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DREAMers Living in the United States: A Contextual Perspective and Clinical Implications.

Undocumented immigration is a controversial issue at the forefront of currentU.S. politicaldiscussion.Among themore than 11 million undocumented immigrants residing in the United States, more than 1 million are acculturated undocumented youths who were brought to the United States as children by their parents (2) and whomeet the requirements “Mr. A,” an 18-year-old undocumented immigrant from Mexico, was referred for consultation to a communitybased psychology outpatient clinic after presenting to urgent care for symptoms of a severe ataque de nervios, or panic-like symptoms with no organic etiology. Mr. A was brought to the United States at age 2 by his undocumented parents and has never returned to Mexico. His father had been the primary provider for their family, but he had recently been deported, and Mr. A is now working multiple jobs to provide for the family, including his ill mother and his two younger U.S.-born siblings. The patient, a graduating high school senior with an excellent academic record, is a recipient of the Deferred Action for Childhood Arrivals (DACA) program. He is interested in going to college, but given the limited financial aid and employment opportunities available to DACA recipients, he does not think he’ll be able to afford it. As a result, he is feeling anxious, worried, depressed, and hopeless. Moreover, since his father’s deportation, Mr. A has had a substantial increase in intrapersonal and interpersonal stressors, including experiencing variations in self-perception and internalization of the undocumented stereotype, which includes feeling inferior to others, regarding himself as a hindrance to the community, and feeling undeserving of social and economic opportunity. As a result, he has experienced decreased self-esteem, a sense of being burdensome, and feelings of guilt and shame. He is also having trouble coping with the self-imposed burden imposedbyhis sense of an inability to repayhis parents and other family members who have made sacrifices for his future in the United States. Despite his academic success in high school, he often feels sad and disappointed at the limited educational and employment opportunities available to him and his inability to help his family advance along the social and economic ladder. He also reports constant fearandworryaboutdeportation, andsymptoms of anxiety, including an inability to concentrate at school, trouble sleeping at night, and multiple unexplained somatic symptoms that have increased in frequency and severity since his father’s deportation. Additionally, he reports a recent increase in fear and avoidanceofpublicplacesanddistrust in others, which he described as disabling. His symptoms are significantly impairing his academic performance, work capacity, and social relationships, and he mentioned feeling at risk for drinking to cope with distress. To emphasize the influence of context and culture on the patient’s symptom presentation, an adapted version of the Cultural Formulation Interview from DSM-5 (1, pp. 749–759) was used in diagnosis. A diagnosis of other specified anxiety disorder was made, with nervios and ataque de nervios as specifiers. Moreover, it was recognized that the patient was facing multiple and chronic psychosocial and environmental stressors requiring clinical attention, including disruption of family by separation, family illness, social exclusion, target of (perceived) adverse discrimination, academic and occupational problems, low income, limited access to health care, and legal difficulties associated with undocumented status. Although the patient attended a few therapy sessions, he was ambivalent about mental health treatment because of stigma, lack of time, and limited transportation. As a result, he terminated treatment prematurely, stating that it was more convenient for him to receive the support that was provided by his church community.