number of jails and prisons are choosing not to comply with requests for noncitizens to be turned over to Immigration and Customs Enforcement when they are released from criminal custody; however, many are still complying with these requests. Whether a client should post bail is an important consideration, and noncitizens in criminal custody should speak with an immigration expert before making such a decision.

• At times, Immigration and Customs Enforcement pursues people they wish to place in removal proceedings at their criminal court appearances. As a result, noncitizens may consider failing to appear in court for fear of being arrested by immigration offi cials. When these questions arise, it is important that an expert in criminal law carefully advise the noncitizen of the consequences of failing to appear in court.

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3) Advocate for noncitizens placed in removal proceedings after having contact with the criminal justice system. In particular: • Generally, people facing criminal charges are provided a criminal

defense attorney if they are unable to aff ord one. Th e same is not true in immigration proceedings. If a noncitizen wishes to be represented in immigration court, he or she must hire an attorney. Civil practitioners can help to connect noncitizens with reputable lawyers, particularly people detained in an immigration facility who are unable to visit a law offi ce. Th ey can also ensure clients avoid seeking legal advice or assistance with their immigration matters from notarios, community members, or other individuals who are not authorized to practice law. Th e Department of Justice maintains a list of free and low-cost immigration attorneys, which is available at http://www.justice.gov/eoir/probono/states.htm.

• Affi davits and testimony provided by social workers, psychologists, and physicians are often critical to a client’s defense in immigration court. Th eir testimony may signifi cantly bolster clients’ claims of rehabilitation, prior injuries, past persecution, or hardship to them or their families if removed.

• Th ere are few diff erences between immigration detention centers and prisons. Many of the reentry services needed after incarceration in a jail or prison—mental health services, assistance obtaining employment, help fi nding housing, and so forth—are also needed after release from an immigration facility.

• After contact with the criminal justice system, noncitizens are particularly vulnerable to deportation. Th ey should be advised to consult with an immigration attorney before having any contact with immigration offi cials, including travel abroad or fi ling of any applications, such as applications to renew a permanent resident card or citizenship applications.

■ NOTES

1. According to the Department of Homeland Security, Immigration and Customs Enforce- ment removed 315,943 people in fi scal year (FY) 2014, 368,644 people in FY 2013, and over 400,000 people in FY 2012 (Immigration Policy Center, 2014; U.S. Department of Homeland Security, 2014b).

2. U.S. Department of Homeland Security (2014b, p. 4). 3. Th is commitment was once again renewed by President Barack Obama’s executive order

on immigration eff ected November 20, 2014 (U.S. Department of Homeland Security, 2014a).

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180 ■ II: IMMIGRATION AND SOCIAL WORK PRACTICE

4. In fact, unauthorized entry and reentry are the most prosecuted federal off enses in the United States (Human Rights Watch, 2013; Transactional Records Access Clearing- house, Syracuse University, 2013, 2015).

5. In 2010, the Supreme Court of the United States held that, pursuant to the Sixth Amendment of the U.S. Constitution, a criminal defense attorney “must advise her client whether his plea carries a risk of deportation” (Padilla v. Kentucky, 2010).

6. Th e grounds of inadmissibility can be found at Immigration and Nationality Act of 1952 (INA) § 212(a). Th e criminal and related grounds of inadmissibility can be found at INA § 212(a)(2).

7. Th e grounds of deportability can be found at INA § 237. Th e criminal grounds of deportability can be found at INA § 237(a)(2).

8. Th e defi nition of good moral character can be found at 8 U.S. Code § 1101(f ). 9. Th e defi nition of a conviction under immigration law can be found at INA § 101(a)(48)(A).

■ REFERENCES

Brabeck, K. M., Lykes, B. M., & Hunter, C. (2014). Th e psychosocial impact of detention and deportation on U.S. migrant children and families. American Journal of Orthopsy- chiatry, 84(5), 496–505.

Dreby, J. (2012, August). Th e burden of deportation on children in Mexican immigrant families. Journal of Marriage and Family, 74(4), 829–845.

Center for American Progress. (2012). How today’s immigration enforcement policies impact children, families, and communities: A view from the ground. Retrieved from https:// www.americanprogress.org/wp-content/uploads/2012/08/DrebyImmigrationFamilies FINAL.pdf

Human Rights Watch. (2013, March). Turning migrants into criminals: Th e harmful impact of U.S. border prosecutions. Retrieved from http://www.hrw.org/sites/default/fi les/reports /us0513_ForUpload_2.pdf

Immigration Policy Center. (2014, March). Th e growth of the U.S. deportation machine: More immigrants are being “removed” from the United States than ever before. Retrieved from http://www.immigrationpolicy.org/just-facts/growth-us-deportation-machine

Padilla v. Kentucky, 130 S.Ct. 1473 (2010). Transactional Records Access Clearinghouse, Syracuse University. (2013, November 25). At

nearly 100,000, immigration prosecutions reach all time high in FY 2013. Retrieved from http://trac.syr.edu/immigration/reports/336/

Transactional Records Access Clearinghouse, Syracuse University. (2015). Prosecutions for 2013. Retrieved from http://tracfed.syr.edu/index/index.php?layer=cri

U.S. Department of Homeland Security. (2014a, November 20). Memorandum regarding “Secure Communities.” Retrieved from http://www.dhs.gov/sites/default/fi les/publications /14_1120_memo_secure_communities.pdf

U.S. Department of Homeland Security. (2014b, December 19). ICE enforcement and removal operations report: Fiscal Year 2014. Retrieved from https://www.ice.gov/doclib /about/offi ces/ero/pdf/2014-ice-immigration-removals.pdf

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https://www.americanprogress.org/wp-content/uploads/2012/08/DrebyImmigrationFamilies

https://www.americanprogress.org/wp-content/uploads/2012/08/DrebyImmigrationFamiliesFINAL.pdf

http://www.immigrationpolicy.org/just-facts/growth-us-deportation-machine

http://trac.syr.edu/immigration/reports/336

http://tracfed.syr.edu/index/index.php?layer=cri

https://www.americanprogress.org/wp-content/uploads/2012/08/DrebyImmigrationFamiliesFINAL.pdf

http://www.hrw.org/sites/default/files/reports/us0513_ForUpload_2.pdf

http://www.dhs.gov/sites/default/files/publications/14_1120_memo_secure_communities.pdf

https://www.ice.gov/doclib/about/offices/ero/pdf/2014-ice-immigration-removals.pdf

7: CRIMES AND IMMIGRATION ■ 181

■ ADDITIONAL RESOURCES

• Immigrant Defense Project: http://immigrantdefenseproject.org ■ Hotline Number: 212-725-6422

• Immigrant Legal Resource Center: www.ilrc.org • National Immigration Project of the National Lawyers Guild:

www.nationalimmigrationproject.org • National Association of Criminal Defense Lawyers: www.nacdl.org • National Legal Aid and Defender Association: www.nlada100years.org • Your local public defender offi ce: Public defender offi ces around the country have

in-house or consulting immigration experts.

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http://www.ilrc.org

http://www.nationalimmigrationproject.org

http://www.nacdl.org

http://www.nlada100years.org

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Th e U.S. culture places a premium on work; a person’s identity is often shaped by the type of work he or she does. Work plays an equally important role in the lives of immigrants and refugees1 who come to the United States. Th e experience immigrants have looking for work, their ability to maintain jobs that allow them to survive and support their families, to contribute to their local communities and society as a whole, and to feel that they are valued members of the commu- nity will determine how well they fare in the United States. Th erefore, it is critical for social workers to have a solid understanding of the issues aff ecting immigrant workers and their communities.

It is common for immigrants to work multiple low-paying jobs to make ends meet and to be able to send money to their families in their homeland to provide them economic support. Th ese remittances are often essential to ensure the survival of families back home and, from a macroeconomic perspective, to raise the standard of living of people worldwide. “Making it” in the United States has a direct correlation to immigrants’ ability to fi nd work and support them- selves and their family back home. However, immigrants face particular barriers to becoming full participants in society, especially when it comes to fi nding and maintaining employment.

Th is chapter begins with a profi le of low-wage immigrant workers. It then explains the rights and remedies available to immigrant workers under labor laws and explores the conditions and factors that lead to their abuse and exploitation. Th e chapter then illustrates the barriers that prevent employers from enforcing labor and employment laws, including lax enforcement of laws by government agencies, the threat of deportation by immigration agents, and government pro- grams that hinder workers from exercising their rights. It concludes with some hypotheticals (based on true cases) that will help social work students be better prepared to identify the employment-related issues immigrant clients may have and how to assist them individually—while also empowering them to advocate and organize collectively to improve their working conditions.

Immigrants and Employment Marielena Hincapié, Susan Lopez, & Joshua Stehlik

c h a p t e r EIGHT

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■ AN OVERVIEW OF IMMIGRANT WORKERS AND THEIR CONTRIBUTIONS

Migration is a global phenomenon, and the core reason for migration is eco- nomic survival. As long as globalization continues and individuals are forced to leave their home countries out of economic desperation, migration to the United States will increase. It is critical that we look at the root causes of migra- tion, which include economic, political, and environmental forces that “push” people out of their home countries, while also examining the economic and political forces “pulling” immigrants into the United States primarily to fi ll low- wage jobs.

Th e United States is the largest receiving country in the world, with nearly 41 million immigrants calling this country their new home (Migration Policy Institute [MPI], 2014). Th e U.S. immigrant population represents about 20% of the total immigrant population worldwide. Although the number of immigrants coming to the United States is at an all-time high, the total percentage of foreign- born individuals is only about 13% of the total civilian population (MPI, 2014), which is slightly lower than in 1890 when foreign-born individuals made up 15% of the total population and much higher than in the 1970s, when immigrants made up only 5% of the population (MPI, 2014).

Th e profound demographic changes over the past few decades have impacted the composition of the U.S. labor force: Th ose considered to be new immigrants— people who entered the United States after 1990—accounted for nearly 50% of the net growth in the civilian labor force during that decade (Brookings, 2012). Th at is, between 1990 and 2000, one out of every two new workers in the United States was a new immigrant. Between 2000 and 2005, two out of every three new workers were recently arrived immigrants. In recent years, this trend has slowed, with immi- grants comprising around 42% of the annual workforce growth. Of all foreign-born workers, approximately 36% are from Central America and Mexico, 29% are from Asia, 12% are from Europe, 9% are from the Caribbean, and 6% are from South America (MPI, 2014).

On average, immigrant workers earn less than native-born workers and are less likely to have attained higher levels of education. In 2013, almost 58% of immigrant workers over age 25 had completed only a high school education, com- pared to about 36% of native-born workers (Bureau of Labor Statistics, 2014).

LOW-WAGE IMMIGRANT WORKERS

As described in Chapter 2, there are many diff erent categories of immigration status, and some of these categories impact employment. Some immigrants

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may be documented, meaning that they have federal authorization to be pres- ent in the United States. Many categories of documented immigrants also receive federal authorization to work in the United States. For example, asylees and refugees may be granted the right to work (Immigration and Nationality Act [INA], 1952).2 Immigrants in other categories may be granted temporary work visas solely for employment purposes.3 Undocumented workers may have entered the country without the government’s permission or they may have entered on a temporary visa but overstayed the period of time they were autho- rized to remain in the United States. Th e remainder of this section discusses employment issues faced by undocumented workers, many of whom work in low-wage jobs.

Because of their relatively recent arrival in the United States and associated language and cultural barriers, undocumented immigrants face a staggering number of obstacles to obtaining even the basic necessities for survival, much less to participating fully in U.S. society. For example, although undocumented immigrants have high employment rates (94% of working-age undocumented men are employed, compared to 85% of authorized immigrant men and 83% of native-born men; MPI, 2014; Pew Research Center Hispanic Trends, 2008), the average family income of undocumented families is nearly 30% below the average income of either legal immigrant or native-born families ($36,000 per year, in contrast to $50,000; Pew Research Center Hispanic Trends, 2008). Th is income diff erential is even more pronounced in light of the fact that undocu- mented and mixed-status households have more workers on average (1.75) than native-born households (1.23; Pew Research Center Hispanic Trends, 2008).

According to the Bureau of Labor Statistics, immigrants comprise a dis- proportionately large share of workers in many of the less-skilled occupations (Bureau of Labor Statistics, 2014). Although they comprise about 5.4% of the workforce (Pew Research Center Hispanic Trends, 2008), undocumented work- ers are overrepresented in low-wage, high-risk jobs such as agriculture, build- ing maintenance, construction, manufacturing, and food services (MPI, 2014; Singer, 2012) and in hazardous occupations within those industries (Segelken, 2014). For example, Latino immigrants constitute 20% of the construction workers in California.

Workplace injuries among U.S. workers who are foreign born are on the rise, and the rate at which foreign-born workers die as a result of workplace accidents far exceeds that of native-born workers (Gregory & Schiller, 2004). Foreign-born workers accounted for 66% of workplace fatalities in 2013, yet make up only 16% of the total workforce (Bureau of Labor Statistics, 2014). Astoundingly, Mexican-born workers in the United States are 80% more likely to die in a work- place accident than native-born workers (Pritchard, 2004).

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■ CONTRIBUTIONS OF IMMIGRANT WORKERS

Notwithstanding the many challenges they face, immigrants are revitalizing many inner-city and fi rst-ring suburban neighborhoods, providing the stimulus behind many of the most successful union- and community-organizing eff orts. Th ey buy homes or rent apartments, establish small businesses, and buy goods, thereby contributing to the economy.

Despite the general misconception that today’s immigrants are not assimilat- ing as fast as previous generations of immigrants, especially compared to European immigrants who arrived a century ago, when one examines states (e.g., California) where immigrants have settled for a longer period of time, there is evidence that immigrants are indeed progressing tremendously. A recent study found that about 33% of Latinos who had been in California for less than 10 years were profi cient in English, compared with about 74% of Latinos who had been in California for over 30 years (Myers, 2008). Similarly, although the rate of poverty among Latinos is severe within their fi rst two decades in the United States, this same study noted a decrease in the poverty level over time (Myers, 2008). Finally, fi rst-generation Latino immigrants in California also had high levels of home ownership, which jumped from about 16% of homeowners among those who had been in country for less than 10 years to about 65% for those who had been here for over 30 years; this number is higher than the overall California homeownership rate of 57% (Myers, 2008).

Th ese economic indicators are important to consider when we look at the future of the United States and understand that immigrants are essential to the U.S. economy. New immigration is likely to contribute between one third and one half of the growth of the labor force through 2030. Between 2010 and 2030, fi rst- and second-generation immigrants together are projected to account for all growth in the U.S. labor force, while the country will be facing an aging crisis as the baby boomer generation begins retiring between 2010 and 2030. We will have a declining number of working-age adults, which may even be below zero in many states (Myers, 2008).

Immigrant workers will be essential to keep the economy strong, to serve as caretakers for the aging population, to contribute to existing health care and Social Security systems, and to help shape the future of the Unites States. It is critical that we have sound immigration and labor policies that protect these workers’ rights to ensure that they can contribute to our country without being exploited and dehumanized in the process.

■ ARE IMMIGRANT WORKERS PROTECTED BY U.S. LAWS?

Th e United States has many complex laws at the federal, state, and local levels that impact immigrant workers. Federal immigration laws govern who can enter

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the United States, how individuals can enter the country, who is allowed to stay, and under what circumstances. Th e Department of Homeland Security (DHS) was created on March 1, 2003, and it includes the Bureau of Immigration and Customs Enforcement (ICE) and the U.S. Citizenship and Immigration Services (USCIS) agencies, which enforce immigration laws. Th e U.S. Department of Jus- tice (DOJ) retains jurisdiction over certain immigration policies. Th e immigra- tion court system, the Executive Offi ce of Immigration Review, is located within the DOJ and is therefore independent from DHS.

Labor and employment laws govern individuals’ rights at the workplace. For example, the National Labor Relations Act of 1935 (NLRA) gives workers the right to organize, elect, or join a union.4 Title VII of the Civil Rights Act of 1964 protects workers from employment discrimination based on race, color, national origin, religion, and gender.5 Th e Fair Labor Standards Act of 1938 (FLSA) pro- vides workers the right to minimum wage and overtime payment, and the Occu- pational Safety and Health Act of 1970 (OSHA) provides workers with the right to a safe and healthy workplace.6 In addition, there are state labor and employment laws that provide further protections for workers. Th e intersection of immigration with labor and employment laws comes into play when dealing with immigrant workers, and these policies have an eff ect on all workers’ rights. In particular, when determining what rights and remedies are available to immigrant workers, espe- cially undocumented workers, the issue of immigration status may arise.

A worker’s immigration status did not factor into his or her employment or civil rights until 1986, when Congress enacted the Immigration Reform and Control Act (IRCA).7 In an eff ort to reduce unlawful immigration into the United States, Congress enacted IRCA, which made it unlawful for employers to knowingly hire a person who was not authorized to work in the United States.8 IRCA also provided sanctions against employers who violated this new provi- sion.9 A new employment eligibility verifi cation process—commonly referred to as the “I-9 process”—was created as a means of monitoring the employer sanc- tions scheme. All employers must complete the I-9 form for all new workers hired after November 6, 1986.10

In response to advocacy by civil rights and immigrant rights organizations concerned that the new employer sanctions would result in increased discrimina- tion against “foreign-looking or sounding” U.S. citizens or authorized workers,11 Congress included antidiscrimination provisions prohibiting citizenship status discrimination and, complementing Title VII of the Civil Rights Act, prohibit- ing national origin discrimination by small employers.12 To enforce the INA’s antidiscrimination provisions, Congress created the Offi ce of Special Counsel for Immigration-Related Unfair Employment Practices (OSC).13

In this context, social service providers may be approached for assistance in employment discrimination. To fi le a citizenship discrimination claim, a person must be a “protected individual,” which only includes:

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• U.S.-born and naturalized citizens • U.S. nationals • Lawful permanent residents (LPR) who fi le for naturalization within 6

months of being eligible • Lawful temporary residents • Refugees and asylees

Th ese legal classifi cations are more fully described in Chapter 2. Th is narrow defi nition of protected individual excludes two large segments of the immigrant population: long-term permanent residents who for a variety of reasons have not applied for naturalization within that 6-month window (8.8 million LPRs are eligible to naturalize, the great majority of whom are no longer in the 6-month window) as well as the estimated 11.4 million undocumented persons living in the United States.

Under the Immigration Act of 1990, Congress amended the INA’s antidis- crimination provisions to prohibit “document abuse” and retaliation.14 Document abuse occurs when an employer requires workers to present more documents than are required by the I-9 employment eligibility verifi cation process or speci- fi es that the employee must present certain documents over others from the list of acceptable I-9 documents. For example, document abuse occurs when an employer requires a newly hired worker to present a specifi c document, such as an Employment Authorization Document or ”work permit” or a resident alien card or “Green Card,” to prove he is authorized to work in the United States. Such an action is considered discrimination because the I-9 process was set up to give the worker the choice of which documents to present from the list of acceptable documents on the back of Form I-9.15

Any work-authorized individual can fi le a document abuse claim. Although these claims are not limited to protected individuals, they also do not cover undocumented workers. Th e reasoning behind this is that IRCA was enacted with the aim of reducing unlawful immigration and saving jobs for U.S. citi- zens. However, there is widespread agreement that IRCA’s employer sanctions have failed to keep employers from recruiting and hiring workers or to deter undocumented workers from migrating to the United States in search of oppor- tunities for their families. On the other hand, employer sanctions have really become employee sanctions, with workers being detained by immigration agents and deported, whereas employers often are left unaff ected. Moreover, one of the unintended consequences of IRCA has been to compel otherwise law-abiding individuals to purchase false documents as a means of fi nding a job and satisfying the I-9 process.

It is against this backdrop, and the growing anti-immigrant sentiment that ensued after the tragic events of September 11, 2001, that the U.S. Supreme Court issued its decision in Hoff man Plastic Compounds, Inc. v. N.L.R.B.16 In this

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2002 decision, the Supreme Court held that an undocumented California factory worker, Jose Castro, who was unlawfully fi red for union-organizing activities, could not be awarded back pay.17 Jose Castro was fi red because of his participation in the union-organizing campaign in violation of the NLRA. At an administrative hearing before the NLRB, Mr. Castro admitted he was undocumented and that he had used false documents to obtain his job.

In its decision, the Supreme Court distinguished Hoff man Plastic, an “inno- cent employer” that did not “knowingly” hire an undocumented worker, from Castro, a worker who had used false documents and therefore engaged in “crimi- nal” activity to gain employment. In denying Castro’s back pay award, the Court also held that undocumented workers are not entitled to reinstatement, one of the traditional remedies, along with back pay, for such violations. (Back pay is a standard legal remedy for unlawful termination; it compensates a wrongfully fi red worker for the wages he would have been paid had he not been illegally terminated.)

Th e Supreme Court referred to IRCA as a changed landscape in which Con- gress created a “comprehensive scheme prohibiting the employment of illegal aliens in the United States.”18 It decided that awarding back pay to undocumented workers who were unlawfully fi red would compensate them for work they could not have lawfully performed. As a result, although undocumented workers may still join a union, may help organize and vote for a union, and may engage in other activities protected by the NLRA aimed at improving their working condi- tions,19 if they are wrongfully terminated, they cannot be reinstated and cannot receive back pay. For a more detailed discussion, see Fisk and White (2005).

Just as with the NLRA, all workers—regardless of immigration status—are protected by most federal and state labor and employment laws. For example, all workers are protected by the federal wage and hour law under the FLSA.20 All workers, regardless of immigration status, have the right to a safe and healthy workplace under the federal OSHA. And unlike the antidiscrimination provisions under the INA discussed earlier, all workers do have the right to be free from discrimination in the workplace under Title VII of the Civil Rights Act, regardless of their immigration status.21 However, since the Supreme Court decision in Hoff man, employers have continuously tried to chip away at the remedies available to undocumented workers. Generally, though, worker advo- cates have been able to successfully limit the expansion of Hoff man into other areas of law.

Th e area where there have been some inroads into immigrant workers’ rights is a person’s right to be compensated for work-related injuries. Th is is of particular concern, given the high prevalence of injuries and fatalities on the job suff ered by low-wage immigrant workers who toil under some of the most dangerous work- ing conditions. In general, when a worker suff ers a work-related injury, he or she is eligible to receive workers’ compensation, which provides the injured worker

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with medical care, medication, lost earnings, and rehabilitation therapy if he or she needs to be trained for a new job.22 Many state courts have held that Hoff - man should not be extended to workers’ compensation cases to prevent undoc- umented workers from receiving workers’ compensation because state workers’ compensation statutes provide workers with a benefi t rather than a remedy for some wrongful act on the part of the employer. However, a couple of states have equated “lost earnings” under workers’ compensation statutes with the “back pay” remedy the Supreme Court struck down in Hoff man.

In Pennsylvania, the state supreme court has held that because a worker is undocumented, his “loss of earning power is caused by his immigration status, not his work-related injury,” and therefore the worker should not receive that benefi t.23 In Georgia, the court of appeals has also held that an undocumented worker cannot receive benefi ts if the worker is only partially disabled because the worker cannot legally seek work.24 However, if the worker is totally disabled and unable to work, he or she is entitled workers’ compensation benefi ts even if he or she is undocumented.25

Workers’ compensation is a matter of state law, so the eligibility of undoc- umented workers who are injured on the job for workers’ compensation will depend on the law in the state in which the injury occurred. Such workers should be referred to a local legal services program or a reputable workers’ compensation attorney for an assessment of their eligibility and their legal options.

■ WHAT BARRIERS PREVENT IMMIGRANT WORKERS FROM EXERCISING THEIR WORKPLACE RIGHTS?

Employer violations of labor and employment laws are rampant. Th is is especially true in low-wage labor markets, where immigrant workers are often concentrated. A landmark survey of the low-wage labor industries in Chicago, Los Angeles, and New York found that 69% of the workers surveyed experienced a meal-break violation that same week, 76% experienced an overtime violation, and 60% of workers were underpaid by more than $1 per hour (Bernhardt et al., 2009). For immigrant workers, the violations are even worse: Foreign-born workers were nearly twice as likely as their U.S.-born counterparts to suff er a minimum wage violation and foreign-born Latino workers had the highest minimum wage vio- lation rates of any racial/ethnic group (Bernhardt et al., 2009). Undocumented workers reported the highest rates of violations, with nearly 40% of undocu- mented workers reporting being paid subminimum wages compared to 26% of work-authorized foreign-born workers, and nearly 85% of undocumented immigrants reporting overtime violations compared to 67% of work-authorized foreign-born workers (Bernhardt et al., 2009, p. 48).

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Notwithstanding the fact that laws governing the workplace apply to all workers, including undocumented immigrants, there are many barriers that pre- vent workers from exercising their rights. One of the major barriers is workers’ lack of information about their rights and their limited English profi ciency. Th is is why it is so important for social service providers to be able to properly inform workers about their rights and to give them appropriate referrals. Increasingly, there are many community-based organizations in immigrant communities that have multilingual and multicultural staff , as well as “know your rights” materials available in multiple languages. Also, the federal government agencies charged with enforcing the nation’s labor and employment laws are required by Title VI of the Civil Rights Act to ensure that immigrant communities have equal access to their services, which means that the agencies should have multilingual materials (such as complaint forms) and bilingual staff or interpreters available.26

Despite government safeguards and nonprofi t advocacy, the unfortunate reality for many immigrant workers is that violations of labor and employment laws by their employers are rampant, particularly in low-wage industries. Many immigrant workers fear being retaliated against by their employer for assert- ing their rights. Retaliation can include employer intimidation tactics such as threatening workers with deportation, or in some cases, even physical harm for complaining about their substandard working conditions. Similar to any native-born worker, for a documented immigrant worker, retaliation may take the form of a demotion, harassment, or termination. For an undocumented worker, all these forms of retaliation pale next to the fear of being deported as a result of exercising his or her rights at work. And employers know all too well the power they hold over workers who do not have authorization to work in the United States.

When workers do exercise their workplace rights by, for example, organiz- ing, joining a union, or fi ling claims for unpaid wages with the U.S. Department of Labor or a state agency, employers, in an attempt to escape liability, often raise the issue of their immigration status, and in some cases contact immigra- tion authorities in the hopes of ridding themselves of complaining workers. Th e threat of immigration enforcement is one of the most signifi cant barriers facing low-wage immigrant workers trying to assert their labor rights. Employers may knowingly hire undocumented workers and only call immigration enforcement when those workers fi le a claim for unpaid wages or join a union campaign.27

Finally, increased immigration enforcement and certain governmental pro- grams designed to assist with immigration enforcement at the worksite also pre- vent workers from exercising and vindicating their rights. Such strategies include workplace immigration raids, I-9 employment eligibility audits, and the DHS electronic employment eligibility verifi cation program called E-Verify. Th ese pro- grams are explored in more detail in the following subsections.

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WORKSITE IMMIGRATION ENFORCEMENT: WORKPLACE RAIDS AND I-9 EMPLOYMENT ELIGIBILITY AUDITS

Congress passed the IRCA in 1986 and it has been a cornerstone of modern immigration policy since then. A central facet of this legislation was the creation of an employment authorization verifi cation regime that imposes civil and even criminal penalties on employers for knowingly hiring or knowingly employing workers who lack authorization to work. To ensure employer compliance with this regime, IRCA requires employers to verify a newly hired worker’s identity and eligibility to work by examining certain identity and work authorization documents and recording that information on the I-9 form. Congress had hoped that these provisions would deter employers from knowingly hiring undocu- mented workers; yet from its inception, the employer sanctions system has failed and workers themselves have borne the brunt of IRCA’s employment verifi ca- tion requirements. Two of the primary mechanisms that ICE has used to enforce IRCA’s employment verifi cation requirements are worksite raids and I-9 audits.

Historically, worksite immigration raids were a primary component of the worksite immigration enforcement operations by which ICE enforced the employer sanctions provisions of IRCA. To conduct these worksite raids, ICE would descend on a worksite in a military-style operation and prevent workers from leaving the premises so that ICE could question them, identify workers who may be working without authorization, detain them, and, ultimately, initiate deportation proceed- ings against them. High-profi le worksite raids include the raids of the Swift & Co. plant and the worksite raids in New Bedford, Massachusetts; Van Nuys, Califor- nia; and Postville, Iowa (“Inhumane Raid,” 2007).28

Although worksite immigration raids are ostensibly a mechanism for enforcing employer sanctions under IRCA for knowingly hiring or continuing to employ unauthorized workers, in reality, workers are the parties who are most adversely aff ected—not employers—and these actions rarely have anything to do with ensuring fair labor standards in the workplace. Th is was most clearly dem- onstrated by the controversial raid conducted against the Agriprocessors kosher plant in Postville, Iowa. Th e United Food and Commercial Workers (UFCW) had been leading a union-organizing campaign there, and advocates allege that this employer engaged in egregious labor violations ranging from child labor to sexual and physical assault of workers. Despite the egregious working conditions and the union-organizing drive, ICE detained 389 immigrant workers.

As a result of such worksite immigration raids, children have been sepa- rated from their parents, left abandoned or placed in foster care while ICE agents detained their parents. Workers have been taken into custody and many have, ultimately, been deported. Employers have lost production capacity and some of their best workers. Immigrants—or those perceived to be immigrants—have been the subject of racial profi ling by ICE, and, in the process, U.S. citizens and

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lawful permanent residents have wrongfully been detained. And by detaining workers who were involved in a union-organizing campaign, such as those in the Postville, Iowa, raid, or otherwise asserting their workplace rights, ICE, through its worksite enforcement, has undermined the working conditions of all workers at such a worksite.

In recent years, the Obama administration has relied less on the use of work- site raids (although they do still occur) and has signifi cantly increased ICE’s audits of employers for compliance with I-9 requirements. In 2008, for example, ICE conducted 503 I-9 audits and debarred one employer from participating in fed- eral contracts based on I-9 violations (MPI, 2013). Between 2009 and 2012, by contrast, ICE audited more than 8,079 employers and debarred 726 employers.29 Advocates often refer to I-9 audits as “silent raids” because they typically garner less public attention than the higher profi le military-style worksite raids, but they often result in the mass termination of immigrant workers.

During an I-9 audit, ICE reviews and inspects an employer’s I-9 forms for each of its employees and may also review supporting documentation, such as a list of current employees, a copy of the payroll, and business licenses. ICE audi- tors inspect the I-9 forms for compliance with I-9 rules. If ICE determines that any of the workers are potentially using suspect identity or work authorization documents, the employer is supposed to provide the worker with an opportunity to prove his identity and work authorization using documents other than those ICE has deemed suspect. If the worker cannot do so, the employer must fi re the worker or risk liability under federal law. If ICE determines that an employer has knowingly hired or continued to employ unauthorized workers, the employer may be fi ned and in certain situations may be criminally prosecuted.

Although I-9 audits are intended to enforce employers’ responsibilities under IRCA to verify their workers’ employment eligibility, the explosion of I-9 audits in recent years has had devastating eff ects on low-wage undocumented employees in particular. ICE conceives of I-9 audits as action that exclusively targets the employer, whose compliance with immigration law is at issue. Workers, who may have the most at stake during an I-9 audit, are considered to be third parties who lack even the right to basic information about the audit process, including con- fi rmation that an audit is occurring and whether ICE has shared any information with the employer that the worker may need to correct.

Workers’ lack of access to information about I-9 audits puts workers at a severe disadvantage and undermines their ability to protect their rights during the process. At the same time, workers’ inability to access information during an I-9 audit opens the door to abusive manipulation of the process by employ- ers, including distorting the nature of the employer’s communications with ICE or using the audit as an excuse for retaliatory action against workers during a workplace dispute. In some cases, unscrupulous employers have even claimed to be subject to an I-9 audit when no such audit is occurring as a pretense for

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reverifying the work authorization documents of workers who are participating in a union-organizing drive or otherwise asserting their rights in the workplace.

Although worksite enforcement actions, such as workplace raids and I-9 audits, are ostensibly a mechanism for enforcing employer sanctions, immigrant workers have often been the most severely impacted. Furthermore, employer sanctions have not had a signifi cant impact on the unlawful hiring of undoc- umented workers, or on unlawful immigration for that matter. Unscrupulous employers often employ and exploit immigrant workers without suff ering any liability for violating basic workplace laws. From its inception, and through eff orts to impose sanctions through worksite raids and I-9 audits, the employer sanctions system has failed. Th e system allows employers to manipulate immi- gration law to circumvent their obligations under labor law, and because of the lack of labor law enforcement, there is a huge incentive to hire and exploit undocumented workers.

For helpful information on how to respond to issues relating to workplace raids and I-9 audits, see the “Additional Resources” section at the end of this chapter.

ELECTRONIC EMPLOYMENT VERIFICATION SYSTEM

E-Verify is another federal program that has become increasingly problematic for immigrant and U.S.-born workers alike. E-Verify is a web-based program that was established to allow employers to electronically verify workers’ employment eligibility with DHS and the Social Security Administration (SSA). Th e program is voluntary for most employers, although, as of 2014, 21 states require the use of E-Verify for at least some employers.30 To use the E-Verify program, employers enter into a memorandum of understanding (MOU) with DHS whereby employ- ers agree to follow certain guidelines when using the program. Employers should only use E-Verify to verify the work authorization of new hires and are prohibited from using E-Verify to prescreen job applicants and to reverify the employment authorization of current employees.

E-Verify is often portrayed as the magic bullet that will provide employers with an easier way to verify which documents presented by a worker to satisfy the I-9 process are valid proof of the worker’s authorization to work in the United States. However, the program has been plagued by problems since its inception in 1997, when it was created by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996.31 Th e program, which is used by only approximately 480,000 employers as of 2013, has been hindered by inaccurate and outdated information in the DHS and SSA databases, misuse of the program by employers, and lack of adequate privacy protections (NILC, 2011, 2013; U.S. Citizenship and Immigration Services [USCIS], 2014a).

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A 2012 independent evaluation of E-Verify commissioned by DHS found that the government databases used for verifi cation contain errors that cause the program to incorrectly identify some work-authorized workers as lacking autho- rization to work in the United States (Westat, 2012). Th ese database errors have a disproportionate impact on lawful permanent residents and other noncitizens working legally in the United States. Th e data from the 2012 study shows that a lawful permanent resident is four times more likely than a U.S. citizen to receive an initial erroneous E-Verify determination that he lacks authorization to work in the United States. Other noncitizens who are legally authorized to work in the United States are 27 times more likely than a U.S. citizen to receive an initial erro- neous E-Verify program fi nding that he is unauthorized to work.32 Because lawful permanent residents and other work-authorized noncitizens are much more likely to receive an initial erroneous E-Verify determination that they are unauthorized to work, and workers who receive an initial system fi nding they lack work autho- rization often face negative impacts, such as suspension from work or reduced pay, the heightened error rate for lawful permanent residents and other work- authorized noncitizens results in discrimination.33

Notwithstanding these major problems, almost every immigration reform bill introduced in Congress over the past several years, and many stand-alone bills, aim to make the E-Verify program a mandatory program for all employ- ers to verify their workers’ employment authorization as a way to enforce the employer sanctions provisions of the INA. Th is is likely to result in thousands of lawfully authorized workers and U.S. citizens being denied the opportunity to work because of government database inaccuracies. Th ese programs are also likely to lead to greater discrimination because employers are more likely to scrutinize workers they perceive to be foreign born based on the color of their skin, limited English profi ciency, or accent. Finally, a mandatory electronic employment verifi cation system will do nothing to address the undeniable real- ity that there are approximately 11.3 million undocumented immigrants in the United States. Th ese workers will simply be pushed deeper into the shadows while their employers pay them off the books and escape liability under federal and state labor and employment laws, thereby depressing working conditions for all workers.

REMEDIES FOR CERTAIN UNDOCUMENTED IMMIGRANT WORKERS: U AND T VISAS

Among the types of immigration relief that may be available to undocumented workers are the U visa and the Traffi cking, or T visa, which are two specifi c forms of immigration relief that Congress created to strengthen the ability of law enforce- ment agencies to investigate and prosecute certain crimes against immigrants and

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to provide relief to victims who may otherwise fear cooperating with law enforce- ment due to their immigration status.

U visas were created as a result of Congress’s Victims of Traffi cking and Vio- lence Prevention Act (VTVPA) in 2000 (USCIS, 2014b). In order to be eligible for a U visa, an immigrant worker must have suff ered substantial physical or men- tal abuse as a result of being the victim of qualifying criminal activity that violated a local, state, or federal law. Th e worker must also have been cooperative with law enforcement in the investigation or prosecution of the qualifying crime. An individual who is granted a U visa obtains lawful status and work authorization in the United States for up to 4 years and is eligible to become a lawful permanent resident after 3 years. Th us, a U visa puts a worker on a path to permanent lawful status in the United States.

In order to be eligible for a U visa, a worker must have been the victim of qualifying criminal activity, which consists of specifi c categories of crimes that are listed in the U visa regulations.34 Th ese crimes range from extortion to felonious assault to sexual assault and rape. Although any qualifying crime could happen in an employment setting, the qualifying criminal activity that is most specifi c to workplaces includes involuntary servitude, peonage, and traffi cking. Other qualifying criminal activity includes obstruction of justice, perjury, and witness tampering, which can arise in situations in which an employer directs workers to lie during the investigation of the workplace by a labor or employment agency or in which an employer attempts to intimidate workers from participating in investigations of the workplace or from bringing complaints against the employer for labor or employment violations.

A visa that is available specifi cally to immigrant workers who have been the victims of human traffi cking is the T, or traffi cking, visa. T visas were also created during the passage of the 2000 VTVPA (USCIS, 2011). T visas are available to undocumented workers who have been victims of human traffi cking and allow such workers to remain in the United States to assist in the investigation and prosecution of the traffi cking. Human traffi cking typically involves the recruit- ment of an individual to the United Stages, often under false pretenses, for the purposes of exploiting that person. Traffi cking is basically a modern-day form of slavery. Human traffi cking victims are often subjected to sexual exploitation, such as forced prostitution, or forced labor, such as debt bondage or involun- tary servitude. Debt bondage occurs when the person who was traffi cked to the United States is forced to work indefi nitely to pay off the person who recruited him or her into the United States. Involuntary servitude occurs when victims are forced to work against their will, often under threat of violence against the workers or the family or threat of some other form of punishment.

To be eligible for a T visa, a worker must be a victim of human traffi cking and must be present in the United States as a result of traffi cking. Th e worker must also have complied with any reasonable request from a law enforcement

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agency for assistance in investigating or prosecuting the traffi cking. Finally, the worker must show that he or she would suff er extreme hardship if deported from the United States. An individual who is granted a T visa obtains lawful status and work authorization in the United States for up to 4 years and is eli- gible to become a lawful permanent resident after 3 years. Th us, like the U visa, the T visa puts a worker on a path to permanent lawful status in the United States. Immigrant individuals who may have been victims of a crime or victims of human traffi cking should be referred to a local legal services organization or a reputable immigration attorney to assess their potential eligibility for a U or a T visa. Given the potentially traumatic nature of the criminal activity that pro- vides the basis for eligibility for both types of visas, individuals who may qualify should also be referred to appropriate social service providers who are trained to provide assistance in these types of cases. For more detailed materials on U and T visas, as well as information about social services agencies that specialize in assisting victims of traffi cking, see the “Additional Resources” at the end of this chapter.

■ CONCLUSIONS

In preparing for our collective future, it is clear that all of our lives are inter- twined and that a managed immigration system is needed whereby immigrant workers continue playing a central role in helping support this country, while enjoying full labor protections and civil rights, so they can be equal and inte- grated participants in our society. However, these new workers are less likely to have access to accurate and accessible information about their rights. New immigrants often turn to their local churches, social service agencies, or perhaps a worker center for help, but these institutions and advocates rarely have the resources to provide technical assistance on the complex legal issues that oper- ate at the intersection of immigration laws and labor and employment laws. It is critical for social service providers to develop a basic understanding of these rights and some of the potential remedies in order to serve their clients better and to help orient them so that immigrants can learn how to solve their own problems, engage in community-organizing eff orts, and become full partici- pants in the society they are helping to build through their hard work.

■ CASE STUDIES

Th e following cases illustrate employment issues commonly encountered by immigrants. You are invited to discuss the questions following each case.

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CASE STUDY #1: BACK PAY AND REINSTATEMENT

A group of 10 workers comes to you. Th ey have been fi red after complaining as a group to their employer that they were not paid for overtime work. Five of the workers are undocumented. Th ree of these presented work authorization cards to the employer with their correct names, but the documents were false. One of the workers used her sister in-law’s work authorization card. One worked under her own name for a time, but after a seasonal layoff , came back to work and used a false name and work authorization card. Th e workers want to pursue back pay and reinstatement. Each was unemployed or had experienced several months of unemployment, and all are now working, using the same cards that they most recently used with this employer.

• What social work practice issues does this case raise? • What legal issues does this case raise? • Can all of the workers get back pay? • Can all of them be reinstated? • How will you deal with the workers’ use of a false name?

CASE STUDY #2: LABOR ORGANIZING

A group of hotel employees is involved in a labor-organizing campaign. During the campaign, the employer fi res seven immigrants and refuses to pay them for their past 2 weeks of work. Th e employer says that they were discharged because it has a policy of verifying Social Security numbers (SSNs) with the Social Security Admin- istration, and the seven workers did not have valid SSNs. You know that at least two of the group of seven who were fi red are documented and have good SSNs.

• What social work issues does this case raise? • What legal issues does this case raise? • What steps can you take to try to help the workers get their jobs back?

Do the undocumented workers have a right to be reinstated? • What claims can they potentially fi le? • Can they get back pay for the work they performed?

■ QUIZ: MYTHS AND FACTS ABOUT IMMIGRANT WORKERS

For each statement, decide whether it is a myth (false) or a fact (true). 1. You need to be either a U.S. citizen or have a Green Card to legally

work in the United States.

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2. All workers have the right to be paid for work performed . . . even if they are undocumented.

3. Employers are only required to verify the work authorization of workers who are not citizens.

4. If an undocumented worker is injured on the job, he or she is out of luck and cannot get medical care.

5. Undocumented immigrants do not have the same employment rights as all other workers.

6. It is illegal for an employer to report a worker to the immigration au- thorities because the worker fi led a complaint against the company.

7. If a worker has been the victim of human traffi cking, he or she may be eligible for immigration relief through a U or a T visa.

8. Employers cannot use the E-Verify program to screen job applicants and make sure they are hiring only citizens and legal workers.

9. If the E-Verify program cannot confi rm that a worker is authorized to work, that means he or she is undocumented.

10. If there is an immigration raid, all workers have the right to remain silent and not provide incriminating information.

Answers: 1—myth, 2—fact, 3—myth, 4—myth, 5—myth, 6—fact, 7—fact, 8—fact, 9—myth, 10—fact.

■ NOTES

1. Note that this chapter uses the term immigrant to refer to all individuals who have made the United States their new home, whether they arrived as immigrants or as refugees who were fl eeing persecution in their home country.

2. Immigration and Nationality Act of 1952, Sec. 208. 3. See, for example, H-1B, H-2A, H-2B visas. 4. Th e NLRA is enforced by the National Labor Relations Board (NLRB). To learn more

about the NLRA, visit the NLRB’s website at www.nlrb.gov. 5. Title VII is enforced by the Equal Employment Opportunity Commission (EEOC),

which also enforces the Age Discrimination in Employment Act of 1967, Americans with Disabilities Act of 1990, and the Equal Pay Act of 1963. To learn more about the EEOC and the laws under its jurisdiction, visit www.eeoc.gov.

6. Th e U.S. Department of Labor (DOL) enforces the FLSA, as well as the Migrant and Seasonal Agricultural Worker Protection Act and the Family Medical Leave Act. DOL also oversees the Occupational Safety and Health Administration. To learn more about the DOL, its agencies, and the laws under its jurisdiction, visit www.dol.gov.

7. Immigration Reform and Control Act of 1986, Pub. L. No. 99–603, § 101(a)(1), 100 Stat. 3359 (Nov. 6, 1986), codifi ed at 8 U.S.C. § 1324a (2000), amending the Immigration and Nationality Act. INA § 274A.

8. 8 U.S.C. § 1324a(a).

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9. 8 U.S.C. § 1324a(e). 10. 8 C.F.R. § 274a.7. 11. See Government Accountability Offi ce, Pub. No. GAO/GGD-90–62, Immigration

Reform: Employer Sanctions and Th e Question of Discrimination (1990) (fi nding a “serious pattern of discrimination” resulting specifi cally from employer sanctions but attributing the problem primarily to employer confusion regarding the array of docu- ments employees could present to satisfy the I-9 employment verifi cation requirements and a lack of awareness of the new law among employers). For a discussion of employ- ment discrimination, see Pursuing Racial Justice (Hincapie, 2002).

12. 8 U.S.C. § 1324b(a)(1)(B) (2001) (prohibiting citizenship status discrimination); ibid., § 1324b(a)(2)(A)-(B) (prohibiting national origin discrimination by employ- ers with 4 to 14 employees). Title VII of the Civil Rights Act prohibits employment discrimination by employers with 15 or more employees.

13. For more information about OSC, visit www.usdoj.gov/crt/osc. 14. Immigration Act of 1990, Pub. L. No. 101–649, 104 Stat. 4978 (codifi ed at INA, 8

U.S.C. §§ 1101 et seq. (2001)) (adding § 274B(a) of the INA). 15. Th e Form I-9, which applies to every employee hired in the United States, is available

at http://www.uscis.gov/fi les/form/i-9.pdf. 16. 535 U.S. 137 (2002). 17. Th e remedy of back pay refers to compensation a worker can receive for the wages he

or she would have earned had he or she not been wrongfully terminated. 18. Hoff man Plastic Compounds, Inc., supra, 535 U.S. at 147. 19. See Sure-Tan v. NLRB, 467 U.S. 883 (1984) (pre-IRCA decision holding that

undocumented workers are covered “employees” under NLRA). 20. See Reyes, et al. v. Van Elk, Ltd., et al., 148 Cal. App. 4th 604, 613 (2007) (holding that “if

the FLSA did not cover undocumented aliens, employers would have an incentive to hire them”), citing Patel v. Quality Inn South, 846 F.2d 700 (11th Cir. 1988) (undocumented worker is employee for purposes of the [FLSA] and may sue for unpaid wages and liqui- dated damages).

21. See Rivera, et al. v. NIBCO, Inc., 364 F.3d 1057 (9th Cir. 2004) (holding that Hoff man does not make immigration status relevant to the determination whether a defendant has committed national origin discrimination under Title VII).

22. Lost earnings is compensation for the wages the worker would have earned had he or she not been injured on the job.

23. See Th e Reinforced Earth Co. v. Workers Comp Appeal Bd, 810 A.2d 99, 107–108 (Pa. 2002).

24. See Martines v. Worley & Sons Construction, 628 S.E. 2d 113, 114 (Ga. Ct. App. 2006). 25. See Wet Walls v. Ledezma, 598 S.E. 2d 60 (Ga. Ct. App. 2004). 26. For more information about access to federal agencies, see Limited English profi ciency—

A Federal Interagency Website, available at http://www.lep.gov. 27. See, for example, Corinthian Vigor Ins. Brokerage, Inc., 25 F.Supp.2d 1053, 1056 (N.D.

Cal. 1998) (fi nding that employer who called Immigration and Naturalization Service (INS) in retaliation for worker’s claim for unpaid wages was retaliation in violation of FLSA); Singh v. Julta, et al. 214 F.Supp.2d 1056 (N.D. Cal. 2002) (Jury awarded $200,000 in damages to worker who had been traffi cked into the United States and reported to INS in retaliation for wage claim).

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http://www.uscis.gov/files/form/i-9.pdf.

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28. For news coverage of these raids, see, for example, “Raid an ‘Outrageous Use of Force,’ Union Says,” CNSNews.Com (December 13, 2006); “Immigration Raid Jars a Small Town,” Washington Post (May 18, 2008); “Inhumane Raid Was Just One of Many,” Boston Globe (March 26, 2007). For a sobering account of the raid in Postville, Iowa, from the perspective of a court interpreter, see “Interpreting after the Largest ICE Raid in U.S. History: A Personal Account,” Erik Camayd-Freixas, PhD, Florida International University (June 13, 2008), available at: http://www.witnessforpeace.org/downloads/ UM_PostvilleCtInt08.pdf

29. Written Testimony of Homeland Security Secretary Janet Napolitano before the House Committee on the Judiciary, Oversight of the Department of Homeland Security, July 19, 2012, available at: http://www.dhs.gov/news/2012/07/17/written-testimony-dhs- secretary-janet-napolitano-house-committee-judiciary-hearing

30. National Council of State Legislatures, “State E-Verify Action,” Sept. 1, 2014, available at: http://www.ncsl.org/research/immigration/state-e-verify-action.aspx

31. Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Pub. L. 104-208, 110 Stat. 3009-655 (Sept. 30, 1996), sec. 401.

32. Th ese calculations are based on the most recent tentative nonconfi rmation error rates cited in the Westat (2012) study. Between April and June 2010, the E-Verify tentative nonconfi rmation error rate for U.S. citizens was 0.2%; the tentative nonconfi rmation error rate for lawful permanent residents was 0.9%; the tentative nonconfi rmation error rate for other noncitizens was 5.4%.

33. See Verifi cation Nation, supra, at p. 5. 34. See 8 C.F.R. § 214.14(a)(9).

■ REFERENCES

Bernhardt, A., Milkman, R., Th eodore, N., Heckathorn, D., Auer, M., DeFilippis, J., . . . Spiller, M. (2009). Broken laws: Unprotected workers: Violations of employment and labor laws in America’s cities. Chicago, IL: Center for Urban Economic Development, UIC 20-72.

Bureau of Labor Statistics. (2014, May 22). Foreign-born workers: Labor force characteristics— 2013. Retrieved from http://www.bls.gov/news.release/pdf/forbrn.pdf

Fisk, C. L., & White, M. J. (2005). Th e story of Hoff man Plastic Compounds, Inc. v. NLRB: Labor rights without remedies for undocumented immigrants. In L. J. Cooper & C. L. Fisk (Eds)., Labor law stories. New York, NY: Foundation Press.

Gregory, V., & Schiller, J. (2004, October 4). Fatality rate is 25% higher for Latino workers: Immigrants face greatest risks of death at jobs. Alameda Times-Star.

Hincapie, M. (2002). Growing immigrant communities face increased employment discrim- ination. Clearinghouse Review—Journal of Poverty Law and Policy, Pursuing Racial Justice, 36(3–4 Pt 2), 249–263.

Migration Policy Institute. (2013). Immigration Enforcement in the United States: Th e Rise of a Formidable Machinery. Retrieved from http://www.migrationpolicy.org/research/ immigration-enforcement-united-states-rise-formidable-machinery

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http://www.migrationpolicy.org/research/immigration-enforcement-united-states-rise-formidable-machinery

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202 ■ II: IMMIGRATION AND SOCIAL WORK PRACTICE

Migration Policy Institute. (2014). Profi le of the unauthorized population: United States. Retrieved from http://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/US

Myers, D. (2008). Th inking ahead about our immigration future: New trends and mutual benefi ts in our aging society. Washington, DC: Immigration Policy Center, American Immigration Law Foundation.

Pritchard, J. (2004, March 13). Mexican worker deaths rise sharply. New York, NY: Associ- ated Press. Retrieved from http://staugustine.com/stories/032104/opi_2188540.shtml# .VdtpsvlViko

Segelken, R. (2014, May 14). Dangerous, underpaid work for the undocumented. Cornell Chronicle. Retrieved from http://www.news.cornell.edu/stories/2014/05/dangerous -underpaid-work-undocumented

Singer, A. (2012, March 15). Immigrant workers in the U.S. labor force. Washington DC: Brook- ings Institute. Retrieved from http://www.brookings.edu/research/papers/2012/03/15 -immigrant-workers-singer

U.S. Citizenship and Immigration Services. (2011, October). Victims of human traffi ck- ing: T nonimmigrant status. Retrieved from http://www.uscis.gov/humanitarian/victims -human-traffi cking-other-crimes/victims-human-traffi cking-t-nonimmigrant-status#T Nonimmigrant Eligibility

U.S. Citizenship and Immigration Services. (2014a, January 17). History and milestones: Chronological summary of the milestones of the E-Verify program. Retrieved from http:// www.uscis.gov/e-verify/about-program/history-and-milestones

U.S. Citizenship and Immigration Services. (2014b, January). Victims of criminal activity: U nonimmigrant status. Retrieved from http://www.uscis.gov/humanitarian/victims -human-trafficking-other-crimes/victims-criminal-activity-u-nonimmigrant-status /victims-criminal-activity-u-nonimmigrant-status.

Westat Corporation. (2012). Evaluation of the accuracy of E-Verify fi ndings. Rockville, MD: Westat, prepared for U.S. Dept. of Homeland Security. Retrieved from http:// www.uscis.gov/sites/default/files/USCIS/Verification/E-Verify/E-Verify_Native _Documents/Everify%20Studies/Evaluation%20of%20the%20Accuracy%20of%20 EVerify%20Findings.pdf

■ ADDITIONAL RESOURCES

GENERAL IMMIGRANT AND EMPLOYMENT WEBSITES

American Civil Liberties Union (ACLU): https://www.aclu.org/immigrants-rights America’s Union Movement (AFL-CIO): www.afl cio.org Change to Win: http://www.changetowin.org/ Council for Occupational Safety and Health, Immigrant Worker Resources and Links: www

.coshnetwork.org/ Equal Employment Opportunity Commission (EEOC): www.eeoc.gov Form I-9: http://www.uscis.gov/fi les/form/i-9.pdf Immigrant Defense Project: http://immigrantdefenseproject.org/

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http://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/US

http://staugustine.com/stories/032104/opi_2188540.shtml#.VdtpsvlViko

http://www.news.cornell.edu/stories/2014/05/dangerous-underpaid-work-undocumented

http://www.uscis.gov/e-verify/about-program/history-and-milestones

https://www.aclu.org/immigrants-rights

http://www.changetowin.org

http://www.eeoc.gov

http://immigrantdefenseproject.org

http://staugustine.com/stories/032104/opi_2188540.shtml#.VdtpsvlViko

http://www.news.cornell.edu/stories/2014/05/dangerous-underpaid-work-undocumented

http://www.uscis.gov/humanitarian/victims-human-trafficking-other-crimes/victims-human-trafficking-t-nonimmigrant-status#TNonimmigrantEligibility

http://www.uscis.gov/humanitarian/victims-human-trafficking-other-crimes/victims-criminal-activity-u-nonimmigrant-status/victims-criminal-activity-u-nonimmigrant-status

http://www.uscis.gov/sites/default/files/USCIS/Verification/E-Verify/E-Verify_Native_Documents/Everify%20Studies/Evaluation%20of%20the%20Accuracy%20of%20EVerify%20Findings.pdf

www.aflcio.org

www.coshnetwork.org/

http://www.uscis.gov/files/form/i-9.pdf

http://www.brookings.edu/research/papers/2012/03/15-immigrant-workers-singer

8: IMMIGRANTS AND EMPLOYMENT ■ 203

Immigrant Legal Resource Center: http://www.ilrc.org/ Limited English Profi ciency—A Federal Interagency Web site: http://www.lep.gov National Employment Law Project: www.nelp.org National Immigrant Justice Center: http://www.immigrantjustice.org/ National Immigration Law Center: www.nilc.org National Immigration Project: http://www.nationalimmigrationproject.org/resources.htm National Labor Relations Board (NLRB): www.nlrb.gov Northwest Immigrant Rights Project: http://www.nwirp.org/ Social Security Administration, Social Security Online, Employer W-2 Filing Instructions &

Information: http://www.ssa.gov/employer/ United States Citizenship and Immigration Service: www.uscis.gov United States Department of Labor (DOL): www.dol.gov U.S. Department of Labor—Bureau of Labor Statistics: www.bls.gov

JUDICIAL DECISIONS

American Federation of Labor and Congress of Industrial Organizations, et al. v. Chertoff , et al., Case No. C07–04472 CRB, U.S.D.C.

Aramark Facility Services v. SEIU, Local 1877, 2008 U.S. App. LEXIS 12704 (9th Cir. 2008).

Contreras v. Corinthian Vigor Ins. Brokerage, Inc., 25 F.Supp.2d 1053, 1056 (N.D. Cal. 1998).

Hoff man Plastic Compounds, Inc., 535 U.S. 137 (2002). Martines v. Worley & Sons Construction, 628 S.E. 2d 113, 114 (Ga. Ct. App. 2006). Palma v. NLRB, 723 F.3d 176 (2nd Cir. 2013). Reyes, et al. v. Van Elk, Ltd., et al., 148 Cal. App. 4th 604, 613 (2007). Rivera, et al. v. NIBCO, Inc., 364 F.3d 1057 (9th Cir. 2004). Th e Reinforced Earth Co. v Workers Comp Appeal Bd, 810 A.2d 99, 107–108 (Pa. 2002). Singh v. Julta, et al. 214 F.Supp.2d 1056 (N.D. Cal. 2002). Sure-Tan v. NLRB, 467 U.S. 883 (1984). Wet Walls v. Ledezma, 598 S.E. 2d 60 (Ga. Ct. App. 2004).

IMMIGRANT LABOR ORGANIZATION AND ADVOCACY

Bacon, D. (1998). Paolo Freire hits L.A.’s mean streets: Organizing day laborers. Retrieved from http://dbacon.igc.org/Imgrants/03daylab.html

Bacon, D. (2001). Why labor needs to organize and defend the rights of immigrant workers. Retrieved from http://dbacon.igc.org/Imgrants/26WhyLaborNeedsToDefend.htm

Fine, J. (2006). Worker centers: Organizing communities at the edge of the dream. Ithaca, NY: Cornell University Press.

Frank, L., & Wong, K. (2004). Dynamic political mobilization: Th e Los Angeles county federation of labor. Working USA—Th e Journal of Labor and Society, 8(2), 155–181.

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http://www.nlrb.gov

http://www.nwirp.org

http://www.ssa.gov/employer

http://www.uscis.gov

http://www.dol.gov

http://www.bls.gov

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Gordon, J. (2005). Suburban sweatshops: Th e fi ght for immigrant rights. Cambridge, MA: Belknap Harvard University Press.

LeDuff , C. (2001). At a slaughterhouse, some things never die. In How race is lived in America: Pulling together, pulling apart (pp. 97–113). New York, NY: Times Books.

Lerner, S. (2003).United we win: A discussion of the crisis facing workers and the labor movement. An immodest proposal: A new architecture for the house of labor. New Labor Forum, 12(2), 9–30.

Milkman, R. (2006). L.A. story: Immigrant workers and the future of the U.S. labor movement. New York, NY: Russell Sage Foundation.

Milkman, R., & Wong, K. (2000).Organizing the wicked city: Th e 1992 Southern California drywall strike. In R. Milkman (Ed.), Organizing immigrants: Th e challenge for unions in contemporary California (pp. 169–198). Ithaca, NY: Cornell University Press.

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Wong, K. (2004). Don’t miss the bus: Th e immigrant workers freedom ride. New Labor Forum, 13(2), 60–66.

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Mehta, C., Th eodore, N., Mora, I., & Wade, J. (2002). Chicago’s Undocumented immigrants: An analysis of wages, working conditions, and economic contributions. Chicago, IL: UIC Center for Urban Economic Development.

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Murray, J., Batalova, J., & Fix, M. (2006, July). Th e impact of immigration on native workers: A fresh look at the evidence. Washington, DC: Migration Policy Institute, Insight No. 18.

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8: IMMIGRANTS AND EMPLOYMENT ■ 207

Reitz, J. G. (1998). Warmth of the welcome: Th e social causes of economic success for immigrants in diff erent nations and cities. Boulder, CO: Westview Press.

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208 ■ II: IMMIGRATION AND SOCIAL WORK PRACTICE

I-9 EMPLOYMENT ELIGIBILITY AUDITS

Employment Eligibility Verifi cation and Protections, National Immigration Law Center: http://www.nilc.org/i9eev.html

U.S. Immigration and Customs Enforcement: http://www.ice.gov/factsheets/i9-inspection What Workers Should Know About I-9 Audits: National Immigration Law Center:

http://www.nilc.org/document.html?id=345

IMMIGRATION RAIDS

Brochure: Rights During Immigration Raids, CASA de Maryland: http://wearecasa.org/wp -content/uploads/2014/03/KYR-booklet_English.pdf

From Raids to Deportation: A Community Resource Kit, National Immigration Project: http://www.nationalimmigrationproject.org/community/Community_Resource_Kit -English_version.pdf (available in other languages, under “Raids” at: http://www.national immigrationproject.org/community.htm)

How To Be Prepared for an Immigration Raid, National Immigration Law Center: http:// www.nilc.org/immraidsprep_2007-02-27.html

Know Your Rights. Video regarding immigration raids, Coalition for Humane Immigrant Rights of Los Angeles (CHIRLA): http://www.chirla.org/Resources

Webpage: Immigration Raids, National Immigration Law Center: http://www.nilc.org/raids .html

What to Do if You Are Stopped by the Police, Immigration Agents, or the FBI (card), ACLU: http://www.aclu.org/fi les/assets/bustcard_eng_20100630.pdf

E-VERIFY

Webpage: Blog of Rights: E-Verify. American Civil Liberties Union: https://www.aclu.org /blog/tag/e-verify

Webpage: Electronic Employment Eligibility Verifi cation Systems. National Immigration Law Center: http://www.nilc.org/employmentverifi cation.html

Webpage: Form I-9 and E-Verify. U.S. Department of Justice Offi ce of Special Counsel for Immigration-Related Unfair Employment Practices: http://www.justice.gov/crt/about /osc/htm/I9_Verifi cation.php

U AND T VISAS

Kinoshita, S., Bowyer, S., Farb, J., & Seitz, C. (2014). Th e U Visa: Obtaining Status for Immigrant Victims of Crime. San Francisco, CA: Th e Immigrant Legal Resource Center.

Lee, I. C., Parker, L. M., & Liou, C. C. (2013). Representing Survivors of Human Traffi ck- ing: A Promising Practices Handbook. Th e Immigrant Legal Resource Center.

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http://www.ice.gov/factsheets/i9-inspection

http://www.nilc.org/document.html?id=345

http://wearecasa.org/wp-content/uploads/2014/03/KYR-booklet_English.pdf

http://www.nilc.org/immraidsprep_2007-02-27.html

http://www.chirla.org/Resources

http://www.nilc.org/raids.html

http://wearecasa.org/wp-content/uploads/2014/03/KYR-booklet_English.pdf

http://www.nationalimmigrationproject.org/community/Community_Resource_Kit-English_version.pdf

http://www.nationalimmigrationproject.org/community.htm

http://www.nilc.org/raids.html

http://www.aclu.org/files/assets/bustcard_eng_20100630.pdf

https://www.aclu.org/blog/tag/e-verify

http://www.nilc.org/employmentverification.html

8: IMMIGRANTS AND EMPLOYMENT ■ 209

Webpage: Resources and Training. Coalition to Abolish Slavery and Traffi cking: http://www .castla.org/legal-resources

Webpage: U Visa. Asista: http://www.asistahelp.org/en/access_the_clearinghouse/u_visa/. Webpage: U Visa: Immigration Relief for Survivors of Domestic Violence and Other Crimes.

Th e Immigrant Legal Resource Center: http://www.ilrc.org/info-on-immigration-law /u-visas

STATUTES

Immigration Act of 1990, Pub. L. No. 101–649, 104 Stat. 4978 (codifi ed at INA, 8 U.S.C. §§ 1101 et seq. (2001)).

Sections § 274B(a) of the INA); 101(a)(15) H-1B, H-2A, H-2B; 8 U.S.C. § 1324a(a) (2008).

REGULATIONS

8 C.F.R. § 274a.7 (2008). Immigration Reform and Control Act of 1986, Pub. L. No. 99–603, § 101(a)(1), 100 Stat.

3359 (Nov. 6, 1986), codifi ed at 8 U.S.C. § 1324a (2000) amended the Immigration and Nationality Act. INA § 274A.

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http://www.castla.org/legal-resources

http://www.asistahelp.org/en/access_the_clearinghouse/u_visa

http://www.ilrc.org/info-on-immigration-law/u-visas

http://www.castla.org/legal-resources

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